What are the symptoms of constipation?
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
- Difficult, painful or hard bowel movements
- Small “ball like” stool
- Feeling bloated or uncomfortable
- Large diameter stools that could clog the toilet
- Presence of a large stool mass in the abdomen or rectum.
Other symptoms that indicate a child may be constipated include:
Abdominal pain. The most common cause of abdominal pain in children is constipation. Pain is typically intermittent (off and on). The child feels increased pain when holding in their stool, and feels better after stooling. Abdominal fullness and decreased appetite are also common complaints.
Children who are constipated will often try not to go to the bathroom. 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 wrongly think that their child is in pain.
Urine accidents. Children can have daytime or nighttime urinary accidents. Some children can have multiple urinary tract infections. 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.
The symptoms of constipation may resemble other medical conditions or problems. Always consult your child’s physician for a diagnosis.
What causes constipation?
More than 90 percent of constipated children have “functional” constipation, which is constipation without any underlying disease.
After children pass hard, painful bowel movements, they learn to withhold stools to prevent further pain. Once the stools are withheld in the colon and rectum, they harden due to water absorption. The rectum becomes increasingly distended, resulting in overflow of stools. This causes accidents in the underwear and decreases rectal sensations. The soiling episodes are sometimes misinterpreted as diarrhea.
Some of the most common causes of constipation include:
- 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.
Which are the symptoms that could indicate an underlying disease might be causing the constipation?
There are certain red flags or alarm symptoms that could hint towards conditions such as celiac disease, hypothyroidism, inflammatory bowel disease, spinal cord issues, neuromuscular diseases, lead poisoning, anal malformations and other conditions. Routine laboratory testing to screen for these conditions is only recommended in children with constipation in the presence of red flags or when symptoms do not improve with routine treatment.
- 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.
How is constipation diagnosed?
Your child’s physician will look at the child’s entire medical history, as well as the duration and severity of the constipation. Your child’s physician will also take into account the patient’s age and whether there is blood in the stool, recent changes in bowel habits or weight loss. Some patients may also need an abdominal X-ray so that the physician can see the extent of the constipation inside the patient’s body. Constipation cannot be diagnosed only based on the presence of stool on an abdominal X-ray.
Why is it important to treat constipation?
Constipation is much more than not being able to “go.” 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.
- In addition, children who have chronic constipation are at risk for the following:
- Complications such as hemorrhoids, which occur by straining to have a bowel movement or 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 can also cause diverticulitis as an adult.
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.
The following steps are recommended for optimal management of 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.
Education. 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.
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
- Vegetables, especially green leafy vegetables
- Fruit, especially apples, raisins, pears, prunes and figs.
When should you seek help from a pediatric gastroenterologist?
As a parent, it can be frustrating just trying to understand if your child’s constipation is a part of growing up or is it severe enough to discuss with your child’s doctor. If dietary changes do not improve constipation or if any of the red flags mentioned above are present along with constipation, it is important to speak with a doctor. 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 alarm symptoms and specialized testing modalities such as motility studies along with treatments tailored to the severity of your child’s case.