Constipation in Children

Constipation is the infrequent passing of food product waste (stool) through the anus. A child who is constipated may have stool that is hard, dry and painful to pass. Or, the child may need to strain in order to have a bowel movement. It may feel as if the bowels still need to be emptied, even after stool has been passed. Constipation accounts for about 3 percent of child visits to general pediatric clinics, according to the American Academy of Pediatrics (AAP).

During normal digestion, food moves from the stomach to the small intestine, where nutrients are absorbed. By the time it reaches the colon (large intestine), only the waste material remains. The colon absorbs water from the waste and passes the stool along via muscle contractions (peristalsis) to the rectum at the end of the digestive tract.

Constipation occurs when waste material moves too slowly through the intestines and too much water is absorbed from the waste – creating hard, dry stool that is difficult to pass.

The longer waste stays in the intestines, the more water is taken from it and reabsorbed into the body.

Many people mistakenly believe that it is necessary for a child to have a bowel movement every day. However, the frequency of bowel movements is dependent on age and can vary greatly from child to child. Some children may have as many as three bowel movements a day, whereas others may have just a single bowel movement every three days. The number of bowel movements decreases during infancy and childhood. A newborn may have eight soiled diapers per day. By the time an infant is two months old, the daily average is four bowel movements (slightly fewer for formula-fed babies) per day. At two years of age, children typically have two bowel movements a day, and by the time a child is four, a single daily bowel movement is normal.

The natural firmness of a child’s stool can also vary. However, the longer a child goes without a bowel movement, the greater the likelihood of experiencing constipation. Passing stool less than three times a week may indicate constipation. Infants and children who do not have a bowel movement over a three-day or four-day period are most likely constipated.

Children who learn to withhold their bowel movements by not acting on urges to defecate may also experience constipation. Signs that children may be trying to withhold a bowel movement include clenching their buttocks together, rocking up and down on their toes or turning red in the face.

Constipation in children is usually not an indication of a serious underlying condition. It is generally short-lived and can be alleviated by drinking more fluids and consuming high-fiber foods. However, chronic constipation may indicate a more substantial problem that requires medical attention. It can potentially cause a variety of complications, including:

Children who are constipated tend to have hard, dry stools that are painful to eliminate during defecation. They may go long periods without any bowel movements and may experience abdominal cramps or stomach ache that is relieved only after a bowel movement. Children may also experience loss of appetite, bloody stools, nausea and vomiting, weight loss, and liquid or stool with the consistency of clay that leaks out onto the underwear.

Constipation in children may be a symptom of dietary problems, lack of exercise, a medical condition, side effects of certain medicines or the result of lifestyle choices. It also appears to have a genetic component in some cases and may run in families. Chronic pain and some mental disorders (such as depression) may also cause constipation. In many cases, no cause of constipation can be determined.

The most common causes of constipation in children are related to diet and a lack of exercise. Low-fiber diets often contribute to a child’s constipation. Fiber in a diet (e.g., fresh vegetables, fruits or whole grains) is not digested by the body and passes through the intestines virtually unchanged. It adds bulk to stool and holds water in the stool, helping to move waste through the intestines. Soluble fiber (e.g., psyllium, oatmeal) turns to a gel when mixed in fluid. Insoluble fiber (e.g., whole grain breads and cereals) does not dissolve in liquid. Both types aid in relieving constipation.

Foods high in fat and sugar (such as many soft, processed foods, including candies and desserts) and foods high in protein can also slow the digestive process, causing too much fluid to be absorbed from stool, and leading to constipation. In addition, a lack of fluids can cause a child’s stools to become hard and dry, increasing the risk of constipation. Sometimes, a sudden change in diet will contribute to a child’s constipation. For example, it is not unusual for infants to become constipated when cereal, other solid foods or cow’s milk are added to their diet. In rare cases, an allergy to cow’s milk can trigger constipation.

Certain major milestones in a child’s life are often associated with bouts of constipation. For example, children are at higher risk of constipation when they make the switch from breast milk or formula to solid foods, when they begin toilet training and at the start of school.

A lack of exercise and sedentary lifestyle can contribute to a child’s constipation. Exercise stimulates intestinal activity, helping to regulate bowel movements. A lack of exercise or too much bed rest can lead to constipation.

Certain factors have been associated with triggering constipation in children. They include:

• Suppressing the urge to have a bowel movement. Children sometimes withhold or delay the release of stool to avoid using public toilets, because they do not want to stop playing or because they are afraid to use a toilet without the support of their parents. However, repeatedly resisting the urge to defecate can lead to insensitivity of the intestines. The usual urges are no longer felt and constipation results.
• Insufficient intake of fluids. Without enough fluids, a child’s body will conserve water in the blood by removing additional water from the stool, leading to hard, dry stool. In addition, beverages that contain caffeine (e.g., coffee, cola) can lead to constipation.
• Diseases and disorders. Various health conditions can cause constipation in children. These include celiac disease (an inherited, autoimmune disease in which the lining of the small intestine is damaged from eating gluten and other proteins found in some grains, barley, rye and possibly oats), Hirschsprung’s disease (a congenital condition in which the large intestine becomes obstructed due to inadequate muscular movement of the bowel) and hypothyroidism (low production of thyroid hormone by the thyroid gland).
• Use of medicines. Use of drugs such as antacids, phenobarbital, painkillers and cough syrups containing codeine can cause constipation in children.

Other factors known to cause constipation in general include:

• Travel. Changes in a person’s schedule, activity level or diet as the result of traveling may interrupt normal digestive processes and cause constipation.
• Stress. It can slow digestion, increasing the amount of water absorbed from waste in the intestines, which can create hard, dry stool that is difficult to pass. Young children may experience such stress when they start school, move or have a new sibling.
• Loss of body salts. When too much salt is absorbed by the kidneys or lost via vomiting or diarrhea. Salt is necessary for the absorption of food in the intestines – too little salt in the body may cause constipation.
• Habitual use of enemas. Frequent enemas may damage nerve cells in the colon and interfere with the colon’s natural ability to contract. This can lead to a loss of normal functioning and include constipation.

Problems outside the digestive tract may also cause constipation in children by slowing the movement of stool through the large intestine, causing too much fluid to be absorbed. These conditions include:

• Stroke (interruption in the flow of blood to the brain)
• Spinal cord and nerve injuries (e.g., spina bifida, cerebral palsy)
• Lead poisoning (high levels of lead in a child’s blood)
• Multiple sclerosis (nerve cell damage affecting the brain and spinal cord)
• Diabetes (high levels of sugar in the blood)
• Scleroderma (connective tissue disease that can harden skin)
• Lupus (chronic inflammation caused by the body’s own immune system)
• Eating disorders (may include laxative abuse)

In most cases, constipation is a temporary problem that requires no medical treatment. Adding fiber to a child’s diet and increasing fluid intake and exercise may be all that is needed to relieve constipation that occurs without fecal impaction (and no underlying medical condition). In some cases, a physician may recommend changing an infant’s formula or eliminating cow’s milk from a child’s diet. Infants may benefit from having a small amount of a water-based lubricant applied to their anus. However, this should not be done without a physician’s approval.

Children who are being toilet trained also are much less likely to become constipated if they are relaxed and feel supported while trying to make this transition. It is natural for parents to want to see their child become toilet trained as quickly as possible. However, parents are urged to be patient with their children, because rushing toilet training can increase the risk of a child developing fears of the toilet that may lead to long-term constipation problems. If a child resists toilet training or expresses fear, the parent should wait a few months and then try again.

If changes in diet or physical activity are not effective, other techniques may be used, including enemas, suppositories and laxatives. Parents should never give these to a child without a physician’s approval. For example, use of laxatives can interfere with the absorption of various medicines. In addition, overuse of laxatives can destroy the colon’s natural ability to contract and lead to dependence on laxatives.

If constipation occurs with fecal impaction, the most common treatment is a tap-water enema. This flushes the stool from the rectum and lower part of the large intestine (colon). A physician may also use a gloved finger to manually remove the stool, or may prescribe laxatives to clear the system. The child may first be asked to drink a solution of salt and polyethylene glycol, which helps clean the digestive system.

Anal suppositories may also be used to relieve a child’s constipation. If this fails to work, laxatives can be taken by mouth in liquid, pill, chewing gum or powder form. In general, suppositories and enemas work more quickly than pills to restore normal bowel movement.

When constipation is a symptom of another medical condition, it is important to treat the underlying condition. Some conditions may not have a cure and may require ongoing treatment to manage symptoms, including constipation.

There is no way to guarantee the absence of constipation. However, there are many diet and lifestyle changes a parent can help a child to make that may help prevent constipation. In addition, parents of children with constipation may wish to check with a physician about medications their children are currently taking, since some may cause constipation. A physician may be able to recommend alternatives that do not cause or aggravate a child’s constipation.

Diet and lifestyle tips to help prevent constipation in children include:

• Do not rush toilet training. Children should not be toilet trained until they are emotionally ready for this transition. If a child strongly resists toilet training, it may be best to wait a few months before trying again.
• Remind the child to defecate regularly. Children may become constipated simply because they forget to use the toilet on a regular basis. In other cases, they may not be comfortable using public restrooms or may resist using the toilet when a parent is not around. However, children should be taught not to ignore the urge to defecate. Recognizing and responding to the body’s signals to defecate can help prevent constipation. Bowel movements that are purposefully withheld or delayed may lead to hard, dry stool that is painful to pass. Parents may want to consider asking their children to spend at least 10 minutes on the toilet at the same time every day, preferably after a meal. It is important that a child’s feet are supported while sitting on the toilet. If the child’s feet do not touch the floor, place a step stool in front of the toilet.
• Exercise regularly. Exercise helps to stimulate intestinal activity, speeding the passage of food through the digestive system. It also tones the abdominal muscles. Swimming, walking or other regular forms of exercise can help a child avoid constipation. Increasing the amount of time a child plays outdoors and decreasing the number of hours spent in sedentary pastimes such as watching television also help.
• Eat a diet high in fiber. Fiber (whole-grain cereals and bread, beans, fresh fruits and vegetables) helps bulk up and soften stool, stimulating intestinal contractions that help move food through the digestive system. The American Dietetic Association recommends the following fiber daily intake: 19 grams (0.67 ounces) for children ages 1 to 3; 25 grams (0.88 ounces) for children ages 4 to 6; 31 grams (1.09 ounces) for boys ages 9 to 13; and 26 grams (0.92 ounces) for girls ages 9 to 13.
• Gradually adding fiber to a diet can help to avoid problems with gas or bloating. For example, adding bran to a child’s baked goods or encouraging consumption of bran cereals can help. Fruits such as apricots or peaches are good, because they contain the ingredient pectin, which helps relieve constipation. Foods such as bananas, dairy products (e.g., milk, cheese, yogurt) and white rice may increase constipation.
• Avoid excessive fats and sugar. Foods high in fat and sugar may cause or aggravate constipation. Excess fat and carbohydrates can slow digestion, causing too much fluid to be absorbed from stool, making it hard and difficult to pass. On the other hand, children who have problems absorbing fats and sugars may experience diarrhea, as stool becomes loose and greasy. Maintaining a balanced diet by avoiding excessive fats and sugar can help promote normal bowel function.
• Add certain ingredients to a baby’s bottle. Giving a baby a bottle of prune juice every day or adding corn syrup or brown sugar to a baby’s bottle can help lower the risk of constipation. Parents are urged to consult their physician about the right amounts of these ingredients.
• Maintain consistent eating times. Eating meals on a regular schedule (at close to the same time every day) can promote normal bowel functioning and help prevent constipation in children.
• Use natural laxatives. Eating foods with natural laxative qualities (e.g., prunes, sauerkraut, green sprouts) can help prevent constipation.
• Drink plenty of fluids. Water and other fluids add bulk to stool, making bowel movements softer and easier to pass. Caffeine (e.g., coffee, soda) and alcohol should be avoided since they have a dehydrating effect.