Understanding childhood constipation through the prism of the caretaker

Aureen Ruby DCunha; Sandeep B Rai; Swathi Sunil Rao; Neevan D'Souza

doi:10.4103/jiaps.jiaps_103_23



ORIGINAL ARTICLE

Year : 2023 \| Volume : 28 \| Issue : 5 \| Page : 400-406

Understanding childhood constipation through the prism of the caretaker

Aureen Ruby DCunha¹, Sandeep B Rai¹, Swathi Sunil Rao², Neevan D'Souza³
¹ Department of Pediatric Surgery, KS Hegde Medical Academy, Deralakatte, Karnataka, India
² Department of Pediatrics, KS Hegde Medical Academy, Deralakatte, Karnataka, India
³ Department of Biostatistics, KS Hegde Medical Academy, Deralakatte, Karnataka, India

Date of Submission	07-May-2023
Date of Decision	30-Jun-2023
Date of Acceptance	04-Jul-2023
Date of Web Publication	05-Sep-2023

Correspondence Address:
Aureen Ruby DCunha
Department of Pediatric Surgery, KS Hegde Medical Academy, Deralakatte, Mangalore, Karnataka
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jiaps.jiaps_103_23

Abstract

Aims: Childhood constipation is presenting with increasing frequency at pediatric surgical clinics. The caregiver's role in prevention and management is pivotal. This study aimed at determining mothers' knowledge, attitudes, and practices with regard to childhood constipation and the association of these with demographic variables.
Materials and Methods: This was a survey-based descriptive study conducted at a tertiary care hospital in South India. Randomly selected mothers of children aged 1–10 years consulting for any problem other than constipation were included in the study. Data collection was done by means of a pretested and prevalidated questionnaire.
Results: There were 169 mothers with a median age of 30 years. Over half were homemakers and of a rural background. Urban mothers scored better than their rural counterparts in the attitude section (P = 0.034). Mothers with greater knowledge had better attitude (P = 0.001) and practice (P = 0.020) scores. Those with higher attitude scores also fared better in the practice section (P = 0.04).
Conclusions: Knowledge, attitude and practice concerning childhood constipation are connected to each other. South Indian mothers are sufficiently aware of the nuances surrounding childhood constipation, but focused large-scale outreach programs and health education are necessary to bridge the gaps.

Keywords: Attitude, childhood constipation, knowledge, practice, prevention

How to cite this article:
DCunha AR, Rai SB, Rao SS, D'Souza N. Understanding childhood constipation through the prism of the caretaker. J Indian Assoc Pediatr Surg 2023;28:400-6

How to cite this URL:
DCunha AR, Rai SB, Rao SS, D'Souza N. Understanding childhood constipation through the prism of the caretaker. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Oct 2];28:400-6. Available from: https://www.jiaps.com/text.asp?2023/28/5/400/385138

Introduction

Childhood constipation accounts for about 3% of all outpatient visits to the pediatrician and a third of all pediatric gastroenterology consultations.^[1] The global prevalence is 0.7%–29.6%,^[1],[2] with functional constipation as the leading cause. The cohort of constipated children seeking outpatient care at pediatric surgical clinics is increasing. Constipated children are often referred to surgeons for digital evacuation of impacted stools, management of fissures and most importantly to rule out surgical causes. Needless to say, a constipated child is an unhappy child. Additionally, the caregivers are burdened by frequent hospital visits, high expenditure, and a child with a myriad of associated problems. Several constipated children suffer from psychosocial and behavioral issues.^[2] The answers to these problems are simple and mostly preventive yet challenging as they require a change of diet and lifestyle combined with commitment and goal direction.

The challenges faced are unique to each society within a defined geographical area. India, in particular, due to its limited economic resources and tradition-driven practices is susceptible to problems like childhood constipation. With increasing number of nuclear families, working parents, fast food, and dependence on technology trending, children's diet and lifestyle bear the brunt. Oftentimes, the knowledge is existent, but acceptance, processing, and translating it into practice is lacking. Several studies exist addressing the burden of constipation and its management; however, literature on caregivers' understanding, beliefs, and practices is sparse. Other than a study on the knowledge, attitudes, and practices among nurses,^[3] there is no data on what caregivers know and follow. We therefore decided to conduct this survey with the primary objective of determining mothers' knowledge, attitudes, and practices with regard to childhood constipation and the association of these with selected demographic variables. In addition, we plan to use the data generated to educate caregivers about the prevention and management of constipation in children and to identify problem areas that need to be addressed while planning large-scale outreach programs.

Materials and Methods

This was a descriptive cross-sectional study conducted at a tertiary care hospital in southern India. Approval to conduct the study was obtained from the institutional review board and ethics committee. The work described was carried out in accordance with the code of ethics of the World Medical Association (Declaration of Helsinki). Data was collected by means of a predesigned and pretested structured questionnaire [Supplementary File 1]. The sample size was calculated based on a 5% level of significance with an estimation error of 7% using nMaster software (developed by Christian Medical College, Vellore, India). A pilot study was done on 8 participants and assessed by subject experts. Informed written consent was taken from each participant with guarantee of anonymity ensured. The participant was given the choice of withdrawing from the study at any point of time.

The study subjects were mothers of children aged between 1 and 10 years who were either inpatients or who were attending the pediatric or pediatric surgical outpatient department for any complaint besides constipation. The participants were randomly selected in order to avoid confounding factors and effect modifiers.

The questionnaire had two parts: demographic data [Table 1] and multiple choice questions to assess knowledge (n = 10), attitude (n = 6), and practice (n = 8). The demographic variables collected included the mother's age, category of residence, place of origin, educational qualification, employment status, and family's monthly income along with the child's age and sex. Mothers were interviewed in their vernacular language by the principal investigator (PI), interns, and residents posted in the department of pediatrics, pediatric surgery, and general surgery. Prompting of answers was not allowed. Any unanswered question was left unfilled. Mothers of children who had been treated for constipation at any given time, those who had participated in any research studies on constipation within the last 6 months, and those who were physically or psychologically unfit to comment during the time of data collection were excluded from the study.

Table 1: Baseline characteristics of the study participants (n=169)

Click here to view

An educational leaflet was given to the participant on completion of the Questionnaire and the contents were explained. The mothers were encouraged to clarify doubts on the subject and to share the knowledge gained among their family and social circles. For quality assurance, the questionnaires were checked for completeness and accuracy of filling by the PI. The average monthly family incomes were classified according to the updated BG Prasad socioeconomic status classification for 2021.^[4]

Frequencies and proportions were calculated for categorical variables and means and standard deviations for continuous variables. Spearman's rank correlation was used to find the relationship between knowledge, attitude, and practice scores. Statistical analysis was done using IBM Corp. Released 2011.IBM SPSS Statistics for Windows, version 20.0. (Armonk, NY: IBM Corp). Confidence intervals (CIs) were set at 95%, and A P value of <0.05 was considered statistically significant.

Results

A total of 180 mothers hailing from various states of India were interviewed. Eleven were excluded from the final analysis due to incomplete questionnaires. The remaining 169 mothers had a median age of 30 years. Most (n = 102) were from a rural background and over half were homemakers (n = 93). About a third of them (n = 65) had some level of secondary schooling and the majority (n = 105) fell into socioeconomic categories of either middle or upper-middle class. [Table 1] elaborates the demographic data.

The responses received and the total scores calculated are elaborated in [Table 2], [Table 3], [Table 4]. Mothers hailing from urban areas fared significantly better in the attitude section compared with those from rural areas (6.24 ± 1.383 vs. 5.79 ± 1.277; 95% CI: −0.854 to − 0.035; P = 0.034). Besides this, there was no association between scores in the three arms and any of the other demographic variables. The scores in each arm positively correlated with each other [Figure 1]. Mothers with greater knowledge had better attitude (r = 0.408; 95% CI: 0.274–0.527; P = 0.001) and practice scores (r = 0.179; 95% CI: 0.029–0.321; P = 0.020). Those with higher attitude scores also fared better in the practice section (r = 0.154; 95% CI: 0.003–0.298; P = 0.04).

Figure 1: Scatterplots demonstrating the positive correlations between knowledge, attitude, and practice

Click here to view

Table 2: Responses to the question “Name 2 food items that can help prevent/cure constipation”

Click here to view

Table 3: Responses to the attitude and practice questions

Click here to view

Table 4: Individual arm scores and overall scores of the participants^a

Click here to view

The knowledge scores were Predominantly (71%) average, with only 20% having good scores. There was 1 open-ended question; “How would you define constipation?” which was answered by 131 participants. Barring 11 grossly incorrect answers, the majority (71%) acceptably defined constipation as the inability to pass stools, passage of hard stool, or spending too much time passing stool.

A large majority (92%) correctly answered that food habits could affect children's bowel movements. In addition, 78% were aware that the first stool should be passed within 48 hours of birth. It was interesting to note that nearly all mothers (90%) could identify at least one of the reasons including unclean toilets, stressful situations, forceful potty training, and purposeful postponement of defecation as triggers of constipation. Most (70%), however, failed to recognize that constipation could have a familial association. Only 35% were able to deduce that soiling in a potty-trained child could indicate constipation.

On being asked to name foods that could prevent or cure constipation, a variety of answers were obtained which are elaborated in [Table 2]. What was promising was that 97% correctly identified these and 87% implemented them at least twice a week. Concerning food habits, we found that junk/fast food formed a consistent part of the daily diet in 16% of children and a majority (83%) of these practices were followed by upper-class mothers.

Although several mothers (70%) felt that their child should pass stool at least once in 2 days, a good number (23%) felt that it was acceptable to wait for a week. Many mothers (72%) recognized that being constipated would adversely affect family and school life. Only a minor group (16%) claimed to feel embarrassed or awkward to talk about constipation.

Positive reinforcement for attempting to pass stools regularly and not soiling was an idea accepted only by about half (52%) of the respondents. A small number (14%) admitted to chastising or reprimanding their child for not passing stools regularly. Successful toilet training by the age of 3 years was achieved by 78%. More than half (63%) of the mothers said that they would employ dietary and lifestyle modifications as a first response to their child's constipation while a quarter said that they would resort to home remedies.

All mothers responded enthusiastically to the information shared with them by means of the educational Leaflet and post-test clarifications. They were eager to share the same with their family, friends, and acquaintances.

Discussion

Knowledge, attitude, and practice (KAP) studies help us to assess the magnitude of common problems, identify deficiencies, and plan interventions at the community level. Although literature on functional constipation in children is aplenty, we did not find any KAP studies conducted among caregivers, and hence, the idea for this study was conceived.

Knowledge of the common causes and the available treatment options for childhood constipation varied among the mothers. When asked about beneficial food items, we noted that only 0.7% quoted milk. Several study findings^{[5],[6],[7],[8]} concur that milk is detrimental to constipation while avoiding it is beneficial.^[9] The role of yogurt, prebiotics, and probiotics is still controversial and pending randomized controlled trials.^[6],[10] Grains^[11] including brown and white rice by virtue of their fiber^[12] have the potential to ameliorate constipation by improving the total colonic transit time. These form a staple part of the Indian diet, but just 5% of the mothers believed that these were beneficial in the prevention or treatment of constipation. Documented evidence exists that constipation could have a familial association.^[7],[8] However, most in our study mothers did not know this.

The attitude arm was meant to assess the effect of mental status on an external stimulus and the impact of traditional beliefs and superstitions on one's ideology/thought process. What was reassuring was that most mothers irrespective of their background recognized that their child being constipated would adversely affect family and school life. In keeping with this finding, there is sufficient literature^[1],[8],[13] to suggest that childhood constipation is detrimental to physical, mental, and social health. Discussion on constipation is considered taboo by some,^[3] yet, in our study, only a minor group claimed to feel embarrassed or awkward to talk about it.

It is well established that infrequent passage of stools leads to a vicious circle of hard stools, constipation, poor appetite, and slow growth.^[8],[14] In this study, nearly a quarter felt that it was acceptable to wait for a week for their child to pass stools. This is an alarming trend that can lead to unnecessary grief in both the child and the parents. Several caregivers are pressured by familial or societal expectations to toilet train their children at an early age. While the ideal age to begin toilet training varies across cultures, the general consensus as mentioned by Yachha et al.^[15] is to not begin before 24 months of age. Majority of the children in the study had been successfully toilet trained by 3 years of age. Toilet training can be difficult, especially in rural areas where the caregivers are fraught with the additional challenge of limited access to indoor toilets and improper sanitation.

Only a few mothers suggested that junk or fast food was part of their child's daily diet, and we found that these answers came predominantly from upper-class mothers. We suggest that affluence, the rising number of nuclear families, and time constraints due to work patterns all have a role to play in their children having greater access to junk or fast food. In addition to correctly identifying foods that would prevent or cure constipation, a reassuring number were able to incorporate their own dietary suggestions reiterating that good practice requires and reflects sound knowledge. The converse, however, is not always true. Richmond and Devlin^[3] in a KAP study on nurses suggested that having knowledge does not necessarily translate into good practice.

It is well established that habitual constipation is successfully managed with dietary and lifestyle modification.^[1],[8],[14] In the present study, however, there were some who felt the need to use medication prescribed by a physician or those available over the counter at the outset of the symptoms. Although these are effective treatment strategies, sensitizing caregivers to a preventive rather than curative intent is the need of the hour. By moving in this direction, we can eventually reduce the economic and health-care burden of constipation on society as a whole.

Rewarding one's child for attempting to pass stools regularly and not soiling was an idea not welcomed by many. The concept of punishment for not doing what is expected is frequently employed by caregivers in a setup where education is limited and traditional beliefs dominate. In the current study, a small but significant number of mothers even agreed to chastising or reprimanding their child for not passing stool. In an already constipated child, the process of defecation or even the thought of it is often traumatic, promotes resistance, and lowers self-esteem. There is evidence to suggest that positive reinforcement can allay the associated grief.^[7],[8] This is a concept that we found deficient in our setup and we plan to encourage caregivers to use it with their children/wards.

With the advent of the internet, Indian children spend less time engaging in outdoor activities and often postpone defecation when they are occupied with the mobile phone, television, or video games. Postponing defecation, stressful situations, forceful potty training, and nonavailability of clean toilets are among the nonobvious precipitators of constipation that caregivers often miss to identify. We, therefore, framed a question with these options to help broaden the mothers' perspectives on causes of constipation. Irrespective of their demographic differences, it was noted that the responses to this question were mostly uniform, highlighting that a good percentage of knowledge comes from nonformal training including certain traditions and handed down information.

While only about a quarter fared well on the overall scores, most respondents had average scores, and a handful performed poorly. Respondents from urban areas performing better in the attitude section suggest that there is less influence of traditions and unscientific beliefs, greater prevalence (and thereby greater knowledge) of constipation, and easier access to information on prevention and management in these setups. That none of the demographic variables had a bearing on the scores implies that educational background, employment status, or socioeonomic status are not solely responsible for the deficiencies. A more complex understanding of the interplay between people's knowledge, attitude, and practice is required to bridge the gaps.

This study highlights that greater knowledge results in better attitudes and improved practices. Two areas of concern that we identified were the inability to identify nonobvious triggers of constipation and penalizing one's child for not passing stools. These lacunae should be filled by improvising educational curriculums to include lifestyle lessons, providing awareness from a health-care point of view, discussing common health issues on community social media platforms, and encouraging dialogs between caretakers and their health-care professionals. Involving children to participate in meal planning, self-care, and timed toilet training are additional directives. The ultimate aim would be to reduce the number of unnecessary medical consultations and change the management goal from cure to prevention. Using the output of this study, we plan to use existing resources to implement educational programs to increase awareness in the community.

The study was limited by the fact that a posttest was not conducted. For the investigators, it would enhance the efficacy and strength of the survey, while for the caregivers, it would have helped to reinforce the correct answers. Several participants additionally had to be excluded due to missing data. This was due to multiple personnel involved in data collection. Close to a quarter of the mothers did not answer the question on defining constipation though it was intended to allow freedom of unrestricted answering. This reiterates that open-ended questions are not the best modality of assessment in a questionnaire-based study.

Conclusion

Mothers' knowledge, attitude, and practice positively correlate with one another. Despite seemingly adequate progress, there are still areas of concern that need to be addressed in order to reduce the burden of the problem. The first step is to accept that childhood constipation is a huge conundrum that is better prevented than treated. Encouraging dialogues, circulation of certifies health information, and diligent practice are the current ways forward.

Acknowledgments

We would like to acknowledge all the interns and residents (no names to be mentioned) who helped in interviewing the survey participants in various languages. In particular, we would like Dr. Susan Jehangir who has been a constant support and guide and also the driving force behind conducting such a study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Supplementary Files

Knowledge

1. How would you define constipation?

2. Can food habits affect bowel movements in children?

3. Constipation occurs because of (May select more than 1 answer)

Poor intake of fiber including fruits and vegetables
Lack of toilet training
Eating lots of bakery food/maida/fried items
Medical condition/disease
Prolonged feeding with milk without introducing complementary feeds

4. How soon after birth should a baby first pass stools?

Within 24-48 hours
Within 1 week
It does not matter

5. Does the chance of your child having constipation increase if there is a family history?

6. Constipation can be cured by (May select more than 1 answer)

Medication alone
Dietary modification and medication
Traditional methods/prayers/chanting
Potty training
Positive reinforcement e.g., rewarding your child for trying to pass stools

7. If a potty-trained child has stool staining on his/her underwear it could indicate

Diarrhea
Constipation
Nothing, it is normal
That there is a problem, but not sure what

8. Name 2 food items that can prevent/cure constipation.

9. Which of these can happen because of constipation? (May select more than 1 answer)

Urinary irregularities and urinary infections
Poor feeding and poor growth
Appendicitis
Cancer
None of the above

10. Which of the following is correct regarding evaluating constipation?

All children must have blood tests or scans done
Investigations are needed only if home remedies fail

Attitude

1. How many days do you think it is ok to wait for till an older child passes stools?

Up to 2 days
Up to a 1 week
1 week to a month
It does not matter as long as they are otherwise healthy

2. What would be your first response if you felt your child was constipated?

Treat with over-the-counter medication
Try dietary and lifestyle modification
Try home remedies like soap water enemas, castor oil, etc.
Go to a doctor
Nothing, it will not cause any problems

3. Do you think constipation can have an effect on family/school life?

4. Do you feel embarrassed or awkward to talk about constipation?

5. Do you think any of the following can cause constipation? (May select more than 1 answer)

Nonavailability of a clean toilet
Stressful events
Forceful potty training
Postponing defection because he/she wants to play/do something else
None of the above

6. Would you reward your child for attempting to pass stool regularly and not soiling?

Practice

1. Which of the following does your child's daily diet include? (May select >1 answer)

Rice/roti/bread
Vegetables
Fruits
Meat/seafood
Fast food/Junk food (Biscuits/Cakes/Chips/Puffs/Chocolates/Bajjis, etc.)

2. How often does your child consume fast food or junk food?

Daily
Less than twice a week
Once in a few weeks
Almost never

3. How often do you give the food items mentioned in question 8 (Knowledge) to your child?

Almost daily
At least twice a week
At least twice a month
Almost never

4. Do you ensure that your child attempts to pass stools daily?

5. Do you personally prepare/plan your child's tiffin box/meals?

6. By what age has your child been toilet trained?

Not applicable
By 3 years
3-6 years
>6 years

7. For how long does your child sit at the potty to pass stools?

<10 minutes
10-30 minutes
>30 minutes

8. Have you ever punished/scolded your child because for not passing stools?

Yes
No
Never had to, my child passes stools regularly

References

1.	Vishal, Madhurima Prasad, Risabh Kumar Rana. Epidemiology, demographic profile and clinical variability of functional constipation: A retrospective study in North Bihar. International Journal of Contemporary Medical Research 2018;5:J7-J10.
2.	Andreoli CS, Vieira-Ribeiro SA, Fonseca PC, Moreira AV, Ribeiro SM, Morais MB, et al. Eating habits, lifestyle and intestinal constipation in children aged four to seven years. Nutr Hosp 2019;36:25-31.
3.	Richmond JP, Devlin R. Nurse's knowledge of prevention and management of constipation. Br J Nurs 2003;12:600-10.
4.	Khairnar MR, Kumar PG, Kusumakar A. Updated BG Prasad socioeconomic status classification for the year 2021. J Indian Assoc Public Health Dent 2021;19:154-5. [Full text]
5.	de Oliveira MB, Jardim-Botelho A, de Morais MB, da Cruz Melo IR, Maciel JF, Gurgel RQ. Impact of infant milk-type and childhood eating behaviors on functional constipation in preschool children. J Pediatr Gastroenterol Nutr 2021;73:e50-6.
6.	Wegh CA, Baaleman DF, Tabbers MM, Smidt H, Benninga MA. Nonpharmacologic treatment for children with functional constipation: A systematic review and meta-analysis. J Pediatr 2022;240:136-49.e5.
7.	Yousefi A, Taghavi Ardakan M, Nakhaei S, Najafi M, Behnoud N. A study of familial aggregation of habitual constipation. Iran J Pediatr 2019;29:e89965.
8.	Gibas-Dorna M, Piątek J. Functional constipation in children – Evaluation and management. Prz Gastroenterol 2014;9:194-9.
9.	Mohammadi Bourkheili A, Mehrabani S, Esmaeili Dooki M, Haji Ahmadi M, Moslemi L. Effect of cow's-milk-free diet on chronic constipation in children; A randomized clinical trial. Caspian J Intern Med 2021;12:91-6.
10.	Tabbers MM, de Milliano I, Roseboom MG, Benninga MA. Is Bifidobacterium breve effective in the treatment of childhood constipation? Results from a pilot study. Nutr J 2011;10:19.
11.	Stewart ML, Schroeder NM. Dietary treatments for childhood constipation: Efficacy of dietary fiber and whole grains. Nutr Rev 2013;71:98-109.
12.	Jung SJ, Oh MR, Park SH, Chae SW. Effects of rice-based and wheat-based diets on bowel movements in young Korean women with functional constipation. Eur J Clin Nutr 2020;74:1565-75.
13.	Russo M, Strisciuglio C, Scarpato E, Bruzzese D, Casertano M, Staiano A. Functional chronic constipation: Rome III criteria versus Rome IV criteria. J Neurogastroenterol Motil 2019;25:123-8.
14.	Bharti LK, Kumar B. Constipation in Indian children. Clin Surg 2017;2:1644.
15.	Yachha SK, Srivastava A, Mohan N, Bharadia L, Sarma MS, Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition Committee on Childhood Functional Constipation, and Pediatric Gastroenterology Subspecialty Chapter of Indian Academy of Pediatrics, et al. Management of childhood functional constipation: Consensus practice guidelines of Indian society of pediatric gastroenterology, hepatology and nutrition and pediatric gastroenterology chapter of Indian academy of pediatrics. Indian Pediatr 2018;55:885-92.