To insist on a referral or am I over reacting?

[Fcukthisshit]

My 2.5 year old Dd has suffered with severe constipation since she was tiny. I’ve been back and fourth to the GP with her numerous times and I feel like I’m being fobbed off with a prescription for laxatives. She has a good diet, with plenty of fibre and lots of exercise. An average day food wise looks like this:

Breakfast - baked beans and cheese on wholemeal toast and an orange.

Lunch - ham sandwich on wholemeal bread, a few crisps, cherry tomatoes and cucumber sticks, a biscuit and some grapes.

Tea: Bolognese made with beef, lentils and chopped veg, wholemeal pasta and cabbage

Snacks: lots of strawberries or blueberries (sometimes a punnet a day) a banana milkshake, an Ella’s kitchen prune pouch (Normal prunes are one of the few things that she won’t eat) and she has milk before bed.

We are currently using movicol but I feel like she shouldn’t need laxatives at all really with her diet. Yesterday, she hadn’t been for 4 days and she was in an awful lot of pain when she finally went. It’s horrible seeing her in so much pain.

The plan is to book another appointment with the GP and take a food diary, but WIBU to insist that they refer DD this time?

I’ve been putting off starting potty training for a while now as I don’t want to make things worse but she’s due to start nursery in August so I really need to get that cracked.

Poor you.

Constipation has always been linked to not getting enough fluids, in my experience. Does she drink a lot? Sorry if that sounds patronising at all - my ds really suffered as he wouldn’t drink water.

Has she been tested for gluten intolerance? Bread twice a day and pasta for tea when you have an intolerance could be the biggest issue. However, that’s something you’d have to talk to the doctor about, be careful about taking advice online.

Ditto the suggestion re water. She does need to be drinking plenty, so I would focus on that.

But failing that, try to see a dietician.

That's wheat three times a day, and minimal other carbs.

Firstly, has she been checked for coeliac? It can present atypically. Secondly, even without having coeliac, people be intolerant to wheat. Try substituting oats and other grains, (without trying to go gluten-free) and potatoes and other roots, to see whether this helps. It could take some weeks, while continuing with laxatives, to see any difference.

What laxatives is she taking? Regular or as needed? IME regular Movicol is better than Lactulose. Two of mine have had constipation problems, one before toilet-training and one after.

The younger one could not toilet-train until the constipation was resolved. Excessive wheat was partly to blame, wholegrain being the worst. Even now, at 18, they lay loo-blocking logs after wheat-heavy days.

The older one was on Movicol for several years, with regular disimpactions. Diet did not seem to make much difference to them.

Your dc does not need to be toilet-trained to go to nursery.

Even if you get a referral, a specialist will definitely get her on to a high dose of laxatives straight away. It was explained to me that babies and young children can naturally have a slow transit, making them v prone to constipation, not necessarily related to diet, and unlikely to be an underlying medical condition. Once a child has become badly constipated once, the bowel stretches, causing more and more faecal impaction, leaking round the blockage and a terrible vicious circle starts.
The answer is a proper clear out (look up Movicol treatment for faecal impaction), then a reasonable dose of Movicol ( at least two sachets a day) for AT LEAST a year. This is the only thing that will allow the bowel to return to normal size and stop the cycle.
My daughter's very good paediatrician explained all of this to me, and he was right and my daughter has now recovered from chronic constipation.
Don't think of laxatives as the enemy, Movicol does not harm you. The consultant explained that for a child with chronic constipation, all the fibre in the world will not help them, only treating it will.
Good luck.

I thought gluten intolerance too BUT the other thing is that too much fibre can cause trouble too. And that's a fairly high-fibre diet there. Raw apple and pear can be good for constipation- include the skins- as they've a high water content. Porridge is also good as it's soluble fibre, which is easier to digest and therefore passes through the gut smoothly.

I'm not an expert but one of my cousins ended up in hospital aged 2 with a twisted bowel due to consuming far too much fibre. Fibre such as beans, pulses and brown pasta all in the same day is too much.

Your GP may not know but there will be a Paediatric Continence Team within your area, push to see them. Movicol was a magic cure for us but only when the doses were altered frequently according to their sliding scale, I spoke to them every couple of days. It was a life-changing referral. Good luck.

I really struggle to get her to drink water, so I’m giving her very weak sugar free squash (on suggestion of the health visitor) which she drinks a reasonable amount of but I agree, probably not enough - I do remind her to drink a lot.

Donelikeakipper - she hasn’t been tested for anything yet. I will mention gluten intolerance to the GP, although the above is just an example day - I’m lucky that she eats brilliantly so it’s easy to give her a variety. She has bread probably 2 - 3 times a week and pasta once or twice.

I agree that rather counterintuitively she may be having too much whole fibre. Whole fibre needs lots and lots of water to soak it up or it can cause issues - which is why fully high fibre diets are not normally recommended for small kids.

Have they given any diet advice? I would be tempted to ask to see a dietician.

Jelly is a good way of getting fluid into a drink-refuser. You could also try herbal teas. Not green tea, it's high in caffeine. But there are lots of very flavoursome fruit teas and herbal teas that might appeal. My eldest refused water at first, but happily drank chamomile tea and fennel tea. They all brew well in cold water, you don't need to pay a premium for anything specially designed for cold-brewing.

And further to my reply above, a referral to a gastro is a good idea, but don't assume they'll be looking for intolerances. In an otherwise healthy child, chronic constipation is usually just ordinary constipation not being managed properly. A specialist will get her onto a proper programme of management. Now that my daughters constipation has been properly treated, she has a perfectly normal digestion and certainly isn't intolerant to anything.

My dd also suffers with constipation. She’s three now and we’ve finally figured a regime with the movicol that seems to be working well and we’ve gone weeks without her getting bunged up. We’ll continue with this for a few months to give her bowel chance to shrink and keep moving.

I know what you mean about medicating your child but the pain and discomfort of constipation is much worse. It’s so difficult to control with diet because, well toddlers

My personal reservation about dissecting it too much at this age without any other symptoms is that as a previous poster stated it’s a common issue that is likely to resolve itself with age. You could go to a dietician and discuss trialling removing foods from her diet to see if there are any triggers but again, due to age, mild intolerances can resolve. I feel it’s almost going looking for problems that could mean unnecessary avoidance of foods in the future (please don’t start removing food groups without a good idea of how to replace what you’re taking away).

It has affected potty training though, partly because of the fear of pain and partly because horrible ‘overflow diarrhoea’ means dd would have to be on the potty more than she’s off it which isn’t a great appeal factor.

If you can crack it through diet then great but imho the aim is to keep pooing as pain free with as little stress as possible.

Home made ice lollies are an excellent way to increase fluid intake though!

What about prune juice mixed with water? My children liked it and I like juice plain prune juice. It’s not to everyone’s taste, but if she likes the sachets she may like the juice. Just a thought.

Fluids are what she needs. Whatever else might be wrong, getting more fluid down her will do no harm and may just do the trick.

Have you tried putting her drinks in something attractive - wiggly straw, or one of those bikers drinks bottle with long tubing.

Or give her ice lollies - you can make them yourself with fruit juice if you are unhappy about the sugar content of bought ones.

I am carer to my disabled OH and constipation is a problem for him so I get ice lollies.

Also lollipop, you make yourself, a little orange juice mixed with water, especially now for the summer, let her have as as many as she wants, as long as it’s not full of orange juice. Try with apple juice, and mixed fruit too, to mix it up a bit.

And I also agree that her diet is probably too high in fibre. If she is still constipated on Movicol then the dose isn't high enough and she may need a disimpaction.

Sorry I cross post with @Mishappening- great minds! Lol

DD was the same - drinking is absolutely key. I used to puree a small number of strawberries and she would make up 'magic juice' by herself by adding it to water.

Don't forget that too much fibre can also make constipation worse, it's a really difficult balancing act. I really sympathise.

Forgot to point out that investigations past observing dietary effects are incredibly invasive for diagnoses and it’s unlikely any doctor would advise more than laxatives and a dieticians advice without more symptoms or family history alerting them to a more serious condition.

Things like coeliac or inflammatory bowel disease can often take multiple investigations to reach a diagnosis and aren’t pleasant.

Drinks - honestly sugar free squash is not the devil - make it at normal strength and get her drinking at least 3-4 beakers a day. It will probably resolve the problem. I think she's constipated as having too much fibre and not enough liquid!

Try cutting gluten out for a few days and see if she improves! My DH gets very constipated if he eats a lot of breads/pasta's etc!

My first two kids suffered horrifically.
They both got piles by the age of 2 because of it.

We tried everything, Movicol was great. My second son was on it until he was 3-4.
We had to give him enemas it was so bad.

When I weaned him I started with broccoli and that was the first thing that constipated him. Who'd have thought?!

They are 8 and 12 now and still suffer occasionally.

Unfortunately it's just part of childhood. There's nothing wrong with my kids they just have sluggish bowels despite having really good diets.

@Jellyslice
Coeliac tends to show as diarrhoea not constipation.

OP- is she afraid of having a poo?

Not sure if anyone has mentioned this but some toddlers can hold it all in as they don't like pooing. If you make it an issue, she may be picking this up and being confused over whether pooing a is good or 'naughty'.

Has this been discussed?

DD had severe constipation. she was under a paed for different issues. they didn't do anything else apart from prescribing movicol. worth checken if she is allergic to gluten. DD wasn't allergic but we took gluten out and symptoms improved hugely. Paed thinks she may have a gluten intolerance (which doesn't show up on tests). but really, I don't think there is s point to get a referral..what do you think this will achieve?

Drinking more is a good idea but probably won't actually solve the problem as she is now chronically constipated and the bowel is likely to be stretched