Is there anything else that causes constipation in children apart from diet?

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Please help - I'm at my wits end and very confused. My son, (aged 3 and 3 quarters,) has been soiling himself for almost a month now. He does just a tiny bit, enough to smear his pants and smell, but seems not to know he needed a poo. He's been potty trained successfully for well over a year, so i don't know why he seems not to recognise the feeling now. When I sit him on a potty or toilet he doesn't/can't go. He will soil 3 or 4 times in one day, which is hard work with cleaning him up and keeping on top of washing pile. We have been to the GP 3 times now, the first time they said 'it might be leakage round some impacted poo, have some lactulose to soften everything and it will sort itself out.' The other two times they happily admitted to having no idea! My son is still on the lactulose, and if we forget or decide to try without, his poo does seem harder than it should be. But generally taking it or not makes no difference to the soiling.
He has a good diet, with plenty of fruit and veg, and has had no changes to his diet - is there anything else that could be causing him constipation? Does too much dairy do this?
What else could be causing all the poo accidents?
Help!!

Don't really have any expertise re children and soiling, but in adults constipation is often down to dehydration- you could try getting him to drink more? Other than that, have you talked to the health visitor?

too much dairy can do it, yes, if he has an intolerance to it

Is he drinking enough? Moving around a lot?

food ontolerance can cause bowel problems , both diarrhoea and constipation

He drinks a lot (much of it milk, but I have been watering this down) and he moves around a lot. Would a food intolerance start out of nowhere at almost 4 yrs old?

We find white bread helps cause constipation, Orange juice with breakfast normally has a positive effect

intolrances and allergies can start at any age I'm afraid.

Dairy and wheat are classic for intolerances causing constipation or diarrhoea

Ask for referral to the paediatric continence nurse.

I could have written your post word for word with dd1 (except she had been dairy intolerant as a baby and grown out of it.

I does in my (very inexpert) opinion sound like an impaction of some sort. When the bowel has been stretched (with any significant constipation it takes a long time to return to it's previous state (think months rather than weeks). DD1 now takes movicol ( much better than lactulose) she was on huge doses at the start but now has a maintenance dose of a sachet a day.

Another good resource is Eric Don't ignore it or get fobbed off anymore by Dr's with the right help it can and does improve!

Yes it could be dairy - was he an unsettled or windy baby?

If not, cut down the milk. He doesn't really need to drink that much now. Give more water and only milk at bedtime.

Consider coeliac disease too...

Yes I agree you should ask to be referred to a paediatrician or be given movicol to try. Movicol softens the poo so should help get any impaction out. My ds has been constipated since birth and although they are looking for a medical reason as they suspect something is wrong with his bowels, the paediatrician did say that generally it's the most common childhood complaint they see and they usually resolve themselves or grow out of it. Lots of fluid, exercise, fruit but no bananas. I would go back to gp.

Lots of smearing might indicate impaction. With the old hard stuff sitting in the bowel and any runny stuff seeping through. This creates a vicious cycle where it's sore to poo so the child holds in more. I'd ask for referral to paeds/continence services as you maybe need a stronger laxative (lactulose not actually a lax just a stool softener).

Also be really thoughtful about how you react to accidents. It's gross yes. But if you show your displeasure or yuck reaction it leads to more holding in. Never praise 'clean pants' or no accidents as again this encourages retention. Instead praise any poos which end up in the potty.

In my experience this can all start from nothing or a tummy upset and then gets into a vicious cycle.

Swap some milk for water. Even if no dairy problems/intolerance lots of milk doesn't help in the same way water does

Thanks all, very good advice! He does eat a lot of dairy, and bananas too!! I will switch us to orange juice and water. We do eat wholemeal bread though.
The leakage isn't particularly runny, (usually sticky or soft) so I wonder about impaction, but it could be that he is holding it in.
He was a windy baby, with silent reflux and we gave him meds for that for some months (and let him sleep on his front). But he has always been a regular, normal and frequent poo-er. It just changed overnight, with suddenly 12 poo accidents in 3 days and then continued..and nothing else has changed in his life. Most confusing. I reward him with a sweetie and lots of praise if he poos in his potty/toilet, and although I don't show disgust when he soils, I do admit I show some frustration. Will try harder to keep calm and breezy.
I will press for a referral i think.

Just been reading the ERIC site, thanks, that's a useful resource.

Are you or Dad bendy? If your dc is too then I may be able to help with the riddle.

Bendy? As in flexible? I'm most def not, sadly, and I wouldn't say that DH is either. Intrigued though!

There are links between autonomic, GI system disorders and hypermobility.

Does he drink enough? Could he drink maybe a little less milk and more water? Some foods can cause constipation, most notably bananas, rice, carrots. Foods which can help relieve constipation are prunes and especially drinking a lot of water.

There was a BBC program recently called 'Trust me I am a doctor' in which they reported that having every day oat porridge for breakfast shows after a six week period a significant increase of good bacteria in the gut, even more successfully then can be achieved with probiotic powders etc. So maybe worth considering if he likes oat porridge.

Don't think that is the case here, but useful info to know, as I have a good friend whose Dd is hypermobile.

Lovesewingbee - carrots? really? goodness me I wouldn't have guessed that one! Right, so cut down on milk, bananas AND carrots. Porridge for brekkie..if he'll eat it - what he likes to eat changes from day to day.

Yes, carrots, that is why you have to be careful when you give carrot puree when you are weaning. You also have to be careful with mushrooms as they can cause blockages in small children.

I also would be cautious with the orange juice. It is brilliant as a laxative but oh so bad for the teeth (natural sugars plus acid). Ideally after the orange juice he should drink some water or rinse his mouth with water. Under no circumstance brush teeth within 15 minutes of having eaten or drunk as you brush softened enamel away.

Thanks Lovesewingbee, I learn something new everyday. I will phone the Gp's tomorrow and ask for us to see a specialist or a paediatrician.
According to the ERIC site, if soiling and constipation problems are caught early enough then they can be helped much quicker. Fingers crossed.

I've been going through this with DD (3) the lactulose does seem to have mostly sorted out the soiling but I think the main issue is that when constipated pooing had probably hurt her and she was too scared to do a poo incase it hurts. She had a slightly red bum so the doctor prescribed a cream that has a numbing effect and we are getting there slowly. She agrees that it doesn't hurt anymore so hopefully she is on the mend. I agree it is very frustrating, I hope you get it sorted quickly.