What is constipation?

Constipation is a condition in which a person has painful or infrequent bowel movements that result in the passage of small amounts of hard, dry stool. Constipation is common in children, accounting for 5% of general pediatric visits and 25% of pediatric gastroenterology visits each year.

More than 90 percent of constipated children have “functional” constipation, which is constipation without any underlying disease. Once children pass hard, painful bowel movements, they learn to withhold stool to prevent further pain. When stool is withheld in the colon and rectum, it hardens due to water absorption, causing the rectum to become increasingly distended. This results in decreased rectal sensations and overflow of stool and causes accidents in the underwear. Parents sometimes misinterpret these soiling episodes as diarrhea.

What causes constipation in children?

Constipation is typically caused by an external factor or change in diet/lifestyle, but more severe or chronic cases of constipation can be due to an underlying condition. Some of the most common causes of constipation in children include:

  • Medications
  • Lack of exercise
  • Not enough liquids
  • Not enough fiber in the diet
  • Irritable bowel syndrome
  • Ignoring the urge to have a bowel movement
  • Changes in habits or lifestyle
  • Problems with intestinal function.

Common life events that are linked to episodes of constipation in children include:

  • Changing from breast milk to formula
  • Introduction of solid foods
  • Starting cow’s milk
  • Toilet training
  • Travel or camping
  • Viral illness.

What are the symptoms of constipation in children?

Although each child may experience constipation differently, symptoms can include:

  • Less than three bowel movements per week.
  • At least one episode of stool leakage per week.
  • Withholding behavior: A child actively tries not to go the bathroom. When needing to use the restroom they will clench their bottoms, cross their legs, get red in the face, hide, cry, shake or dance around. Parents sometimes misinterpret this behavior and think that their child is in pain.
  • Difficult, painful or hard bowel movements
  • Stool that is small and “ball like”
  • Feeling bloated or uncomfortable
  • Large diameter stools that could clog the toilet
  • Presence of a large stool mass in the abdomen or rectum.
  • Abdominal pain: The most common cause of abdominal pain in children is constipation. Pain is typically intermittent (off and on) and is relieved after a bowl movement.
  • Urine accidents: Constipation takes up a large amount of space in the abdomen, which often leads to dysfunction of the bladder. Along with that, about 10% of children with constipation have recurrent urinary tract infections that can also cause daytime or nighttime urinary accidents. Learn more about urinary tract infections.
  • Blood-coated stools: Passage of hard stools can cause anal tears (fissures) leading to blood streaked stools or blood on the toilet paper.
  • Behavioral issues: Behavioral problems can result from the pain due to constipation, or the social embarrassment that a child faces due to soiling of their underwear at school or in public places.

Ideally, children should have soft bowel movements each day that resemble Types 3 through 6 on the Bristol Stool Chart.

Bristol Stool Chart, showing range of poop textures from hard and lumpy to watery

The symptoms of constipation may resemble other medical conditions or problems. Always consult your child’s physician for a diagnosis.

How is constipation diagnosed?

The following tests and procedures are used to diagnose and find the cause of a child’s constipation:

  • Medical history analysis: Your child’s doctor will ask about duration and severity of constipation, as well as any changes in weight, bowel habits or appetite.
  • X-ray: Some children may need an abdominal X-ray so that the physician can see the extent of the constipation inside the patient’s body.
  • Blood tests: Blood tests may be ordered for some children to look for signs of infection or other underlying illness.

How is constipation treated?

Mild constipation may be treated with dietary changes. Increased fiber in the diet along with normal water or fluid intake may soften the stools. Fruit juices made from prunes, apples, peaches and pears can be used due to their high sorbitol content. Sorbitol works as a mild osmotic (water retaining) laxative. It is important to note that most of the water we drink is reabsorbed in the colon and is not available to soften the stools; therefore it is not necessary to drink tons of water. Learn more about the amount of water children should drink each day. Children with soiling or more severe constipation usually require medication. However, making changes in your child’s diet at the same time may help wean them from medications more quickly. Getting children, especially toddlers, to change their diet may be a tough task but the extra effort will lead to happier symptom-free children.

What are good fiber sources?

There are a variety of foods that can be great sources of fiber in a child’s diet:

  • Fiber-enriched cereals
  • Whole grain items
  • Whole wheat items (such as whole wheat bread)
  • Fiber-rich granola bars or cereals
  • Oats
  • Beans
  • Vegetables, especially green leafy vegetables
  • Fruit, especially apples, raisins, pears, prunes and figs.

Why is it important to treat constipation?

Constipation results in much more than a child not being able to “go.” Therefore, eliminating a child’s constipation may also:

  • Reduce the child’s urinary tract infections, as about 10% of children with constipation have recurrent urinary tract infections. Learn more about urinary tract infections.
  • Reduce abdominal discomfort.
  • Reduce episodes of incontinence. Constipation takes up a large amount of space in the abdomen, which often leads to dysfunction of the bladder. This can cause incontinence, urgency of urination, frequency of urination or a sensation of having to urinate when there is little or no urine to urinate. Learn more about incontinence.
  • Reduce the amount of daytime urine accidents, as one-third of constipated children experience daytime incontinence (urine accidents).
  • Improve the child’s vesicoureteral reflux, as constipated children with reflux are more likely to have breakthrough infections. Learn more about vesicoureteral reflux.
  • Decrease a child’s stool accidents and stool leaking. Often stool accidents (known as encopresis) is actually a sign of constipation. Families should make an appointment with their child’s doctor to get help determining if the child’s diarrhea may actually be stool leakage due to constipation.

Chronic Constipation in Children

Chronic constipation occurs when symptoms last for a prolonged period, typically longer than 3 weeks, despite efforts to treat the condition.

Treatment of Chronic Constipation

Treatment of children with chronic constipation is necessary to reduce their risk of developing other complications such as:

  • Hemorrhoids, which occur by straining to have a bowel movement
  • Anal fissures (tears in the skin around the anus), which occur when hard stool stretches the sphincter muscle. This can result in rectal bleeding. Learn more about hemorrhoids.
  • Rectal prolapse, in which a small amount of intestinal lining pushes out from the anal opening.
  • Fecal impaction, which takes place when the hard stool packs the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool.
  • Long-term constipation leading to diverticulitis as an adult.

Managing Chronic Constipation

The following steps are recommended for optimal management of chronic or severe constipation that needs medical attention:

Disimpaction. The best way to start off treatment of a constipated child is to evacuate the old stool from the rectum and colon. This can be achieved by giving rectal enemas followed by oral intake of high doses of osmotic (water retaining) and stimulant laxatives.

Maintenance regimen. Once no longer impacted with stool, the child needs to be on a daily regimen of laxatives as recommended by the physician. Maintenance treatment should continue for at least two months, if not longer. All symptoms of constipation should be resolved for at least one month before the treatment is stopped. Treatment should be decreased gradually. During the phase of toilet training, laxatives should be only stopped once toilet training is achieved.

Often, the pediatrician or gastroenterologist may recommend the child take polyethylene glycol 3350 (Miralax®). This is an osmotic laxative that is very well tolerated and effective in children. It has limited known side effects that can include gas, nausea, vomiting, diarrhea and abdominal pain. A child should take Miralax® according to the instructions on the packaging or according to the doctor’s instructions.

Lifestyle Changes. Along with medications, children with severe constipation must make dietary and lifestyle modifications:

  • Eat the right amount of fiber. The correct amount of fiber is equivalent to your child’s age plus 5 grams. For example, a child who is 5 years old should eat 10 grams of fiber each day (5+5=10), or a child who is 9 years old should eat 14 grams of fiber each day (9+5=14).
  • Children need to sit on the toilet two to three times each day for five to 10 minutes each time. The best time to sit on the toilet is 5 to ten minutes after a meal, since food entering the stomach stimulates movement of the colon.
  • While sitting on the toilet your child can be given balloons or pinwheels to blow in order to increase the pressure on the abdomen.
  • When the child sits on the toilet, his or her feet should be touching the ground or a step stool so that their legs are not dangling.
  • Most important, always be positive and never punish or scold a child who is toilet training or having difficulty with bowel movements.

Constipation symptoms that could indicate an underlying disease

There are certain red flags or alarm symptoms that could suggest an underlying condition is responsible for a child’s constipation. Laboratory testing to screen for these conditions is only recommended in children with chronic or severe constipation in the presence of red flags or when symptoms do not improve with treatment.

Red Flags

  • Constipation starting early in infancy
  • Recurrent fevers
  • Vomiting bile
  • Severe abdominal swelling
  • Poor feeding
  • Bloody diarrhea
  • Poor growth
  • Pus collection around anus
  • Feeling cold even when it is warm
  • Developmental delays
  • Problems with walking.

Some diseases that commonly cause constipation include celiac disease, hypothyroidism, inflammatory bowel disease, spinal cord issues, neuromuscular diseases, lead poisoning, and anal malformations.

When should my child see a doctor?

It is important to speak with your child’s primary care doctor about their constipation when:

  • Episodes of constipation last longer than three weeks and dietary changes or adding hydration has not helped.
  • The parents can’t relieve the child’s pain.
  • The child is unable to participate in normal activities because of constipation.
  • The child soils his clothes.
  • The child develops abdominal pain or swelling that could be a sign of another medical problem.
  • There is blood in the stool.
  • Dietary changes do not improve constipation.
  • Any of the red flags mentioned above are present with constipation.

Find a nearby CHOC pediatrician and make an appointment.

When should my child see a pediatric gastroenterologist?

In most cases, your child’s pediatrician can manage constipation. If, with treatment, the child’s constipation does not go away, talk to the child’s doctor about seeing a pediatric gastroenterologist. The pediatric gastroenterologist will obtain appropriate screening evaluations based on symptoms as well as specialized testing modalities, such as motility studies, and treatments tailored to your child’s case.

Chronic Constipation in Kids

Constipation is a common problem that can make kids – and their parents – miserable. “I think I have changed more lives by treating constipation than any other condition,” says Dr. Mitchell Katz, a CHOC pediatric gastroenterologist. Constipation is a decrease in the frequency of bowel movements, compared to a child’s usual pattern. How often a child makes a bowel movement varies. Chronic constipation is usually painful and causes the child great discomfort.

Small boy being comforted by his father