Constipation in children with cancer

What is constipation?

Constipation is an abnormal pattern of bowel movements that causes a person to pass harder and smaller stools (poo), less often than usual. Constipation makes passing stools uncomfortable. In more extreme cases, there may be soiling (encopresis).

Everyone has a different bowel pattern. A normal frequency of stools can vary from several times a day to once every few days. If your child’s stools have become harder, smaller or the pattern has slowed down, they may be constipated.

With constipation, stool may build up in the bowels over time. This build-up can cause stomach cramps and pain. Often, children who are constipated will strain to pass smaller, hardened stools. Straining can potentially cause a tear in the anal region, which is painful and can put your child at risk for infection. Small soft smears (which can be frequent) or soiling on underwear may indicate that the rectum is blocked with a large, hard stool.

Some common causes of constipation in a child with cancer are:

• not drinking enough liquids or not eating a balanced diet due to not feeling well
• medications, such as pain medications (e.g., morphine), chemotherapy (e.g., vincristine) or supplements (e.g., calcium)
• inactivity because of not feeling well
• physical and social barriers (for example, holding stools because bathrooms are unavailable or hard to get to, or stools have become hard and painful to pass)

Treating constipation

If your child has not had a bowel movement for two or more days, your child may need medication to help them to have regular bowel movements. The goal is that they have at least one soft bowel movement daily.

• For children less than 6 months old, laxatives such as lactulose can be used to make bowel movements softer.
• For children over 6 months old, PEG 3350 powder (PEG Flakes, Lax-a-day®, Pegalax®, Clearlax®) or lactulose pull water from the bowel into the stool to help soften the stools and reduce straining. PEG 3350 is tasteless when dissolved in a drink or mixed with soft food. It can also be given through a feeding tube (such as an NG-tube or G-tube) diluted with water or mixed with feeds. PEG 3350 is available over-the-counter, without a prescription. Some children may need a prescription from their health-care provider for stimulant laxatives, such as sennosides (Senokot®) or bisacodyl (Dulcolax®) to have a bowel movement. These laxatives work by making the muscles around the intestines squeeze to push stool out. They may cause stomach cramps or loose bowel movements. Stimulant laxatives should not be used for greater than one week unless instructed by your health-care provider.
• Please consult your pharmacist or health-care provider about when and how your child should use these medications.

Things to avoid

• Do NOT use suppositories or enemas unless they are prescribed by your child’s health-care provider. In some cancer patients, suppositories or enemas may lead to bleeding, infection or other harmful side effects.
• Bulk forming laxatives (medicines that make stool bulkier and softer so they are easier to pass) such as Metamucil® or Benefibre® are NOT recommended because they take a long time to work and require your child to drink a lot of fluid.
• Only use stimulant laxatives such as sennosides (Senokot®) or bisacodyl (Dulcolax®) if prescribed by your child’s health-care provider.
• The use of mineral oil is not advisable because it can cause irritation to the lungs if aspirated.
• The use of probiotics and herbal formulations is not recommended. If you have any questions, please consult your pharmacist or medical team for information.

If your child begins to have large, loose or frequent bowel movements:

• Stop giving the laxative to allow your child’s bowel movements to become firmer or less frequent.
• If after stopping the laxative your child does not have a bowel movement for more than one day, restart the laxative at half of the previous dose.
• If you are unsure when to restart the laxative or of how much to give, call your child’s nurse during clinic hours.

Notes

My usual pattern of bowel movements is: __________________________________

My usual laxative of choice is: __________________________________

My dose is: __________________________________

My stimulant laxative is: __________________________________

My dose is: __________________________________

How to prevent constipation

To prevent your child from experiencing constipation, the following strategies may be used:

• increasing the amount of fibre in your child’s diet with foods such as bran, fruits and vegetables (e.g., figs) and prune juice
• increasing fluid intake — the dietician looking after your child can review the amount of fluid your child needs
• encouraging exercise and movement when your child is feeling well
• establishing a regular bowel routine at home and in the hospital
• being aware of your child’s usual pattern of bowel movements so that you can start the laxative early to prevent constipation
• using a support to bring your child’s knees higher than their hips when they are trying to have a bowel movement

You should call your doctor if you notice that your child has:

• blood in the stool. This can look like red blood, blood on underwear or a sticky tar-like substance (digested blood).
• stomach cramping, pain that does not go away
• fever
• loose or watery bowel movements
• rectal pain

Take your child to the nearest Emergency Department if:

• your child develops severe abdominal pain
• your child is vomiting (throwing up) repeatedly or vomiting dark green material (bile)
• your child’s abdomen (belly) becomes swollen