By: Patrick T. Reeves, MD, FAAP & Christine Wassdorp Hurtado, MD, MSCS, FAAP
Constipation is a common problem in children. In fact, roughly
1 in every 20 visits children make to a doctor are because of constipation. Children with constipation may have stools (poops or bowel movements—BMs) that are hard, dry and difficult or painful to get out. Some children with constipation have infrequent stools.
Read on for more information about constipation (signs and symptoms, causes and treatment) and how to help your child develop good bowel habits.
What is normal pooping?
An important milestone in the life of a child is learning to poop in the toilet. Different children poop different amounts and number of times each day. Some poop one time a day and others may go after every meal (three or so times per day).
The most important aspect of pooping is the character (or "softness") of the poop. You can use the
Pediatric Bristol Stool Form Scale for Children (see below) to determine if your child's poops are the correct softness. The goal is to poop a Type 3 or a Type 4 on the scale.
Image courtesy Patrick T. Reeves, MD, FAAP, adapted from Lane et al.
Types of constipation in children
There are two main types of constiptation: organic and functional.
Organic constipation is a fancy way of describing when painful poops occur because of a disease. These types of constipation are very rare and might include celiac disease, thyroid problems or other
Most children have
functional constipation. It can happen when children hold back bowel movements. It also can happen after a child has had a gastrointestinal infection.
Functional constipation usually results from withholding behaviors: a fear of pain or discomfort from pooping, or a lack of awareness of the body's signs for needing to poop, have led to significant discomfort for the child. For example:
Your child may try not to go because it hurts to pass a hard stool. (Diaper rashes can make this worse.)
Children aged 2 to 5 years may want to show they can decide things for themselves. Holding back their stools may be their way of taking control. This is why it is best not to push children into
Sometimes children don't want to stop playing to go to the bathroom.
Older children may hold back their stools when away from home (such as camp or school). They may be afraid of or not like using public toilets.
It is important to note that some children may develop functional constipation after a gastrointestinal illness (diarrhea stomach "bug" or stomach flu). This is known as post-infectious functional constipation.
What happens if constipation gets worse?
Sometimes, a withholding cycle—when the child holds in the poop day after day—can cause more severe symptoms like:
What is encopresis?
When poop overflows like diarrhea because of constipation, we call this
encopresis. Encopresis can be very alarming to children and parents because it can look like diarrhea caused by infections. However, it is actually the child's body attempting to evacuate a large amount of poop.
What are other signs of constipation a parent can look for?
The large, rocky hard poops caused by constipation can cause injury to the skin around the rectum and anus when a child finally has a poop. This can lead to pain with pooping, but the hard poops can also tear the skin around the rectum. This can cause bleeding. Most often, the blood loss is minimal and only noticed when blood is seen on the toilet paper after wiping.
Sometimes children have already developed constipation and are becoming backed up, but have not yet reached the point of encopresis. When this happens, sometimes passing gas (farting/ flatulence) can lead to small streaks/chunks of poop smearing in the underwear, known as fecal streaking.
How is constipation treated?
Many treatments and strategies exist to help children manage their constipation. While some of these medicines are over the counter, we recommend that you discuss any treatments with your child's doctor before starting. Let's look at some of these options:
There is no specific "constipation diet" that has been shown to be effective in preventing or treating constipation. However, increasing water intake and the use of natural fibers from fruits and vegetables are a healthy option that can be recommended to children.
Making sure that children
drink enough water every day is crucial to many bodily functions. When the body does not get enough water, it becomes dehydrated and takes water from the gut and pushes it to other important places in the body, like the heart. This can be what starts the cycle to make poops harder. Increasing a child's water intake without medicines is not an effective treatment for constipation.
There are many sources of fiber including from foods and supplements. Food-based, natural fibers are recommended over supplements. Many fruits that children enjoy-like kiwi- are higher in fiber content. These options can be a healthy, important portion of the child's diet.
Eat 5! A simple way to make sure your child is getting enough fiber is by making healthful food choices. If your child is eating at least 5 servings of fruits and vegetables each day along with other foods that are good sources of fiber, there is really no need to count fiber grams.
Add 5! If you find it helpful to keep track of total grams of fiber that your child is eating, add 5 to your child's age. For example, a 5-year-old would need about 10 grams of fiber each day. (The total daily recommended amount of up to 25 grams for adults can be used as a general guideline for children.) Some foods are high in fiber. Beans, vegetables, fruits and whole grains are good sources of fiber.
Can fiber supplements make constipation worse?
It is important to note that fiber supplements taken without enough
water can worsen your child's constipation!
There is not enough research to support the use of these therapies for children with constipation.
Change toilet posture
Children sometimes have bad posture on the toilet: they slump at the waist and do not sit up straight, they cross their legs, their legs dangle in the air or they clinch their bottom cheeks together.
One tool to improve toilet posture is the defecation posture modification device, a potty stool. This kind of stool can improve toileting posture by promoting the relaxation of the puborectalis muscle and straightening of the "ano-rectal" angle to make passing a poop easier. A
recent study showed that the potty stool is safe and effective (when used with medicines) to treat functional constipation in toilet-trained children.
There are many laxative medicines available to treat children with functional constipation including stool softeners, osmotic laxatives, stimulant laxatives, secretagogue laxatives and rectal therapies.
Examples include docusate sodium. These medications attempt to bring water that is already nearby, but outside of the poop, into the poop to make it softer and easier to expel.
Examples include polyethylene glycol 3350 (PEG), PEG 4000, Milk of Magnesia (magnesium hydroxide), and Magnesium Citrate. These medications attract more water to the colon to ease, hydrate, and soften poop. PEG 3350 is the recommended osmotic laxative to be used in infants and children. Recently, there has been non-scientific, sensationalized media about the concerns for association of PEG 3350. The latest
PEG 3350 does not cause autism spectrum disorders
PEG 3350 is safe in infants, toddlers, children and adults and does not cause increased levels of glycol in the body,
Children do not develop a dependence on PEG 3350 or other osmotic laxatives.
Examples include: senna (and other sennokot plant derivates), bisacodyl and Sodium picosulfate (not sold in United States). These medications work by stimulating the muscles of the colon, the organ that holds the poop, to flex and push poop out of the body.
evidence shows that stimulant laxatives are safe in children. Children do not develop a dependence after short-term or long-term use of stimulant laxatives.
These are highly specialized medications that should be used by pediatric gastroenterologists. They are not approved for use in children by the U.S. Food and Drug Administration. When recommended by your gastroenterologist, these medications are "off label."
Rectal therapies include suppositories (which give medicine directly to the rectum) and enemas (which given medicine higher into the colon to provide additional hydration, lubrication or stimulation to evacuate poop). Evidence shows that enemas are equally effective for fecal disimpaction (a "cleanout") as PEG 3350, but should not be used as the first choice for daily (maintenance) therapies.
Constipation action plans
There is research showing that children and parents benefit from receiving a
Constipation Action Plan at the time of diagnosis. These plans help parents understand what amounts (doses) of medicines to give at what times, and, if need be, to give larger doses in response to worsening symptoms.
How long does my child need to take their medicines for constipation?
Some children may need a medical disimpaction (or cleanout) before starting maintenance therapy. If this is the case, there is a 3-step process to treatment:
The initial cleanout removes the backed-up poop from the body. Usually this requires much higher doses of the medicine (such as PEG 3350) over the course of 1-4 days before going to a lower daily dose. The goal of Step 1 is to produce diarrhea because we are evacuating the buildup of poop. The diarrhea will stop when the cleanout is completed.
Maintenance (daily) therapy prevents stool build-up by keeping stool soft thus cutting down on withholding behavior and allowing the colon to return to its normal shape and muscle tone. During this step, it is important to encourage regular bowel movements in the toilet.
Counseling and behavior modifications may help children who are embarrassed or feel they are "bad" because of the soiling. A counselor can help structure the treatment plan and help the child cooperate.
Constipation should be treated with maintenance medications for at least 2 months. After the 2-month period is completed, the child should be treated for at least 1 additional month while they are asymptomatic.
Constipation while potty trainingChildren can become constipated during toilet training. If this happens, your child should CONTINUE toilet training and take their medicines until toilet training is completed and they have been free of symptoms for one additional month.
What if all of these options fail?
In rare cases, children with functional constipation can undergo more testing to determine if the brain and nerves of the gut are working appropriately. The most common test for this is performed by pediatric gastroenterologists and is known as anorectal manometry. This testing can be done when the child is awake but can be associated with some discomfort.
In addition, there are highly specialized therapies that can be used by pediatric gastroenterologists and pediatric surgeons if the above medications by mouth strategies fail. Please ask your gastroenterologist about these options.
If you have any questions or concerns about your child's health, talk with your child's doctor.
About Dr. Reeves
Patrick T. Reeves, MD, FAAP, is a consultant Pediatric Gastroenterologist at Brooke Army Medical Center and a father of two. Dr. Reeves has published more than 20 PubMed cited articles, received three grant awards, developed two point-of-care medical applications and created numerous clinical tools with the intent to improve patient care.
He has a research focus is the development of medical education curricula and clinical point-of-care instruments to facilitate the care of children.
About Dr. Waasdorp Hurtado
Christine Wassdorp Hurtado, MD, MSCS, FAAP, is a member of the American Academy of Pediatrics and North American Society of Pediatric Gastroenterology Hepatology and Nutrition. She is an Associate Professor of Pediatrics at the University of Colorado School of Medicine and practices in Colorado Springs.