Constipation.

Q Our 13-year-old son has cerebral palsy and mental retardation. He has always had some problem with constipation, but up until the last two years we were able to deal with it using prune juice and mild laxatives. Now it has gotten worse and we end up giving him enemas about once a week. Many of his classmates have problems with constipation, too. Do you have any suggestions?

A Constipation is a problem for many people with disabilities. It may be caused by immobility, insufficient dietary fiber and water consumption. h is also a side effect of certain medications prescribed for these children, for example: muscle relaxants (such as diazepam and baclofen), seizure medications (such as valproic acid and Dilantin [R]) and antihistamines (given for excess drooling).

Cerebral palsy, for example, may impair coordination in the anal muscles and/or the muscles of the pelvic floor, making defecation more difficult. Spina bifida can cause a lack of sensation in the bowel (neurogenic bowel) which prevents a reflex that tells the brain about the need for a bowel movement. Additionally, the muscles of the pelvic floor and abdomen may be weak or paralyzed and unable to help with evacuation.

Diets may also cause constipation. "Picky" or poor eaters -- such as some children with autism or those on restricted diets such as the ketogenic diet for treatment of epilepsy -- are at risk. Children who are enterally fed with gastrostomy or jejunostomy tubes may also have difficulties with constipation.

It is difficult to get children to eat a well-balanced diet with adequate amounts of fiber and fluid, even when they are able. Adding medications to treat constipation to the mix, particularly if they taste bad, is problematic.

Identifying the problem

Parents may not realize their children are constipated. Symptoms of constipation can include unexplained fussiness, apparent abdominal pain, decreased appetite, vomiting and a distended (swollen) abdomen. Physicians should ask specific questions about these symptoms at all visits, even regular checkups.

Chronic constipation can cause erratic absorption of medications due to slowed movement through the intestines. Severe constipation also increases the likelihood of urinary tract infections. In addition to the health and comfort issues, constipation makes toilet training more difficult, regardless of the disability.

Ironically, constipation is sometimes first diagnosed when the parent brings the child to the physician for diarrhea. Severe constipation with impaction (passage blocked by a stool plug) gives the impression of diarrhea because only very liquid stool can pass around the blockage (encopresis). A rectal exam, and, on occasion, an x-ray of the abdomen, may be required to diagnose impaction or severe constipation.

Getting relief

Enemas are typically required to completely empty the intestinal tract before other treatments and medications can be effective for maintenance. I usually recommend a mineral-oil enema followed by a Fleet [R] enema. This combination may need to be repeated. If the constipation does not respond, then a liquid osmotic agent (a medication that brings extra water into the bowel) -- GoLYTELY [R] -- may need to be administered under the direction of a physician.

It is important that your son try to have a bowel movement at least every day. Feed him foods that are naturally high in fiber, such as beans, whole wheat bread, peanut butter and dried fruit such as apricots, peaches, prunes and raisins. Wheat germ can be sprinkled on other foods, especially high-fiber cereals.

Liquids are also important. Depending on your son's weight, he may need up to 56 ounces of fluids daily, preferably water and fruit juices. He'll need even more in warm weather.

When diet and adequate fluids are not enough, supplemental fiber, laxatives, medications or even occasional suppositories and enemas may be required. We have used supplemental fibers such as Citrucel [R] and Metamucil [R] with success, although flavor and texture can be an issue. For some older children and teenagers, chewable FiberCon [R] tablets are a more palatable alternative. Some of my patients who are fed enterally are exclusively on formulas with added fiber or a combination of plain and fiber formulas, depending on what works best for them.

The most commonly used laxatives are magnesium compounds such as milk of magnesia and magnesium citrate. Relatively large doses may need to be given if constipation has been a long-standing problem.

If these do not work, we often try non-absorbable sugars, such as Lactulose  available by prescription only) and sorbitol (available over-the-counter). You should always check with your son's physician when determining dosage of these medications. We do not recommend Colace [R], Senakot [R], cascara or phenolphthalein compounds (i.e. Ex-Lax [R]) for long-term use because of their side effects, such as cramping and potential damage to the colon. Sometimes, we prescribe motility medications such as cisapride (Propulsid[R]). As always, the possible contraindications and side effects of any drug, as well as its interactions with the child's other medications, should be carefully considered before prescribing these medications.

I occasionally recommend mineral oil and various mineral-oil preparations, such as Kondremul [R], as maintenance preparations. Because of the possibility of "silent aspiration" (chronic inhalation of fluids or foods into the lungs without significant symptoms) however, I am reluctant to use such preparations for more than a few weeks at a time.

Constipation can cause significant problems in children with special health care needs and should be treated very seriously. Fortunately, most problems can be avoided with careful observation, the dietary suggestions I have outlined and the use of some safe and readily-available supplemental fibers and mild laxatives. If this approach does not work, contact your child's physician.