Constipation in Children

Constipation is probably the most common identifiable cause of recurrent or chronic abdominal pain in children. Even if a child is not constipated, sometimes understanding what causes constipation in children can help prevent it in the first place.

How is constipation defined?

In order to understand what constipation is, it’s important to realize that how often a person goes to the bathroom varies tremendously. Some people go once a day, while others go once a week without any difficulty whatsoever. Individuals tend to have their own patterns of bowel movement frequency. Therefore the definition of constipation is based mostly on the presence of symptoms of discomfort such as abdominal pain, rectal pain, and hard stools rather than the frequency of passing stools.

Can a child be constipated even without typical symptoms?

Yes, children become constipated over time. In most cases, this happens by holding back the stool often because they’re too busy playing or having fun to go to the bathroom. The rectal area gets used to this and does not empty as it should. The more the child holds it in, the more the stool overloads the intestine. It is this “intestinal overload” that causes pain by “pressing” the intestines. This is known as stool(fecal)retention. Typically, the abdominal pain in children who are constipated may worsen after a meal. This is due to the “gastro-colic reflex“, which is a message from the stomach to the intestine telling it to get rid of the stool because more is coming down. So in response, the intestines will cramp down or contract, resulting in pain.

What about babies?

Babies have to learn to pass stool and during the first few weeks, they may grunt, seem fussy or even seem to be straining before passing a (usually normal) stool. Often this is a sign that they are learning to pass a stool rather than of constipation. A baby is considered to be constipated only if the bowel movements are hard, painful, and/or associated with signs of discomfort such as abdominal pain or crying while passing a stool. Also, the stool frequency in breastfed babies can vary even more, for example from 8-12 per day to one bowel movement every few days; This does not mean a baby is constipated. Generally, once a constipated baby has been evaluated, and all are found to be normal, the problem may be treated simply by giving the baby more liquid or by adding some table sugar to the milk. Please speak to your doctor about what is recommended for your specific situation.

How is constipation confirmed?

In some cases, it is obvious by the history of symptoms and the physical examination. In other cases, a very simple abdominal x-ray will reveal that the intestines are abnormally full of stool.

Are there any other problems that can arise from constipation?

Constipation most commonly causes abdominal pain and discomfort. Additionally, it can cause small tears in the anal area known as fissures which can bleed and cause pain. Treating anal fissures is important, because children may refuse to have a bowel movement fearing that it will be painful resulting in holding it in, and making constipation worse. The treatment of fissures is to apply local creams and importantly to address constipation. Very rarely,  some children are born with abnormalities in the muscle of the large intestine which can present as severe and/or difficult to treat constipation. This condition is known as Hirschprung’s disease which only a surgical procedure can cure. Fortunately, in most constipated children there are no associated intestinal abnormalities.

How is constipation treated?

There are 3 parts to the treatment of constipation:

  • Emptying the intestine with:
    • oral medications or liquids such as mineral oil* or oral laxatives,
    • suppositories
    • enemas

*In certain situations mineral oil may be prescribed for up to several months.NOTE: Although some of these medications(including laxatives)are available over the counter, they should only be used on prescription by and under the care/supervision of a doctor.

  • Toilet “re-training”:

Because constipation often lasts a long time, children get used to this situation and they need to re-train their intestines to get used to going to the bathroom regularly. This is the most important part of the treatment of chronic constipation in children. To re-establish a routine, the child should sit on the toilet on a daily basis, preferably after a meal, and at the same time each day, for at least 15 minutes. During this time the child can read a book or play games. This will help create a routine and “re-train” the intestines. Consistency, patience, and persistence are the keys to success.

  • Diet:
    A high-fiber diet is very important. Children who have poor fiber intake tend to be more constipated. It is important to assure that children get enough high fiber in their diet. High fiber foods include:

    • Fruits
    • Vegetables
    • Brown bread
    • Bran muffins
    • Cereals(high fiber like All Bran)
    • Popcorn(….yes popcorn!)

Are there any other problems that can arise from constipation?

Encopresis is the medical name for a stool or fecal overflow or “soiling. It is currently believed that encopresis is a physical problem resulting from a large amount of stool in the intestine, rather than a psychological one. Encopresis, in most instances, is an “overflow” phenomenon in a child with long-standing fecal/stool retention, an extended form of constipation. In some instances, this can develop in the absence of constipation symptoms. The child’s rectal control has been “numbed”, and cannot feel the urge to defecate. The result is that stool “leaks” resulting in soiling which obviously is embarrassing to the child. The approach here is to identify the problem and treat it as we do with constipation. For more information on soiling click here.

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Pediatrician DR.PAUL Roumeliotis is certified by the American Board of Pediatrics and Royal College of Physicians and Surgeons of Canada. The information provided above is designed to be an educational aid only. It is not intended to replace the advice and care of your child’s physician, nor is it intended to be used for medical diagnosis or treatment. If you suspect that your child has a medical condition always consult a physician.