6 yo Girl with Chronic constipation

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Welcome! Forums 6 yo Girl with Chronic constipation

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    • #1563
      Rebecca Pilkington
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      Constipation started in South Africa on holiday 6 months ago. Unsettled time and is an anxious girl, who struggles with change. Constipation with 8-10 accidents, which can vary from slight markers in the pants to needing a change. GP put her on 1 sachet of Movicol p/day, 2nd doc increased this to 2 p/day with lactulose.

      Now under paediatrician and on 8 sachets plus 5ml sodium picosulphate p/day, and introduced regular toilet times that have helped. Dropping sachets 1 p/wk but symptoms have reverted and now having frequent accidents.

      Child seems to have lost ability to know when she needs to pass a bowel movement and mother can get called to school due to accidents, which isn’t helping the anxiety. At 5 years old saw a urology consultant as was having similar situation but 5 wee accidents p/day.

      Emergency c-section baby and 10 days of breastfeeding before formula was introduced. Antibiotics at 20 months for respiratory infection.

      Working with an osteopath due to emotional outbursts and this is helping.

      Diet has vegetables and fruit rich in fibre such as apples. Child loves food and very good weaner. Have put on dairy free diet and ran a GI effects stool test with results below:

      Faecal fat – triglycerides 3.3 high
      Faecal secretory IgA 627
      SCFA 39.3
      n-butyrate 28.5
      Beta-glucuronidase DL
      Gastrointestinal microbiome
      Those high include:
      Bacteroides prevotella, bacteroides vulgatus, Odoribacter spp., Faecalibacterium prausnitzii, pseudoflavonifractor spp, veillonella spp
      Low in ruminoccus spp.
      In culture, klebsiella pneumoniae and bacillus species non pathogenic at 2+
      Lactobacillus and e.coli NG, No parasites detected

      Any thoughts appreciated.

      Posted by Rebecca Pilkington on 23/05/2016

    • #1625

      Hello Rebecca,

      Thank you for posting this question here. I am glad that this family has sought out support from you with their daughter’s chronic constipation, and that they have been working with their paediatrician and an osteopath as well. Although it sounds like the osteopath is doing some work with the emotional issues that may be underpinning her symptom of constipation, there may be value in seeing a counselor or child psychologist as well.

      There are many items in this child’s history which highly suggest a poor state of gastrointestinal health: emergency C-section birth, minimal breastfeeding, and antibiotic use at a young age. Children born via C-section have been found to lack Bacteroides spp. while children subject to frequent antibiotic use are less diverse in terms of both bacterial species and strains. The absence of breast feeding can further contribute to an altered microbiota. Of course, many of these things cannot be changed, and were likely chosen due to necessity at the time. But moving forward it is important to know that these all contribute to the balance of flora in the gut particularly during the first few year of life, and the impact beyond this is largely unknown. However, we all know quite well that the gastrointestinal microbiome is not a system separate from the other systems of the body, and affects mood, immunity, and much more.

      Rutayisire E, et al. The mode of delivery affects the diversity and colonization pattern of the gut microbiota during the first year of infants’ life: a systematic review. BMC Gastroenterol. 2016 Jul 30;16(1):86. http://tinyurl.com/h82vaf8

      Yassour M, et al. Natural history of the infant gut microbiome and impact of antibiotic treatment on bacterial strain diversity and stability. Sci Transl Med. 2016 Jun 15;8(343):343ra81. http://tinyurl.com/h3sh9c5

      Azad MB, et al. Impact of maternal intrapartum antibiotics, method of birth and breastfeeding on gut microbiota during the first year of life: a prospective cohort study. BJOG. 2016 May;123(6):983-93. http://tinyurl.com/zkmeqf8

      Although the laxative combination of Movicol and sodium picosulphate is currently resolving the constipation, both of these things are treatments I would definitely want to eliminate as soon as possible. Sodium picosulphate is a stimulant laxative and overuse of stimulant laxatives can lead to dependency. Movicol is a preparation of polyethylene glycol (PEG) which is often used without abandon for paediatric constipation as it is felt to not be bioactive or absorbed. However, I have seen children who were subject to long term use of a PEG-type laxative develop various complications ranging from haematuria to a PEG-related sensitivity and seizure disorder with exposures. Although these are only my clinical experience and many paediatricians would argue that they are both very safe, the existence of many parent’s groups opposed to PEG-derived laxatives would suggest otherwise.

      Anxiety is a very common contributor to gastrointestinal symptoms. As her symptoms of constipation did exist prior to her travel to S. Africa, I would suspect it as a primary contributor rather than the possibility of travel-related dysbiosis. I often see treatments geared at resolving anxiety be very effective in improving gastrointestinal symptoms particularly in paediatrics. They are much more sensitive to their environment, and are less likely to “override” their instincts than adults. Adults often continue to overwork or use substances, etc., which impede the correction of underlying emotional issues driving health conditions.

      Stress is connected with digestive function as the vagus nerve/acetylcholine place a role in moderating its function. The vagus nerve is parasympathetic controller of digestive tract and heart – with stress the sympathetic to parasympathetic balance weighs on the side of sympathetic tone. Thus therapies that support parasympathetic balance can be of use. Activities that support the vagus nerve are belly breathing and gargling among other things.

      The gastrointestinal microbiota also plays a role in supporting normal gastrointestinal motility, as many of the neurotransmitters which are often thought of in an isolated setting of mental health are produced and active here. The microbiota can influence the enteric nervous system activity by producing molecules that can act as local neurotransmitters, such as GABA, serotonin, melatonin, histamine and acetylcholine and by generating a biologically active form of catecholamines in the lumen of the gut.

      Carabotti M, et al. The gut-brain axis: interactions between enteric microbiota, central and enteric nervous systems. Ann Gastroenterol. 2015 Apr-Jun;28(2):203-209. http://tinyurl.com/gvhrf4n

      Asano Y, et al. Critical role of gut microbiota in the production of biologically active, free catecholamines in the gut lumen of mice. Am J Physiol Gastrointest Liver Physiol. 2012 Dec 1;303(11):G1288-95. http://tinyurl.com/hjenoy3

      A couple things which may improve anxiety and can be used in children include magnesium, L-theanine, gamma-Aminobutyric acid (GABA), and 5-Hydroxytryptophan (5HTP). Some of these things such as 5HTP and magnesium may directly impact constipation apart from their effect on the central nervous system. Magnesium, as an osmotic laxative, is well recognized for this effect. Gradually substituting magnesium for the Movicol may be effective as you work with the other factors contributing to constipation.

      Herbal and nutritional combinations also exist which stimulate the migrating motor complex. I use nutritional/botanical combinations for this purpose in my practice when indicated. The combination I use most often for individuals with constipation due to poor motility contains 5-hydroxy tryptophan (5HTP), vitamin B6 (pyridoxal-5-phosphate form), acetyl-l-carnitine, in combination with a fairly high dose of ginger.

      5-HTP stimulates enteric neurons through activation of 5HT4 receptors. Acetyl-l-carnitine supports autonomic neuronal health and contributes acetyl groups for the synthesis of acetylcholine, supporting neurotransmission of signals to encourage healthy motility. Pyridoxal 5’ phosphate is a cofactor for 5-HTP decarboxylation to serotonin. Ginger is a digestive antispasmodic, anti-inflammatory, and also supports circulation. As children often do not take capsules and do not like the heat of ginger, an alternate of papaya may be appropriate. 5HTP and B6 are also supportive to the reduction of anxiety.

      McCarty MF. High-dose pyridoxine as an ‘anti-stress’ strategy. Med Hypotheses. 2000 May;54(5):803-7. http://tinyurl.com/zty76ka

      Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Altern Med Rev. 1998 Aug;3(4):271-80. http://tinyurl.com/zw8wfb7

      The ileocecal valve (ICV) is a little-known valve located proximal to the appendix. The ICV separates the ileum – the last part of the small intestine – from the cecum, the first part of the large intestine. Normally, the ICV is closed in its relaxed position, and opens only to pass food bolus from the small intestine to the large intestine. The ICV is an important barrier to reflux of colonic material from the colon into the small intestine. In the case of an abnormally open or closed ICV, there is an increased likelihood for small intestine dysbiosis due either to the backflow or prolonged holding time of small intestinal material. More on the Clinical Education group pertaining to the ICV function can be found here – http://tinyurl.com/z5bye4g.

      There are visceral manipulation techniques which specifically address ICV dysfunction. Some videos showing how this can be done which your client may find helpful are here – http://tinyurl.com/nxq8zsj & http://tinyurl.com/qgrvx46. Watching these videos yourself and speaking with her parents about performing them in conjunction with castor oil packs may be very effective at improving her constipation.

      Topical castor oil applied to the abdomen and right upper quadrant of the liver are very supportive for supporting gastrointestinal healing and resolution of constipation. Dr. Todd Born recently wrote about the many benefits of castor oil which can be read here – http://tinyurl.com/kqsrfga. I generally instruct clients to use a simplified castor oil pack by simply massaging castor oil into the region, applying a cotton cloth to protect other garments from the oil, and using the body heat to draw the oil internally. With constipation gentle massage in a circular pattern working up the ascending colon, across the transverse, and down the descending is also recommended. A warm water pack may also be applied for a period of 15 – 20 minutes. Children generally are very receptive to this and the aspect of touch is also very therapeutic.

      Elimination of dairy can help resolve constipation for many children, and I am glad you have suggested they try this. Additionally, many children do not drink sufficient water, and improving water intake can greatly improve constipation. It is wonderful however that she loves fruits and vegetables, and continuing to encourage the consumption of high fiber nutrient dense foods will have lifelong benefits. You may wish to suggest they utilize the probiotic combination with stewed apples as she has been shown to have low levels of normal flora. More information about how stewed apples in combination with probiotics support mucosal healing and tolerance (as well as the recipe) can be found here – http://tinyurl.com/o9kpezx.

      I also use homeopathy and occasionally flower essences in my office, and these can be very supportive to improving anxiety and response to transition. Recommending they seek support from a colleague that uses these modalities if you do not may also support them.

      The following supplements are suggested for you to consider in light of your relevant expertise and understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for. Dosages listed here are appropriate for a child of approximately 30 kg.

      200 mg of Zen (ARG): 1 capsule 2-3 times a day. http://tinyurl.com/89vstsf Supports reduction of stress overall and prior to meal consumption, as well as GABA/glutamate balance.

      OR

      Liposomal Zen (ARG): 2 – 4 pumps as needed up to three times a day. http://tinyurl.com/ljaxow4 Supports reduction of stress and anxiety.

      Caricol (ARG): 1 sachet 20 minutes before food. http://tinyurl.com/pr69u3a Supports reduction of gastrointestinal inflammation, protein digestion (if taken with meals), and stool pattern normalization.

      For use with stewed apple recipe:

      Saccharomyces boulardii (ARG): 1 capsules. http://tinyurl.com/35392bw Open capsule and sprinkle on the top or swallow separately. Do not heat.

      Culturelle® Lactobacillus GG (ARG): 1 capsule. http://tinyurl.com/66yuha6 Open capsule and sprinkle on the top or swallow separately. Do not heat.

      Bio-Bifido BacT (BRC): ½ – 1 tsp. http://tinyurl.com/n9n56wv Sprinkle on the top or swallow separately. Do not heat.

      Combination therapy for support of motility (supports serotonergic and cholinergic neurotransmission in the GI tract):

      Neuro-5-HTP Plus (BRC): ½ – 1 capsules in evening. http://tinyurl.com/p7ozwdq Supplies 5HTP (25 – 50mg), B6 (5-10mg), and small amount of L-theanine (25 – 50mg).

      AND

      Acetyl-L-Carnitine (ARG): ½ – 1 capsules (250 – 500mg) in evening with Neuro-5-HTP. http://tinyurl.com/m4gyeg5

      AND

      Caricol (ARG): 1 stick after meals. http://tinyurl.com/p5gjrkk Source of fermented papaya.

      AND

      Topical castor oil with gentle massage nightly and ICV manipulation once weekly.

      Please consider these suggestions in light of the other clinical information pertaining to this individual. If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.

      In health,
      Dr. Decker

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