30.1 Introduction
After the definitive correction of anorectal malforma- tions (ARM), two different new diseases frequently occur: chronic constipation and stool incontinence.
Chronic constipation is sometimes associated with smearing, staining, or overflow incontinence, which should not be confused with true incapability to re- tain stools due to an insufficient sphincter mecha- nism. Digital and electromanometric investigations under resting and squeezing conditions are very help- ful for the differentiation. According to Holschneider et al., only 11.8% of the high-, 22.7% of intermediate-, and 63.3% of low-type malformations became com- pletely continent without need of any additional help [1]. Total continence corresponds to the continence behavior of a healthy person who does not soil, does not have constipation, and can regularly and volun- tarily have bowel movements. Another group of pa- tients become continent with some aid, which means they need occasionally a light constipating diet or laxatives for the regulation of their stools. 23.5% of the patients with a high, 13.6% of children with an intermediate, and 22.7% of cases with a low type of imperforate anus behave this way. Taking these two groups of patients together, 35.3% of the high-, 36.3%
of the intermediate-, and 86.3% of the low-type anal atresias became acceptably continent. In the literature this behavior is usually called “good continence”.
The so-called “satisfactory results” in the litera- ture involve two groups of patients: children who are
chronically constipated and patients with a partially incompetent sphincter. However, the problems of the patients in both groups can be managed sufficiently by conservative means. Only the last small group in Holschneider’s new classification [1], the “bad re- sults” with complete therapy-resistant fecal incon- tinence need surgical therapy either due to untreat- able chronic constipation or complete incompetence of the anorectal sphincters. The surgical therapy for incurable constipation is described in Chap. 32 and consists of resection of a megarectum. In contrast, complete insufficiency of the anal sphincters needs strengthening, sometimes of the external anal sphinc- ter muscles, by a continence-improving operation, which will be described in the Chap. 31. This very unsatisfactory group of children comprises 20.6% of the high-, 9.1% of the intermediate-, and 4.5% of the low-type malformations.
The largest group of patients is, as mentioned above, the so-called “satisfactory results.” The conti- nence behavior of these patients is, per se, not satisfac- tory at all. They consist of two different, postoperative newly appearing diseases, which have to be treated by different therapeutic means: chronic constipation and stool incontinence.
Fecally incontinent patients suffer from hypopla- sia of the muscle complex and an absence of smooth muscle fibers. For this group of patients, the diet must be constipative (e.g., bitter chocolate with 70% or more portion of cocoa, blueberries, bananas, apple pie, and carrot soup). Carrot pie however, may have a laxative effect due to its high amount of cellulose.
Administration of activated carbon for medical use or loperamide, or the use of soft anal tampons after suf- ficient bowel cleaning may help.
Chronic constipation needs a totally different diet.
The definition of the term constipation is difficult and imprecise. If bowel movements are only possible when the patient exerts the utmost pressure or after convul- sive cramps, if there is a sensation that the bowel has not been completely emptied, if the stools are hard, if no bowel movements occur for a period of 3–4 days, or if an overflow soiling occurs, all of these occur-
Contents
30.1 Introduction . . . 385 30.2 Dietary Fiber . . . 386 30.3 Dietary Stimulants . . . 387 30.4 Lifestyle . . . 388
30.5 Weaning . . . 388 30.6 Laxatives . . . 388
30.6.1 Slow-Transit Constipation . . . 389 References . . . 390
30 Dietary Prevention of Constipation
Petra Stommel and Alexander M. Holschneider
rences are referred to as constipation [2,3]. Overflow soiling is the most common sign of chronic constipa- tion in children after ARM repair. Rectal examination shows an impacted rectum that cannot be evacuated completely. The first therapeutic procedure described in Chap. 29 consists, therefore, of rectal washouts, as described in Chap. 31. After cleaning of as much colon as possible, either retro- or anterogradely, a laxative diet should be administered. This diet should take into account the underlying reasons for the constipation.
Constipation can occur in an acute form (e.g., due to a change in diet when traveling, after febrile illnesses, after being bedridden for some time, because of lo- cal anal complaints, or after taking medication). They can occur, for example, if too little food is ingested, if insufficient roughage is consumed, if the amount of ingested liquids is insufficient, if the defecation stimu- lus is repressed, if the patient uses too many laxatives over longer periods, and/or if the patient has too little exercise. A medical examination will be necessary to clarify whether we are dealing with an acute and/or a chronic disorder, or if the constipation is the result of organic disease, (e.g., Hirschsprung’s disease, dysgan- glionoses, or anal stenoses). The most frequent cause for chronic constipation in ARM are inborn motility disorders of the extra- or intramural nerve supply to the rectum, malformations of the rectal smooth mus- cle structure, or damage to the neuronal or vascular supply of the rectum during surgery. Whatever the reasons for the digestive complications, an optimal diet can have positive effect on constipation [3,4].
The best effect is achieved by a combination of dif- ferent factors. These may include treatment of the un- derlying disease, a diet calculated to loosen the stools, drinks, bowel training, and exercise.
30.2 Dietary Fiber
Roughage, or fiber, plays an important role in the passage of chyme. Roughage increases the digestive juices in the gastrointestinal tract. In the intestine the roughage swells due to its absorption of water.
It serves as a culture medium for the bacteria in the colon, allowing them to multiply more quickly and contribute to the volume increase. The breakdown of the fibers by bacteria creates gases and acids, which in turn stimulate the peristalsis of the intestinal wall.
The consistency of the stools becomes softer, and the distension of the intestinal wall and increased pro- pulsive motility shortens the transit time and reduces water resorption.
For roughage to have the optimal effect, it is im- portant to drink enough liquids. Children between the ages of 1 and 4 years should drink at least 950 ml, children between 4 and 10 years of age should drink at least 1100 ml, between 10 and 13 years at least 1200 ml, and children between 13 and 15 years at least 1300 ml [5,6]. The more roughage the food contains, the more should be drunk. It is also important to in- crease the fluid intake if there is increased sweating, for example during sports. Insufficient fluid intake may lead to bowel obstruction. Mineral water, still mineral water, unsweetened fruit tea or herbal teas, and sugar-free fruit juices diluted with mineral water are all suitable. The amount drunk can be monitored using a checklist. Certain types of receptacles, drink- ing bottles, or jugs are useful aids to monitor fluid in- take. To begin with, the current fluid intake should be monitored by recording all fluids ingested and then the amounts should be slowly increased until the de- sired daily amount is reached. Milk is not considered as a drink, but as a liquid meal. Too much milk often results in too little being eaten or drunk.
Roughage is indigestible vegetable material, which can be found in leaves, fruits, or roots. It is also re- ferred to as raw fiber, vegetable fiber, or indigestible carbohydrate. Roughage cannot be broken down by digestive enzymes, but it can be partially broken down by the bacteria in the colon. The most impor- tant types of roughage are water-insoluble cellulose, lignin, and the partially water-soluble hemicellulose, together with water-soluble pectins. No single type of roughage is an essential food; however a certain amount of roughage is indispensable, beginning in the second half of the 1st year of life at the latest, to ensure that the bowel functions properly [7,8].
Nonpurified vegetable fibers are the fibers found in cereals, fruits, and vegetables. Purified vegetable fibers are fibrous and polymer substances such as lignin, cellulose and pectins, if they are ingested alone. These must be differentiated from synthetic fibers, such as crystalline cellulose, lignin, and cellulose, which are used in synthetic products. They are referred to as fill- ers because they have only a limited ability to swell.
Hemicellulose and pectin are both bulking agents;
however, pectin absorbs more water. Vegetable food- stuffs usually have less than 15% roughage. The decla- ration of the raw fiber content of foodstuffs in nutri- tional indices always refers to cellulose, hemicellulose, and lignin [7,8].
To increase the roughage intake, the amount of veg- etable foodstuffs should be increased and the amount of animal products ingested should be reduced. This
will result in a mechanical stimulation of the bowel.
An increase in roughage can be achieved not just by increasing the percentage of vegetable foodstuffs ingested, but also by choosing products with more roughage. As fruits and vegetables largely consist of cellulose, such a substitution is limited, because the roughage in fruits and vegetables, with the excep- tion of pulses, is only around 1–3% [7,8]. Berries and dried fruits have the highest roughage content. The vegetables with the highest amount of roughage are green peas, leeks, cabbages, and pulses; however, they are also more indigestible and can lead to flatulence.
One should eat four to five portions of vegetables, uncooked vegetables, salads, fruit, and/or fruit juices every day.
Cereals consist in the main of hemicellulose that has a high capacity to absorb water. If wholegrain, multigrain, or wholemeal breads, pumpernickel, Graham bread, crispbread, or products such as gra- nola, linseed, wholemeal gruel, wholemeal noodles, or brown rice are eaten instead of white bread, the roughage intake can be increased without increasing the size of the portions.
The roughage intake can also be increased by eat- ing wheat bran, oat bran, or products containing wheat or oat bran. The volume of chyme is increased by the coarse bran’s capacity to bind water and swell.
Products made with coarse meal are more effective than those made of finely ground meal or bran flour, as their water absorption is limited. Wheat and oat bran are both available as supplements that can be added to granola and can be purchased either roasted or crisped.
Due to the hydrophilic nature of bran, ingesting around 5–10 g bran will require an additional 200 ml of liquid to be drunk; in other words, after the inges- tion of bran it is important to drink enough. If it is not possible to ensure sufficient liquid intake, then the bran should be soaked prior to consumption, for ex- ample in water or juice. If sufficient amounts of liquid are ingested together with the bran, the time required for passage can be reduced. Bran can also be added to milk products, compotes, soups, and stews, and even to dishes with minced meat, to potato dumplings, and potato pancakes [4,9].
Various roughage supplements with different ef- fects are available. These supplements have a high capacity to bind water and can increase the mois- ture content in the stools, increase the volume of the stools, and/or serve as a nutrient substrate for colon cells. The choice of supplement is an individual deci- sion [4,9,10].
Nuts, almonds and sesame seeds also contain rela- tively high amounts of roughage and can promote the passing of stools.
Foodstuffs made of very finely ground meal (for example white bread rolls, toast bread, milk bread rolls, cake, and biscuits), are very unsuitable because these foodstuffs contain very little roughage. Other products with little roughage are noodles made of semolina wheat flour, white rice, desserts, sweets, and confectionery [10].
Foodstuffs that consolidate the stools, such as ba- nanas, blueberries, boiled carrots, rice, low-fat curd cheese, hard-boiled eggs, cocoa and black tea, should initially be avoided. If the symptoms improve it may be possible to reintroduce them.
30.3 Dietary Stimulants
In addition to the mechanical stimulation provided by roughage, a chemical stimulation may also im- prove bowel peristalsis. The laxative effect of lactic acid, for example, is well known. It has an impact on intestinal motility via the bacterial flora and shortens the transit period. Lactic acid is found in yogurt, but- termilk, soured milk, kefir, vegetables that have been pickled, such as sauerkraut and pickles, and vegetable juices such as sauerkraut juice or red beet juice. Other organic acids, such as the tartaric acid found in grape juice, malic acid, which is found in grape juice but also in the juice of pip fruits and stone fruit, especially in apple, prune or fig juice, the citric acid in citrus fruits, and the acetic acid in wine vinegar are also believed to improve intestinal peristalsis.
Lactose or concentrated sugar solutions made of lactose also stimulate intestinal motility because lac- tose is digested more slowly than sucrose (normal sugar) due to the physiologically reduced activity of lactase in the small intestine. If larger amounts are in- gested the lactose will reach the intestine without be- ing digested. The laxative effect is due to the increase in the amount of liquid because of the osmotic activ- ity of the lactose. The increased distension stimulus in the colon leads to an increase in intestinal motility.
Lactose is partly broken down in the colon by bac- teria in a similar manner to water-soluble roughage.
This results in the creation of short-chain fatty acids, such as lactic acid, acetic acid, and formic acid, and carbon dioxide. In addition to the increased motility because of intestinal gas formation, the short-chain fatty acids help regenerate the intestinal mucosa and create an acidic intestinal milieu. Intestinal bacteria,
such as lactobacilli and bifidobacteria, which prefer an acidic environment, multiply more rapidly, reduc- ing the numbers of pathogenic organisms.
Sugar substitutes such as fructose, sorbite, sorbitol, mannitol, and xylitol also have a laxative effect. Their resorption is passive and therefore slower than that of glucose, which has an osmotic effect. Flatulence is a frequent side effect. Here again, it is important to gradually increase the dose.
Thermal stimulation through cold drinks, for ex- ample one glass of cold mineral water or fruit juice drunk before breakfast on an empty stomach, can have a gastrocolic effect. Cold food or drinks in the small intestine can improve colonic peristalsis.
Carbonated drinks can also accelerate the progress of chyme through the intestine.
In addition to gradual changes in diet so as to in- clude more roughage and a sufficient amount of fluids, it is necessary to consistently train the intestine until it reacts with a normal defecation reflex. Defecation training should be carried out at certain fixed times of the day, preferably 30 min after breakfast, lunch, and dinner. Active pressing, carried out every day at the same time, together with sufficient calm, should accustom the bowel to being voided. This requires practice and does not work on command. If the urge to defecate occurs at a different time, it should on no account be suppressed.
30.4 Lifestyle
Modern life is often characterized by a lack of exer- cise. This means that muscles are exercised less. The measures outlined should ideally be combined with regular sports activities and other types of exercise.
This will stimulate the metabolism, which in turn will also stimulate intestinal activity. A stomach massage using slow, circular, clockwise movements or damp, warm compresses may bring some relief.
At the beginning of the change in diet there may be some abdominal discomfort, which will take the form of flatulence and spasmodic cramps due to the for- mation of intestinal gases, but this can be expected to disappear after some time. It is possible to make food more digestible by thoroughly chewing it, making sure that meals are unhurried, and ensuring that there are sufficient rest periods between meals. It is best to be- gin with more easily digestible foodstuffs such as fruit purées, boiled vegetables, salads, oatmeal, and bread made of more finely ground wholemeal. Flatulence or a feeling of fullness can be relieved by drinking fennel
tea, caraway tea, fennel-caraway-aniseed tea, or mint tee, or caraway can be added to food during cooking.
From infancy on a child should be given a varied mixed diet which should include products made of wholemeal, potatoes, vegetables, fruit, and curdled milk products. Sweets, cookies, cakes, and ice cream should not be forbidden, but they should make up only a small part of the daily food intake. A list of the appropriate amounts of food depending on the child’s age can be obtained from the Research Institute for Child Nutrition or the German Society for Nutrition (Table 30.1).
30.5 Weaning
The possibilities available during the 1st year of life are much smaller. In breastfed babies who re- ceive only breast milk, normal bowel movements may range from several times a day to once every 10 days, because breast milk is very digestible [2]. If the baby is given formula, it is important to ensure that the choice of formula is appropriate for the baby’s age, that the formula is properly prepared, and that the baby receives the optimum daily amount at the proper intervals. These points must all be resolved before attempting to loosen the stools by giving the baby lactose, germ oil, or medium-chain triglyceride oil. The digestive tract of a baby is not yet fully devel- oped and cannot fully resorb larger amounts of fat, so fat allows the chyme to slide more easily through the bowel. When beginning with solids it is important to avoid giving the baby foodstuffs that will consolidate the stools. The solids given at lunch can be prepared once or twice a week using wholemeal noodles or brown rice instead of potatoes. Wholemeal flakes and fruit purées should be used to make the evening por- ridge of milk and cereals. It is very important to en- sure that the baby drinks sufficient amounts of liquid in the form of fruit tea or water. The more solid food the baby is fed instead of milk, the higher the liquid intake should be.
30.6 Laxatives
Many different laxatives exist and different groups have different effects. Laxatives should not be given indiscriminately, but only after consultation with a doctor and for short periods of time. They do speed up the passage of food through the bowel and result in defecation. If they are the only form of therapy
used without any corresponding change in diet or lifestyle, they will not be effective in the long term.
Inappropriate use may result in complications such as fluid imbalance, loss of electrolytes, and disturbances of the acid-base metabolism. If laxatives are taken to supplement the altered diet and lifestyle, they should not be stopped abruptly, but gradually phased out.
30.6.1 Slow-Transit Constipation
If constipation is caused by intestinal neural dysplasia or slow-transit constipation, a diet with large amounts of roughage may be contraindicated. Due to the lack of distension stimulus the bowel peristalsis will not be sufficient for the passage of chyme. In this case it is important that the child receives a laxative diet with very little roughage.
As mentioned above, a laxative effect can be elicited by:1. Acids, such as lactic acid, wine vinegar or cider
vinegar, and citric and acetic acid.
2. Carbonated drinks.
3. Thermal stimulation.
4. Lactose.
Fig syrup also has a slightly laxative effect as it con- tains inverted sugar.
Malt extract is a polysaccharide, which consists chemically of various starch breakdown products that have been reduced enzymatically, a lot of maltose, and a small amount of dextrines. Depending on the amount of maltose, it affects the bowel by promoting fermentation and can therefore have a positive effect on constipation. One teaspoon of malt extract can be added 1–3 times per day to tea or in soup. The use of lactulose syrup may also be helpful. The amount given will depend on the child’s age.
For children with intestinal neural dysplasia, in addition to a laxative diet with little roughage and the intake of lactulose syrup it is important to avoid the ingestion of foodstuffs that will consolidate the stools; the child must also drink sufficient amounts of liquid.
Table 30.1 Desirable and undesirable food in the treatment of chronic constipation
Desirable food Undesirable food
Fruits All kinds of fruit (better fresh than cooked), nuts, almonds
Bananas, blueberries, raw apples Vegetables Vegetables of all kinds, especially legumes, cabbages
and potatoes, if possible raw (except raw carrots) Cooked carrots Cereals and breads Wholemeal bread, rye bread, bread with linseed,
sesame bread, crisp bread, wholemeal rolls, muesli, bran, millet, linseed, cake or biscuits with whole- meal, whole-wheat pasta, whole-wheat rice, porridge
White bread, sandwiches, rolls, croissants, cakes, crescents, biscuits, cookies, pudding (nothing with starch flour), pasta, rice, semo- lina puddings, semolina dumplings, sweets only occasionally, farinaceous products
Fat Butter, plant margarine, olive oil Lard
Bread spreads Berry marmalades (blackberry, rasp-
berry, strawberry, gooseberry), honey Peanut butter, chocolate cream, mar- malade without seeds
Milk and milk
products Buttermilk, yoghurt Cream cheese, cheese (under 30% fat)
Liquids Mineral water, water, tea, fruit spritzer, fruit juice
with fibre, fruit juice (after meals), malt coffee Skim milk, curds, tea (with a lot of sugar), cocoa Sweets Dried fruit (figs, prunes, apricots, dates)
with a lot of water to increase volume Ice cream, marzipan, nougat, chocolate, sweet paste made from cocoa, sugar and crushed nuts Other Milk sugar (lactose), malt sugar (malt-
ose), juice from figs or plums Not forbidden, but
restricted foods Meat, ham, cream, eggs, cheese
with more than 30% of fat Strongly forbidden: fast food
References
1. Holschneider AM, Esch NK, Tragholz E, Pfrommer W (2001) Surgical methods for anorectal malformations from Rehbein to Peña – critical assessment of score sys- tems and proposal for a new classification. Eur J Pediatr Surg 12: 3–82
2. Wachtel U, Hilgarth R (1994) Ernähung und Diätetik in der Pädiatrie und Jugendmedizin. Band II Diätetik.
Thieme Verlag, Stuttgart, pp 76–80
3. Müller S-D (2000) Ernährung bei gastrointestinalen Er- krankungen. VitaMinSpur 15:121–124
4. Küpper C (2003) Obstipation und diätetische Abhil- femöglichkeiten. Ernährung Med 18:44–47
5. Deutsche Gesellschaft für Ernährung und Aid (2004) Voll- wertig essen und trinken nach den 10 Regeln der DGE. 21 Auflage
6. Verschiedene Broschüren des Forschungsinstituts für Kinderernähung. Dortmund
7. Wachtel U, Hilgarth R (1994) Ernähung und Diätetik in der Pädiatrie und Jugendmedizin. Band I Ernährung.
Thieme Verlag, Stuttgart, pp 20–25
8. Berg G (1978) Ernährung und Stoffwechsel. Schöningh Paderborn UTB, pp 145–147
9. Sailer D (1999) Obstipation und Ernährung. Ernährungs- umschau 46:380–382
10. Morlo M (2004) Gut gekaut ist halb verdaut. VFED aktuell 79:14–18
