What is constipation?
Constipation is either a decrease in the frequency of bowel movements or the painful passage of bowel movements. Children 1–4 years of age typically have a bowel movement 1–2 times a day, and more than 90% of children have a bowel movement every day or every other day.
Children that have a bowel movement every other day may be constipated (retaining excessive amounts of stool in their large intestine). When children are constipated for a long time, they may begin to soil their underwear. This soiling is involuntary, and the child has no control over it.
How common is constipation?
Constipation is common in children of all ages, especially during potty-training and in school-aged children. Of all visits to the pediatrician, 3% are in some way related to constipation. At least 25% of visits to a pediatric gastroenterologist are due to problems with constipation. Millions of prescriptions are written every year for laxatives and stool softeners.
Why does constipation happen?
Most constipation is functional, meaning that either the colon is slow to push the bowel movement out or that water is absorbed excessively from stool, making it hard. In functional constipation, there is no identifiable structural cause, such as a narrow anus or a spinal cord injury.
In some infants, straining and difficulties expelling a bowel movement (often a soft one) are due to their immature nervous system and/or uncoordinated defecation. Also, some healthy breast-fed infants can skip several days without having a bowel movement.
In children, constipation can begin when there are changes in the diet or routine, during toilet training, or after an illness.
Occasionally, children may hold stools when they are reluctant to use unfamiliar toilet facilities. School or summer camps, with facilities that are not clean or private enough, are common triggers for withholding.
Once the child has been constipated for more than a few days, retained stool can fill up the large intestine (colon) and cause it to stretch. An over-stretched colon cannot work properly and retains more stool. This makes passing the stool very painful, and many children will attempt to withhold stool because of the pain.
Withholding behaviors include tensing up, crossing the legs, or tightening leg/buttock muscles when the urge to have a bowel movement is felt. These withholding behaviors often are misinterpreted as attempts to push the stool out. Stool withholding will make constipation worse and treatment more challenging.
How does your healthcare provider know if constipation is a problem or your child?
The following symptoms indicate that your child may be constipated:
- If your child has hard or small stools that are difficult or painful to pass
- If your child consistently skips days without having normal bowel movements
- If your child has large stools that clog the toilet
Other symptoms that can accompany constipation include stomach pain, poor appetite, crankiness, and blood in the stool. Patients with constipation may have small amounts of blood in their stool because they have an tear in the anus from passing hard stool, called an anal fissure.
In most cases, there is no need for testing prior to treatment for constipation. However, depending on the severity of the problem, your doctor may order X-rays or other tests.
How is constipation treated?
Treatment of constipation varies according to the source of the problem and the child’s age and personality. Some children may only require changes in diet, such as an increase in fiber (often found in fresh fruits and vegetables) or the amount of water they drink each day.
Other patients may require medications, such as stool softeners or laxatives. Stool softeners are not habit-forming and may be taken for a long time without worrisome side effects. Some medications used to treat constipation include lactulose, polyethylene glycol, milk of magnesia, and senna.
A few children may require an initial “clean-out” to help empty the colon. This typically means taking laxatives by mouth or even suppositories or enemas for a short period of time.
It is often helpful to start a bowel training/retraining routine in which the child sits on the toilet for 5–10 minutes after every meal or before the evening bath. It is important to do this consistently to encourage good behavior habits. Praise your child for trying.
If the child is not toilet-trained yet, it is best to wait until constipation is under control.