CONSTIPATION

• A frequent problem in infants and children
• Definition of constipation is relative and depends on stool consistency, stool frequency, and difficulty in passing stools.
• Normal bowel frequency varies widely
  • On an average baby passes 3 to 6 stools per day in the neonatal period
  • 1-2 stools per day at 1 year of life
  • 1 stool per day or every other day in preschool years

• Thus constipation can be defined as delay or difficulty in defecation that has been present for 2 weeks or longer
• Absolute constipation: Absence of evacuation of faeces and flatus and is due to intestinal obstruction from congenital or acquired conditions. This is a surgical emergency and needs urgent attention. The most common symptom of absolute constipation is vomiting with abdominal distension

Organic causes

• Intestinal: Hirschpung disease, anal stenosis, anal fissure, fistula in ano
• Drugs: narcotics
• Endocrine: hypothyroidism
• Neuromuscular: Cerebral palsy, mental retardation, spinal cord lesions, myotonic dystrophy.

Functional

• Dietary: poor intake of fluids
• Low fibre diet
• Excessive intake of proteins and fats
• Poor bowel habits: suppression of the urge to defecate

CLUES FROM HISTORY

Is constipation present since birth

• The commonest cause of organic constipation with onset usually in the neonatal period is congenital aganglionic megacolon. Present at birth with delayed passage of meconium. Other causes: anal stenosis, hypothyroidism

 Functional constipation 

• Starts after the neonatal period usually in a child older than 18 months

 Types of stools

• Stool of breastfed baby- golden yellow, loose in consistency (due to increased lactose content in human milk)
• Stool of a baby receiving top milk or formula milk is pale and firm in consistency. They tend to be constipated. 

 Dietary History

• Inadequate intake of fluids, cereals, vegetables and fruits ie. food with low fibre content can lead to constipation

Bowel Habits

• Pain associated with defecation: any painful condition in anorectal region can lead to constipation.

History of blood in stools: 

• Seen in anal fissure

History of neonatal jaundice and feeding difficulty:

• In a child with cretinism there would be a history of feeding difficulty and prolongation of jaundice

Developmental History

• Features of hypothyroidism, mental retardation 

• Estimation of T3, T4, TSH
• Barium Enema: helpful in diagnosing Hirschsprung disease. 
• Rectal Manometry
• Rectal biopsy
• MRI spine

• Surgical correction if needed
• Hormonal replacement therapy if required
• Proper dietary practices
• Bowel training

Ayurvedic management

• Deepana Pachana Vatanulomana
• Restrict intake of milk
• Avoid pulses especially kalaya
• Encourage use of fruits like ripe papaya,draksha

Internal medicines 

Kashayas 

• Gandharvahasthadi kashaya /Amrutothara kashaya / Chiruvilwadi kashaya/ Katukaamalakadi
  • Up to 1 year: for mother: 2 tsp sookshma choorna is boiled in 2 glass water, strained and given to mother. If agni bala permits give 1 tsp thrice to the child
  • 1 year to 5 years: ½ tsp powder boiled in 1 glass water and given as divided doses mixed with sugar or jaggery
  • Upto to 10 years: 1 tsp powder boiled in 1 glass water and given as divided doses mixed with sugar or jaggery
  • 10-15 years: 1 ½ tsp powder boiled in 1 glass of water and given twice daily mixed with sugar or jaggery

Arishtas 

• Amalakyadarishta,Abhayarishta,Jeerakarishta,Draksharishta,Mridweekarishta
  • Upto 2yrs- ½ tsp arishta diluted with 1 tsp water
  • 2-5 years- 2.5ml-5ml diluted with 5 ml boiled water
  • 5-10 years- 10ml
  • 10-15 years- 15ml

Choorna 

• Ashta choorna / Vaishwanara/Avipathi /Trivruth /Triphala
  • Infant: 2-3 gm, 
  • Toddler- 5gm, 
  • School going- 7-10gm

Lehyas

• Trivruth /Hridyavirechana /Manibhadra guda /Kalyanaka guda /Agasthya hareetaki/ Dashamoola hareetaki/ Sukumaram
  • Upto 6 years: ½ tsp
  • 6-12 years: 1 tsp

 Sneha virechana

• Sukumara eranda/ Gandharva eranda with milk
  • 2-5 years: 2.5ml
  • 5-10 years: 5ml

 Procedures

• Per rectal administration of Anulomana Kashaya like Amrutothara , Sapthasara Kashaya or Murivenna based on the vyadhyavastha

For babies on exclusive breast feeding

• Give medicines for mother 
• For baby- sthanyapana after sthana lepana with Hareethaki kalka
• Rajanyadi choorna with breast milk