Constipation in Children

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What is constipation?

Constipation is defined as:

• A decrease in frequency of bowel movements, compared to a child's usual pattern (some health care providers define constipation as fewer than three bowel movements per week).

• The passage of hard, oftentimes large-caliber, dry bowel movements.

• Bowel movements that are difficult or painful to push out.

However, normal stool elimination may consist of having a bowel movement three times a day or three times a week; it depends on the person. Constipation is one of the most common gastrointestinal complaints, resulting in 2.5 million health care provider visits annually.

What causes constipation?

Sometimes, there is no identifiable reason for constipation in children. However, some of the causes may include:

• Diet

  • Some children eat too much of foods that are high in fat and low in fiber (such as fast foods, "junk" foods, and soft drinks).

  • Some children do not drink enough water and liquids.

• Lack of exercise. Children who stay inside, watching TV and playing video games, do not get enough exercise. Exercise helps move digested food through the intestines.

• Emotional issues

  • Preschool- and school-aged children are sometimes embarrassed to use public bathrooms and hold in their bowel movements, causing constipation.

  • Toddlers can be overwhelmed by toilet training, especially when a parent is more anxious for the child to be out of diapers than the child is.

  • Toddlers can also become involved in power struggles with their parents as they learn to assert their independence, and may intentionally hold bowel movements in.

  • Some children who experience stress at school, with their friends, or in the family, may have constipation.

• Busy children

  • Some children ignore signals their intestines give them to have a bowel movement. This can happen when children are too busy playing and forget to go to the bathroom.

  • Constipation can also be a problem when children start a new school year, since they are no longer able to go to the bathroom whenever the urge strikes and have to change their bowel routine.

  • Once a child becomes constipated, a vicious cycle can develop. Hard, dry stools can be painful to push out, and the child can avoid using the bathroom to avoid the discomfort. Eventually, the intestine will not be able to sense the presence of stool.

Physical problems that can cause constipation include the following:

• Abnormalities of the intestinal tract, rectum, or anus

• Problems of the nervous system, such as cerebral palsy

• Endocrine problems, such as hypothyroidism

• Certain medications (for example, iron preparations and narcotics such as codeine)

Why is constipation a concern?

Hard stools can irritate or tear the lining of the anus (fissure), making it painful to have a bowel movement. The child may avoid having a bowel movement, which can cause further constipation.

What are the symptoms of constipation?

The following are the most common symptoms of constipation. However, each individual may experience symptoms differently. Symptoms may include:

• Not having a bowel movement for several days, or passing hard, dry stools

• Abdominal bloating, cramps, or pain

• Decreased appetite

• Clenching teeth, crossing legs, squeezing buttocks together, turning red in the face as the child tries to hold in a bowel movement to avoid discomfort

• Small liquid or soft stool smears that soil the child's underwear

The symptoms of constipation may resemble other conditions or medical problems. Always consult your child's health care provider for a diagnosis.

How is constipation diagnosed?

A health care provider will examine your child and obtain a complete medical history. Depending on the age of your child, you might be asked questions such as:

• How old was your baby when he or she had their first stool?

• How often does your child have a bowel movement?

• Does your child complain of pain when he or she has a bowel movement?

• Have you been trying to toilet train your toddler recently?

• What does your child's diet consist of?

• Have there been any stressful events in your child's life lately?

• How often does your child soil his or her pants?

Occasionally, in addition to a physical examination, your child's health care provider may want to perform other diagnostic tests to determine if there are any problems. These tests may include:

• Digital rectal examination (DRE). In this procedure, a doctor or other health care provider inserts a gloved finger into the rectum to feel for anything unusual or abnormal.

• Abdominal X-ray. A diagnostic test to evaluate the amount of stool in the large intestine.

• Barium enema. A procedure performed to examine the large intestine for abnormalities. A fluid called barium (a metallic, chemical, chalky liquid used to coat the inside of organs so that they will show up on an X-ray) is given into the rectum as an enema. An X-ray of the abdomen will show strictures (narrowed areas), obstructions (blockages), and other problems.

• Anorectal manometry. This test measures the strength of the muscles in the anus, nerve reflexes, ability to sense rectal distention, and coordination of muscles during defecation.

• Rectal biopsy. This test takes a sample of the cells in the rectum to be examined under a microscope for any problems.

• Sigmoidoscopy. A diagnostic procedure that allows the health care provider to examine the inside of a portion of the large intestine. Sigmoidoscopy is helpful in identifying the causes of diarrhea, abdominal pain, constipation, abnormal growths, and bleeding. A short, flexible, lighted tube, called a sigmoidoscope, is inserted into the intestine through the rectum. The scope blows air into the intestine to inflate it and make viewing the inside easier.

• Colorectal transit study. This procedure shows how well food moves through the colon. The patient swallows capsules containing small markers which are visible on X-ray. The patient follows a high-fiber diet during the course of the test, and the movement of the markers through the colon is monitored with abdominal X-rays taken several times three to seven days after the capsule is swallowed.

• Colonoscopy. A procedure that allows the health care provider to view the entire length of the large intestine. A colonoscopy can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It involves inserting a colonoscope, a long, flexible, lighted tube, in through the rectum up into the colon. The colonoscope allows the health care provider to see the lining of the colon, remove tissue for further examination, and possibly treat some problems that are discovered.

When should you contact a health care provider?

Do not hesitate to contact your child's health care provider if you have any questions or concerns about your child's bowel habits or patterns. The National Institutes of Health recommends that you talk to your child's health care provider if:

• Episodes of constipation last longer than two weeks.

• The child is unable to participate in normal activities because of constipation.

• Normal pushing is not enough to expel a stool.

• Liquid or soft stool leaks out of the anus.

• Small, painful tears appear in the skin around the anus.

• Hemorrhoids develop.

• Abdominal pain, fever, or vomiting 

What are treatments for constipation?

Specific treatment for constipation will be determined by your child's health care provider based on the following:

• Your child's age, overall health, and medical history

• Extent of the condition

• Type of condition

• Your child's tolerance for specific medications, procedures, or therapies

• Expectations for the course of the condition

• Your opinion or preference

Treatment may include:

• Diet changes. Often, making changes in your child's diet will help constipation. Consider the following suggestions:

  • Increase the amount of fiber in your child's diet by:

    • Adding more fruits and vegetables.

    • Adding more whole grain cereals and breads (check the nutritional labels on food packages for foods that have more fiber).

  Foods	Moderate fiber	High fiber
  Bread	Whole wheat bread, granola bread, wheat bran muffins, Nutri-Grain waffles, popcorn
  Cereal	Bran Flakes, Raisin Bran, Shredded Wheat, Frosted Mini-Wheats, oatmeal, Mueslix, granola, oat bran	All-Bran, Bran Buds, Corn Bran, Fiber One, 100% Bran
  Vegetables	Beets, broccoli, brussels sprouts, cabbage, carrots, corn, green beans, green peas, acorn and butternut squash, spinach, potato with skin, avocado
  Fruits	Apples with peel, dates, papayas, mangos, nectarines, oranges, pears, kiwis, strawberries, applesauce, raspberries, blackberries, raisins	Cooked prunes, dried figs
  Meat substitutes	Peanut butter, nuts	Baked beans, black-eyed peas, garbanzo beans, lima beans, pinto beans, kidney beans, chili with beans, trail mix

  • Encourage your child to drink more fluids, especially water.

  • Limit fast foods and junk foods that are usually high in fats and offer more well-balanced meals and snacks.

  • Limit drinks with caffeine, such as cola drinks and tea.

  • Limit whole milk as directed by your health care provider.

  Plan to serve your child's meals on a regular schedule. Often, eating a meal will stimulate a bowel movement within 30 minutes to an hour. Serve breakfast early so your child does not have to rush off to school and miss the opportunity to have a bowel movement.

• Increase exercise. Increasing the amount of exercise your child gets can also help with constipation. Exercise aids digestion by helping the normal movements the intestines make to push food forward as it is digested. People who do not move around much are often constipated. Encourage your child to go outside and play rather than watch TV or engage in other indoor activities.

• Proper bowel habits. Have your child sit on the toilet at least twice a day for at least 10 minutes, preferably shortly after a meal. Make this time pleasant; do not scold or criticize the child if he or she is unable to have a bowel movement. Giving stickers or other small rewards, and making posters that chart your child's progress, can help motivate and encourage him or her. If these methods do not help, or if your health care provider notices other problems, he or she may recommend laxatives, stool softeners, or an enema. These products should ONLY be used with the recommendation of your child's health care provider. DO NOT use them without consulting with your child's health care provider first.

What is the long-term outlook for a child with constipation?

The outlook depends on what type of condition caused the constipation. Those children with diseases of the intestine, such as Hirschsprung's disease, may have chronic problems. However, most of the time, constipation is a temporary situation.