Constipation is defined as abnormally delayed or difficulty in defecation (bowel opening). If your child continues to have symptoms despite changing the diet, modifying the lifestyle and increasing fluid intake (see previous article Constipation in Children – What Is It?), then your child may need treatment.

Treatment of childhood constipation

Around 97% of cases of constipations are functional which can be managed using the by modifying their diet or with medication if required as directed by your doctor. Rare causes of constipation due to structural gut abnormalities such as anal stenosis or imperforate anus, anal tear (fissure) or Hirschprung’s disease require surgical intervention by a paediatric surgeon. Neurological disease such as spinal bifida or cerebral palsy can also cause constipation.

Medication options

  1. Faecal softeners such as DUPHALAC, LACTUL & FORLAX work by drawing fluid into the faeces making it soft to pass out. Take the medication as directed by your doctor or pharmacist.




  1. Suppository such as DULCOLAX works by softening impacted stool at the rectum. Take the medication as directed by your doctor or pharmacist.



Once the cycle of constipation is treated successfully, you still need to encourage your child to change the habit and lifestyle to prevent recurrence by following these principles:

  • Increase fluid intake
  • Increase dietary fibre and avoid fatty, sugary or starchy foods
  • Avoid sweet drinks before meals
  • Encourage your child to exercise (avoid being sedentary)
  • Develop a regular meal schedule
  • Get the child to have regular bathroom breaks
  • Encourage your child not to be frighten of going to the toilet

Download Teleme’s mobile app and ask any health questions



Constipation occurs when a child does not go to toilet to defecate regularly resulting in difficult or painful bowel opening (pooping). The peak incidence of constipation is between 2-4 years of age when parents start to toilet train their children.  Around half the kids experience constipation at least once during childhood!

The frequency of defecation depends on the child’s age; beginning with around 4 times a day during neonatal and infant period but gradually decreasing to twice daily during early years of age and once daily by the age of 4 years when children are able to achieve anal sphincter control.

Symptoms of constipation

  • difficulty or pain in defecation
  • hard dry stools (see stool chart below)
  • irregular bowel movements
  • abdominal pain or distention (bloated)
  • bleeding when it causes an anal tear or fissure
  • pain during defecation causes the child to withhold the stool even more thereby setting up a vicious cycle of stool retention

Stool Consistency is best described using the Bristol Stool Chart

Source: Wikipedia

Contributory factors to constipation

  • Low fibre diet (not enough fruits and vegetables)
  • Insufficient fluid intake (see below)
  • Poor quality diet (too much junk food)
  • Being overweight
  • Sedentary lifestyle (not enough exercise)
  • Psychological factors (such as stress or anxiety)
  • Family history
  • Organic bowel disorder


Image Source: YMCA Harrisburg

Prevention is the best option and you can follow the following principles:

  • Increase fluid intake
  • Increase dietary fibre and avoid fatty, sugary or starchy foods
  • Increase sorbitol in the diet (apple, prune or pear juice)
  • Encourage your child to exercise (avoid being sedentary)
  • Develop a regular meal schedule
  • Get the child to have regular bathroom breaks

Recommended fluid intake (including fluid in food and drinks)

The table below is just a guide and more may be required if the child is active and sweats a lot.

Download Teleme’s mobile app and ask any health questions



Vaccines work by introducing a weakened or dead form of either the bacteria or virus (known as the antigen). This vaccine encourages the body to create antibodies against this antigen so that when the person is exposed to the infection, the body is able to fight the infection quickly without being affected too severely by the illness. In short, vaccines prepares the body to fight the disease in case the person gets infected in the future.

Source: M Klingensmith

Although there may be some side effects during the vaccination, the benefits outweigh them. In 2018, it was reported that in Malaysia, there were:

  • 6 deaths from measles (none of them receive vaccination)
  • 5 deaths from diphtheria (4 of them did not receive vaccination)
  • 22 deaths from pertussis (19 of them did not receive vaccination)

Reference: Star News Malaysia 22 Jan 2019

Do read the link below on how a lecturer had ‘wished his parents had him vaccinated’ as a baby but instead contracted polio at the age of 18 months and lost his ability to walk properly since then.

Download Teleme’s mobile app and ask any health questions



This is the recommended vaccination schedule for children in Malaysia. Do share this article with your friends with young children to keep as reference and useful reminder.

Explanation Notes

  • Bacillus Calmette–Guérin (BCG), vaccine that gives protection against tuberculosis
  • DTaP is the combination of diphtheria(D), tetanus(T) and accelullar pertussis (aP)
  • DT is a booster dose which protects against diphtheria (D) and tetanus (T)
  • Hib is Haemophilus Influenza type B
  • MMR is the combination of Measles(M), Mumps(M) and Rubella(R)
  • MR vaccine provides protection against Measles (M) and Rubella (R). MR Dose 2 at 7 years old
  • JE is vaccine against Japanese Encephalitis (This vaccine is only provided in Sarawak)
  • HPV is Human Papilloma This vaccine is provided only for girls aged 13 years. Dose 2 is given 6 months after dose 1

This an additional list of vaccines which you can discuss with your doctor about the suitability for your child:


Download Teleme’s mobile app and ask any health questions



Hernias and hydrocoeles are the commonest conditions seen by paediatric surgeons as they occur in about 3-5% of children. The cause for both these conditions is the failure of the processus vaginalis to close before or just after birth (see Figure 1).

  • If the processus vaginalis is small, there is a passage between the abdominal peritoneum and the tunica vaginalis of the testis may allow fluid from the abdomen to trickle down and collect as a hydrocoele around the testis. This is called a HYDROCELE
  • If the tract is larger, the bowel or momentum can also go into This is called an INGUINAL HERNIA

Hydrocoeles are harmless and majority spontaneously resolve by 2 years of age or require surgical closure if they persist beyond 3 years of age.

Figure 1: Hydrocele

Figure 2: Inguinal Hernia

Indirect inguinal hernias on the other hand, do not go away and can cause problems to the child especially for the under 1 year-old.

The risks are:

  • Incarceration where the hernia is stuck causing bowel obstruction
  • Strangulation of the hernia where the blood supply to the herniated bowel is cut off causing necrosis and perforation of the bowel
  • The hernia may compress on the blood vessels to the testis at the inguinal ring and cause testicular atrophy (and loss of sperm production) in boys

Image Source: US News

Hernias must be corrected as soon as possible, especially in the under 1 year-old. When the hernia is stuck (incarcerated) or strangulated, they will need urgent reduction or emergency surgery to prevent damage to the bowel or testis.

How to distinguish a hydrocele from an inguinal hernia

  • Age of onset: hydroceles can be seen soon after birth as a non-tender scrotal swelling whereas hernias usually presents early in premature infants but usually within the first 2 years of life in term babies

Image Source: Getty Images

  • Constancy: hydroceles are seen most of the time and often smaller in the mornings and gradually increase in size as the day passes. Hernias on the other hand, comes and goes and often appears when the child cries. It helps if the parent can take a photo to show the doctor
  • Location: hydroceles are usually located are in the scrotum except for encysted hydroceles of the cord (see Figure 3 below) whereas hernias extend can from the inguinal area to anywhere down towards the scrotum
  • Physical exam: one can get above a hydroceles whereas one cannot get above hernias
  • Reducibility: Non-incarcerated hernias can often be reduced (made smaller in size) while hydroceles cannot
  • Transilluminate: Hydrocoeles generally can transilluminate with a light while hernias look opaque

How the bowel gets stuck in the inguinal hernia

Figure 3

A painful non-reducible groin swelling associated with vomiting and constipation is an emergency and the child must to referred to a paediatric surgeon for reduction or surgery to prevent the bowel from getting strangulated.

Surgical Treatment of Hernias and Hydrocele

Treatment of inguinal hernias is surgery to prevent complications mentioned above. There is no role for any conservative treatment or bandages (Truss) to contain the hernia.

Image: US News

Hernias can be repaired by an open procedure or using laparoscopic (keyhole) surgery. In up to 15% of children, a hernia can also be found on the opposite side. Laparoscopy allows for the contralateral side to be examined and repaired at the same time using the same incision.

Hydroceles that persist beyond 3 years of age also need surgery. There is no role of aspiration of the hydrocele as they often recur or can lead to an infection.

Download Teleme’s mobile app and ask any health question

 Dr. Nada Sudhakaran

Dr. Nada Sudhakaran

Paediatric surgeon




Biliary Atresia is a progressive inflammatory fibrosis of the biliary tract and the disease starts in the extra hepatic bile ducts and extends into the intra hepatic ducts. Liver cells produce bile to help with fat digestion in the intestine. When bile cannot flow into the intestine, the bile builds up in the liver causing liver damage resulting in scarring and cirrhosis.

The incidence in Asia is around 1 in 10,000 – 20,000 live births. Some infants (around 10-15%) with biliary atresia have other congenital problems such as spleen abnormality (polysplenia), blood vessel anomalies or intestine mal-rotation.

Image Source: National Institute of Diabetes, Digestive and Kidney Diseases NIH

Prolonged jaundice can be normal in breast-fed babies however if there are signs of obstructive jaundice in a neonate, alarm bells should ring. Signs of obstructive jaundice are yellowing of the skin and whites of the eyes (sclera), pale coloured stools with dark coloured urine in an otherwise normal child. Infants with biliary atresia typically develop jaundice by 3 to 6 weeks of age.

Image Source: Fotolia

An infant with jaundice and pale stools should be referred to a paediatric surgeon urgently. The serum liver function test is usually abnormal. Typically, with biliary atresia, the conjugated fraction of serum bilirubin is more than 20% of the total serum bilirubin. (although the bilirubin total may not be extremely high).

Ultrasound scan may show fibrosis of the extra hepatic biliary tree and liver biopsy.  A cholangiogram (a dye injected into the gall bladder with an X-ray to see the flow of the dye in the liver) will give the definitive diagnosis.


Image Source: US News

Surgical management for biliary atresia is the Kasai porto-enterotomy procedure to re-establish bile flow out of the liver and into the intestine.  The outcome for biliary atresia surgery is correlated to the timing of surgery. The earlier the procedure (ideally before 60 days), the better the rate for survival of the child’s own liver. The success of the procedure also depends on how damaged the liver is at the time of surgery and the number of viable ducts left in the liver to drain the bile. Some infants unfortunately, may still need a liver transplant later on in life.

In addition to surgery, the infant needs careful supervision of daily diet to include:

Image Source: Parents

  • Well balanced diet
  • Vitamin supplements
  • Addition of medium chain triglyceride (MCT) oil to the diet to add extra calories
  • High calorie liquid feeding if the infant is too ill to eat normally

Download Teleme’s mobile app and ask any health question

 Dr. Nada Sudhakaran

Dr. Nada Sudhakaran

Paediatric surgeon