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When there are rocks but they’re not rolling

Online since 10.04.2018 • Filed under Health • From Seventeen - April to June 2018 page(s) 26-27
When there are rocks but they’re not rolling

What is constipation and when should you worry? Dr Caroline Zabiegaj-Zwick, a paediatric surgeon, dispel some myths and offers her guidance about dealing with a child who has difficulty stooling.

When you become a parent, it is amazing how the dinner table discussion shifts from parliamentary shuffles to the bodily emissions of your baby. No conversation is safe from a discussion about baby’s pooping habits, eating and burping routines, and funny projectile emission stories. However, there is much mystery and a fair amount of assumption about what is normal stooling (pooping) and what is abnormal. Added to this, there are often many wellmeaning aunties, grannies and mothers who have ‘been there, done that, and got covered in poo’ who will offer advice regarding ‘constipation’.


The definition of constipation is a decrease in frequency of stools, or passage of hard, dry stools. You can appreciate that this is rather vague as the ‘normal’ frequency for one child is not necessarily the norm for another. Rather than giving a definition of what constipation is, I would like to dispel some myths and give some guidance about dealing with a child who has difficulty stooling, as well as highlighting some of the red flags that should prompt seeking medical attention at various ages.


New-borns and infants (up to two years)

I often have moms worried that their babies do not pass adequate amounts of stool. When breastfeeding, the good news is that there is a wide range that is considered normal: some babies will pass stools with every feed, whereas some babies will only pass stools once a week, which is because the baby’s body absorbs almost all the breastmilk and leaves nothing more to be excreted. The following are considered red flags in this age group and should prompt seeking medical advice:

• Not passing meconium (the sticky black stool) within the first 24 hours of birth

• Constipation that is associated with a very distended tummy

• An abnormal looking anus (bum)

• A sore, red looking tummy

• Any vomiting, especially if green in colour

• If stooling habits change dramatically after introducing solids


Toddler group (two to five years)

This is the age group that is most difficult to contend with. Toddlers are wonderful angels that can sometimes be devious little devils. During the pottytraining ages, children make the connection between their behinds and their brains (which is the point of potty training). This ultimately means that children realise that they can control their stools, and because such a fuss is made about them going to the potty, it becomes quite the bargaining tool, with some back firing (or a lack thereof). The idea behind potty training is to form a connection between the rectum (the large intestine that stores the stool) and the brain. Once the rectum is distended, a message is sent to the brain to ask if there is the green light to go ahead to the toilet. In the brain, this message will then be analysed and if it is appropriate, the muscles relax, and stool is passed. If the timing is inappropriate, the muscles contract, keeping the stool in and allowing the person/child to buy some time to find the appropriate place or time to go and pass a stool. In toddlerhood, there are often far more amazing things to discover (in the sandpit, in the tree or under the rock) and people to play with, so going to the toilet is not a priority. The children then withhold the stool until they are reminded that they should go to the toilet, or in slightly more dramatic circumstances until they are unable to hold the stool back anymore, in which case an ‘accident’ happens.

The withholding behaviour can have some rather negative consequences though, as passage of hard stools then leads to tearing of the sensitive tissue around the bum, which leads to anal fissures. The child then starts associating going to the toilet with pain, and therefore withholds stool more often and then we get into a cycle of withholding, passage of hard stools leading to tearing and fissures, and painful stooling, more withholding, and so on. The aim in this group of children is to make going to the toilet fun, to get into a routine, and to avoid the withholdingfissure-pain cycle. By teaching good habits at a young age, you can avoid many problems with chronic constipation and the sequelae thereof.


Red flags:

• Constipation that is only relieved by enemas or associated with prolapse or bleeding

• Children who are vomiting (especially if green)


Childhood (age six and up)

This group of children poses a new set of challenges, sometimes for which there are not many answers from a medical point of view. Children go to school, meet new people, have new expectations and learning structures, which means that going to the toilet when the need arises is not always a feasible option. Added to that the toilet facilities may not be inviting for the child to feel relaxed enough to go to the toilet, leading to a withholding behaviour even if they did not have the tendency to withhold before. If there is a child who already had previous issues with constipation, this may then be exacerbated by the various changes that occur.

Additionally, in the digital age there are now new issues that are sadly affecting our children – less play time outside for multiple reasons: children’s safety, increased demands from increased school work, more time in front of the television, and greater time spent playing on devices. Our diets leave a lot to be desired too. People have less time to cook hearty wholesome meals, which means they resort to food that is quick and easy to cook, including take outs, foods low in fibre, or junk food. There is also the aggravation of children who have a sugar addiction – they don’t drink enough water and resort to drinking fizzy drinks.

Together, these factors lead to both weight issues and constipation.


Red flags:

• Encopresis – this is faecal incontinence when the child was continent before

• Constipation that is difficult to manage

• Vomiting (yes, especially if it is green)


Ultimately, this is a vast topic with many nuances. If it were a minor issue there would not be more than 12 million sites online about how to treat it. However, I can say that often the cause for the constipation is not related to anatomical abnormalities but rather to a combination of various environmental factors. Having said that, children who have severe constipation can become severely affected – abdominal pain and cramps, decreased concentration at school, encopresis, anxiety, and even multiple absences from school (and from work for the parents) because of repeated admissions to hospital. If there is any doubt or concern, parents should rather seek medical attention to help treat a very real but treatable condition, and if there are any red flags, please seek medical attention for your child.


After graduating from UCT in 2007 and completing her internship training in Johannesburg, Caroline Zabiegaj-Zwick returned to the Western Cape in 2010 and began working at the Red Cross War Memorial Children’s Hospital as a medical officer in the trauma front room before accepting a position at Tygerberg Hospital in paediatric surgery. After six years of training, Caroline attained her Fellowship in the College of Paediatric Surgery in South Africa in 2016, as well as a Masters’ in Medicine in Paediatric Surgery from Stellenbosch University in the same year. After completing her studies, Caroline took some time off to have a baby, and has since been working in private practice, mainly at N1 City Hospital, but also offering a paediatric surgical service to several hospitals in Cape Town. She also helps with theatre lists, clinical duties and teaching at both Tygerberg Children’s Hospital and Red Cross War Memorial Children’s Hospital. Caroline’s special interests in paediatric surgery include neonatal surgery, hepatobiliary and oncology surgery. For more information, call

021 000 2353 or email reception@capepaediatricsurgery.co.za

Seventeen - April to June 2018

Seventeen - April to June 2018

This article was featured on page 26-27 of Babys and Beyond Seventeen - April to June 2018 .

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