In this article:
- Constipation is one of the most commonly reported health complaints among children and is characterized by difficult, painful, infrequent, or incomplete bowel movements.
- Children can get constipated due to behavioral reasons as well, which include deliberately holding back bowel movements to avoid going to the loo or an inability to adjust to new washrooms.
- Diet modifications, such as increasing water and fiber intake, exercise, and proper toilet training, can help in alleviating chronic idiopathic constipation (CIC) or functional constipation.
- The social aftermath of chronic constipation can have an adverse effect on the general health and well-being of children, and thus they require considerable parental support.
While a regular bowel pattern is indicative of a healthy body, occasional digestive distress, which may cause constipation, is common.
Constipation is a health problem that results in infrequent, painful, or difficult bowel movements and can be characterized by:
- Dry, hard, or lumpy stools
- Incomplete bowel movements despite daily excretions
- Less than three defecations per week in children
Constipation is a commonly prevalent digestive distress that affects 0.7%-29.6% of children worldwide. (1) It causes major concern among parents as it can cause discomfort in children if not treated promptly.
Pediatric constipation refers 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 in a day, which gradually decreases to one to two defecations in a day during infancy. Approximately 98% of children develop the ability to control their sphincter by the time they turn 4. (2)
How Does Constipation Happen?
The large intestine, or the colon, is responsible for absorbing water from digested food. Muscle contractions direct the movement of the food in the colon. As the food passes through the colon toward the rectum, water is absorbed, and solid stool formation takes place.
If the muscle contractions become weak or slow down, the movement of the food retards. This enables the colon to absorb more water, rendering the stool hard and dry, which ultimately results in constipation.
Stages of Constipation
Constipation occurs with varying severity:
- Acute constipation, or short-term constipation, has a sudden onset, which may be due to starting a new school, traveling, or an acute illness. Acute constipation generally resolves on its own or may require the help of simple remedies.
- Chronic constipation, or long-term constipation, persists for more than 2 weeks and usually occurs as a consequence of intestinal diseases. Chronic constipation can cause frequent vomiting and nausea in children since the emptying of the stomach is slowed down. It is recommended to seek medical help if your child is chronically constipated as home remedies may not work.
Types of Constipation
Pediatric constipation has two types:
- Organic: Organic constipation is a rare type of constipation that develops due to biologic causes, which include:
- Structural disorders
- Neurologic problems
- Toxic/metabolic reasons
- Intestinal disorders
- Functional: 90%-95% of all cases of constipation are the functional type. (2) Functional constipation occurs due to behavioral or idiopathic causes, which implies that 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 when:
- Starting solid foods
- Toilet training
- Starting preschool or a new school
Constipation can occur due to various reasons that include:
- Diet: The lack of fiber and water in a child’s diet can affect the bowel movements. Excess consumption of meat, white bread, cheese, bagels, and processed foods can also contribute to constipation.
- Distraction: When children are preoccupied, especially during playing, they tend to ignore the urge to pass stool, which can lead to constipation.
- Illness: A child’s diet may change due to a lack of appetite caused by any ailment, leading to constipation. Conditions like hypothyroidism (underactive thyroid gland) can also induce constipation.
- Stress: Anxiety arising from family problems can cause constipation. The digestive system is affected by emotional upsets in children, resulting in constipation or diarrhea.
- Medications: Constipation may happen as a side effect of some medicines that the child is taking, which include:
- Over-the-counter (OTC) cold medications and antacids
- Chemotherapy drugs
- Narcotic pain medications such as codeine
- Medical conditions: Rarely, constipation in children could be symptomatic of digestive problems, metabolic disorders, or anatomic malformation.
- Family history: The chances of a child being constipated increase when a family member also has the same problem. Such a tendency may be due to the shared genes or influence of environmental factors. (3)
- Cow milk allergy: Some children may be allergic to cow milk, and its intake may induce constipation. Consuming excessive dairy products can also result in constipation. (4) A study conducted in 2011 stated that allergy to cow milk is the most prevalent reason for constipation in children up to 3 years of age. (5)
Functional constipation often results from 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
- Reluctance to get toilet-trained
Children may be unwilling to go to school toilets due to the lack of privacy or being bullied or teased there. Studies have shown that constipation in children may be a sign of abuse (emotional, sexual, or physical). (6)
Collected data show that, worldwide, 4%-16% of children are physically abused, 5%-10% are sexually abused, and around 10% feel neglected. (7)
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. (7)
Symptoms of Constipation in Children
Constipation, in itself, is a symptom that may arise due to an underlying disease. The following symptoms may indicate constipation in children:
- Less than two defecations in a week
- Hard, lumpy, or dry feces
- Bloating or swelling in the abdominal region
- Pain while excretion
- Lack of hunger
- Irritability and crankiness
- Frequent urinary tract infection or loss of bladder control
- Blood in hard stool
- Soft or liquid stool marks on the child’s underwear, which may indicate leakage of feces
The child may show certain behavioral signs that indicate holding in the feces:
- Clenched teeth
- Crossed legs
- Redness in the face
- Squeezing the buttocks
In some cases, the child may appear to have diarrhea when he is constipated. This phenomenon is known as overflow incontinence and 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.
A study of the child’s medical history and the severity and duration of constipation can help in the diagnosis of constipation. The doctor may consider different factors, including:
- Presence of blood in the stool
- Changes in bowel habits
- Weight loss
Generally, a physical exam is the only diagnostic procedure required and is conducted by:
- 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 or tenderness
- Lumps or masses
The doctor may advise specific diagnostic tests if he/she suspects any problems. These tests can include:
- Laboratory tests – urine test, stool test, or blood tests
- Barium enema
- Digital rectal examination (DRE)
- Anorectal manometry
Treatment for Constipation
Functional constipation in children can be treated with the following measures:
- Behavior interventions
- Parental education
- Close follow-up
- Adjustment of medication
Parents need to support their child in taking steps that facilitate the occurrence of complete bowel movements at regular intervals.
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 advise a substitute or may change the dosage of the medication.
1. High-Fiber Foods
Fiber is a natural laxative and helps in treating constipation by softening the stool and promoting regular bowel movements. Include fiber-rich foods, such as whole-grain bread, beans, vegetables, whole-grain cereals, and fruits, in your child’s diet.
However, a sudden increase in fiber content may cause gas formation and bloating. Therefore, gradually add several grams of fiber into the child’s food daily, if he/she is not accustomed to a high-fiber diet. (8)
2. Dietary Modifications
Constipation can be managed by adding Greek yogurt and other sources of probiotics in the child’s diet. Probiotics, or good bacteria, can help in the effective treatment of constipation as they increase the frequency of bowel movements. (9)
Incorporating salads, vegetables, and fruits in all the meals can help in providing relief from constipation. Eating fruits and vegetables unpeeled is highly beneficial. (10)
It is also important to avoid the consumption of foods with low fiber content, including:
- Fast foods
- Frozen meals
- Processed foods such as hotdogs
- Microwavable dinners
- Rice cereal for some children
While bananas promote colon health, they may lead to constipation, especially in children. Unripe bananas are rich in tannins (100-250 mg/100 g banana) and amylase-resistant starch, which can aggravate or induce constipation. (12)
Ripe bananas contain soluble fibers (3 g/120 g banana), soluble sugars, and lesser amounts of tannins and amylase-resistant starch. Therefore, it is recommended to avoid giving bananas to constipated children. (12)
3. Eating Habits
Persuade your child to have three proper meals in a day instead of snacking throughout the day. This ensures adequate appetite during meal time, enabling the child to eat more vegetables rather than snacking on cookies and crisps. A full stomach also facilitates proper bowel movement.
Children often create a fuss over food, which results in constipation. It is important to deal with your child patiently and bring a gradual change in their eating habits.
Maintaining a record of your child’s food and liquid intake can help a medical professional in determining if the diet causes constipation.
Dehydration is a common reason for pediatric constipation. A decrease in water levels in the body impedes the functioning of the digestive system, resulting in the formation of dry and hard stool. A deficiency in fluid and fiber intake is known to worsen the symptoms of constipation. (11)
Adequate intake of clear liquids, around 2 ounces per gram of fiber, is vital. You can give fluids to your child in the form of:
- Water (13)
- Apple, prune, and pear juices (for alleviating constipation) (21)
- Whole fruits (due to the high fiber content) (12)
- Flavored water
- Coconut water
- Vegetable juice
At times, children may try to refrain from drinking water. This problem can be overcome by using special cups or straws that look inviting or flavoring the water with lemon or cucumber.
5. Physical Activity
Daily exercise is equally important for adults and children. Regular exercise helps in preventing obesity in children, releasing stored energy, teaching good habits, and maintaining healthy bowel movements. (14)
Physical activity facilitates a quick movement of food along the large intestine and helps in muscle contraction, leading to the expulsion of feces.
6. Fixed Toilet Routine
Kids often get constipated because they withhold their bowel movements when they are preoccupied, especially while playing. A fixed toilet habit helps your child develop the practice of routine defecation.
To train your child, try making them sit on the toilet after meals for 10 minutes each. Make sure that it is an enjoyable time for the child, and avoid getting agitated if he/she fails to make a bowel movement.
Using a foot stool may provide leverage for easy excretion. If the child feels comfortable, accompany them while training.
Stomach massages may act like laxatives as they can stimulate bowel movements. An abdominal massage is a safe option for constipation treatment as it has no side effects on the child’s health. (15)(16)
A gentle massage on the belly can help in relieving discomfort. Alternatively, rotating your child’s legs in a clockwise direction when he/she lies down on the back with legs flexed onto the belly may also be helpful.
Clinical trials have demonstrated the efficacy of acupuncture therapy in relieving constipation. (17)
Acupuncture has also been shown useful in the treatment of hospital-induced constipation in retrospective case studies. However, the effects are yet to be verified with the help of randomized controlled trials. (18)(20)
Consult a pediatrician before considering acupuncture therapy for children.
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 some complications, including:
- Encopresis: A condition where children above four years of age, who are toilet trained, leak stool into their underwear is called encopresis, also known as stool soiling. It usually occurs as a result of chronic constipation.
- Enuresis: Involuntary urination or bed-wetting is known as enuresis and may occur due to a dilated colon. It usually subsides with the removal of impaction or the passing of stool. Around 40% of children with constipation experience enuresis.
- Urologic concerns: An enlarged, dilated colon due to constipation may lead to urinary tract infections, rectal ulceration, intussusceptions, or prolapse.
- Negative self-image: 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. (19)
In rare cases, chronic constipation can be indicative of the following problems:
- Problems in the spinal cord
- Anus or rectum abnormalities
- Hirschsprung’s disease (a condition in which the intestinal wall is devoid of nerve cells)
When to See a Doctor
While acute constipation is common, chronic constipation could be indicative of or lead to health problems. Therefore, consult a doctor before your child’s constipation becomes a cause of concern.
It is recommended to seek medical help for your child in the following cases:
- Younger than 2 months and constipated
- Resists toilet training by withholding stool
- Blood in the feces
- Sore anus
- Needs laxatives frequently
- Lacks appetite and thirst
Parents or guardians should be attentive to their child’s health problems. Sudden onset of constipation, without any apparent cause, could be indicative of abuse. Pediatric constipation is often associated with emotional, sexual, and physical abuse. (6)
What you may ask your doctor:
- Is it a chronic condition?
- What would be the bowel function usually?
- What steps can I take to provide immediate relief to my child?
- Should I change my child’s dietary habits?
What your doctor may ask you:
- Since when did your child have the symptoms?
- What is the child’s diet?
- Does the child exercise in any form?
- Is the child taking any medications?
Expert Answers (Q&A)
Answered by Candice W. Jones, MD, FAAP (Pediatrician)
Constipation is a very common problem in kids and usually is not serious. Your child may have constipation if they go several days without a bowel movement, have a hard time having a bowel movement, or produce hard, painful stools.
The signs and symptoms of constipation include:
• Having small smears of stool in the underwear
• Finding a small amount of blood on tissue paper after wiping stool
• Feeling overly bloated or full
If these signs and symptoms fail to improve or your child has severe stomach pain, vomiting, or blood in the stool, then please see your pediatrician or seek emergency care.
The most common cause is a diet high in processed foods, which lack fiber needed to move the bowels properly. Other causes are:
• Lack of hydration
• Holding in stool
• Certain health conditions such as irritable bowel syndrome
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 the holding habits by setting a schedule for the child to sit on the toilet regularly.
The best remedy to soften a child’s stool is to include fiber and fluids in the diet and exercise in the daily routine.
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 the 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.
About Dr. Candice W. Jones, MD, FAAP: Dr. Jones is a board-certified physician practicing as a general pediatrician in Orlando, FL. Dr. Candice is committed to the health and well-being of underserved children and adolescents in areas affected the greatest by health inequalities.
In 2016, she launched DrCandiceMD.com, a website focused on kid health education. Dr. Candice completed her residency in pediatrics at the Johns Hopkins School of Medicine in Baltimore, MD. She earned her medical doctorate at the Morehouse School of Medicine in Atlanta, GA.
She is a spokesperson for the American Academy of Pediatrics (AAP), a member of its Council on Communications and Media (COCM), and a member of the Florida Chapter of the American Academy of Pediatrics (FCAAP).