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Pediatric constipation is a common digestive problem that leads to a decrease in bowel movements in children.
The defecation rate varies with age. The normal bowel habit of a newborn child is above four excretions a day, which gradually decreases to one or two defecations a day during infancy.
Approximately 98% of children develop the ability to control their anal sphincter by the time they turn 4. The anal sphincter is a ring of smooth muscles at the end of the rectum that controls bowel movement. It remains tightly contracted at rest to hold in the stool and relaxes to allow defecation. (1)
How Does Constipation Occur?
Intestinal muscle contractions push the digested food through the colon toward the rectum, during which some of the water is absorbed from the stool.
Weakening or slowing of these muscle contractions inhibits the movement of the stool. The longer the stool remains in the colon, the more water is absorbed from it. The hard and dry stool then becomes difficult to pass, leading to constipation.
How Common Is Constipation in Children?
Stages of Constipation
Constipation occurs with varying severity:
- Acute or short-term constipation has a sudden onset and generally resolves on its own or with the help of simple remedies.
- Chronic constipation persists for more than 2 weeks, causes frequent vomiting and nausea, and usually occurs as a consequence of intestinal diseases that are beyond the scope of home treatment.
Types of Constipation
Pediatric constipation has two types:
Organic constipation is a rare type of constipation that develops due to biologic causes, which include structural disorders, neurologic problems, toxic/metabolic reasons, and intestinal disorders.
90%–95% of all cases of constipation are the functional type. (1) Functional constipation occurs due to behavioral or idiopathic causes.
This means the symptoms are not a result of organic reasons such as injury, a blood disorder, infection, or anatomic abnormality.
Causes of Constipation in Children
Children often develop constipation upon introduction to solid foods, in the midst of toilet training, and when starting preschool or a new school.
Constipation can occur due to various reasons that include:
- Consuming a diet that lacks fiber and water but is rich in meat, white bread, cheese, bagels, and processed foods.
- Withholding stool due to some distraction or being engrossed in play.
- Illnesses, such as hypothyroidism, that cause loss of appetite.
- Stress, emotional upsets, anxiety, or any kind of psychological trauma.
- Medications such as cold medications, antacids, anticonvulsants, antidepressants, chemotherapy drugs, and narcotic pain medications such as codeine.
- Medical conditions such as digestive problems, metabolic disorders, or anatomic malformation.
- Family history on account of shared genes or the influence of environmental factors. (3)
- Cow milk allergy, which is the most prevalent reason for constipation in children up to 3 years of age. (4)
- Excessive dairy intake. (5)
- Behavioral aspects including lack of routine, change in routine due to starting a new school, avoiding school toilets due to the unpleasant smell or lack of tissue paper, and reluctance to get toilet trained.
Symptoms of Constipation in Children
Constipation, in itself, is a symptom that may arise due to an underlying disease. In children, constipation is characterized by three markers:
- Dry, hard, or lumpy stools
- Incomplete bowel movements despite daily excretions
- Less than three defecations per week
The infrequent bowel movements may be accompanied by:
The child may show certain behavioral signs that indicate holding in the feces:
- Clenched teeth
- Crossed legs
- Redness in the face
- Squeezing the buttocks
Overflow incontinence occurs due to partial blockage of the child’s rectum by a huge mass of formed feces. The freshly created soft stool passes around it and causes soiling.
Medical Treatment for Constipation
The first step in treating constipation is the removal of old stool from the rectum, which can be done by using:
- Rectal enemas
- Oral osmotic (water-retaining) and stimulant laxatives
OTC laxatives can be used for the management of constipation and should be discontinued once the condition improves. Consult your doctor before using OTCs or enema on your child.
Certain prescription or OTC drugs may cause constipation. In this case, the doctor may lower the dosage or recommend a suitable substitute.
The doctor will consider the child’s medical history and relevant health factors as well as the severity and duration of constipation to identify the cause of constipation.
This is followed by a physical exam, which is generally the only diagnostic procedure required. It involves:
- Measuring body temperature, heart rate, and blood pressure
- Checking for signs of dehydration
- Listening to abdominal sounds using a stethoscope
- Checking the abdomen for pain, tenderness, swelling, lumps, or masses
The doctor may conduct some diagnostic tests to rule out specific problems, which include:
- Laboratory tests – urine test, stool test, or blood tests
- Barium enema
- Digital rectal examination (DRE)
- Anorectal manometry
Child Abuse and Constipation
Global estimates show that nearly 4%-16% of children are physically abused, 5%-10% are sexually abused, and around 10% feel neglected. (6)
Child maltreatment poses severe mental stress on the child, which causes changes in gastrointestinal motility, alterations in autonomic function, visceral sensitivity, and hypothalamic-pituitary-adrenal dysfunction. (6)
Moreover, children may be unwilling to go to school toilets due to the lack of privacy or being bullied or teased there.
Risk Factors for Constipation
Factors that predispose children to constipation include:
- Lack of activity
- Medical problems in the anus or rectum
- Neurological disorders
- Lack of fiber and fluids
- Some medications
Complications Associated With Constipation
Chronic constipation may lead to the following complications:
- Encopresis, or stool soiling, is a condition where toilet-trained children leak stool into their underwear, usually due to chronic constipation.
- Enuresis is involuntary urination or bed-wetting, which occurs in nearly 40% of children with constipation due to a dilated colon and subsides after the impacted stool is excreted.
- Urologic problems, such as urinary tract infections, rectal ulceration, intussusceptions, or prolapse, may occur due to the enlarged, dilated colon, which is characteristic of constipation.
- A negative self-image may develop in the child. Chronic constipation can cause soiling that the child may be unaware of until it is almost complete. This problem has social ramifications. It can affect the child’s self-image and can have an impact on their social and emotional development. (7)
When to See a Doctor
Acute constipation is common but chronic constipation can indicate the following problems, which require special medical attention:
- Problems in the spinal cord
- Anus or rectum abnormalities
- Hirschsprung’s disease (a condition in which the intestinal wall is devoid of nerve cells)
See your pediatrician or seek emergency care if your child:
- Is younger than 2 months and constipated
- Resists toilet training by withholding stool
- Has severe stomach pain, vomiting, or blood in the stool
- Has a sore anus
- Needs laxatives frequently
- Lacks appetite and thirst
Parents or guardians should be attentive to their child’s health problems. Sudden-onset constipation, without any apparent cause, could be indicative of abuse. Pediatric constipation is often associated with emotional, sexual, and physical abuse. (8)
Expert Answers (Q&A)
Answered by Candice W. Jones, MD, FAAP (Pediatrician)
Vomiting is not a common sign of constipation. A child who is vomiting should be evaluated by a doctor.
The pain of passing a hard stool can cause a child to withhold poop. This can lead to a more serious problem called encopresis, where stool is packed into the rectum. The child experiences leakage of stool and is unaware of it until they find it in the underwear.
It is important to prevent and treat constipation but also work on holding habits by setting a schedule for the child to sit on the toilet regularly.
In most cases, constipation is preventable and easily treated. Parents should make sure their children are:
• Getting plenty of fluids
• Eating 5–6 servings of fruits and vegetables daily
• Eating whole grains
• Going to the bathroom regularly
• Not holding their stool
Also, over-the-counter medications can help, but you should seek the recommendation of your doctor before giving them to your child.
It happens commonly with constipation. However, every child is different, and the focus should be on stool consistency, which is hard in constipation.
Some gastrointestinal conditions are known to cause constipation in kids, such as Hirschsprung disease, celiac disease, neuromuscular diseases, and thyroid disease.
Functional constipation in children can be treated through behavior interventions, parental education, regular follow-ups, and adjustment of medication.
Parents need to support their child in taking steps that facilitate the occurrence of complete bowel movements at regular intervals.