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Constipation

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Definition

  • Can't pass a stool or pain when passing a stool
  • Crying when passing a stool (bowel movement or BM) or
  • Can't pass a stool after straining or pushing longer than 10 minutes or
  • 3 or more days without passing a stool (exception: breastfed and over 1 month old)
  • Caution: any belly pain from constipation comes and goes. Most often, it is mild. Use the Abdominal Pain (Stomach Pain) care guide if there is constant belly pain.

Causes of Constipation

  • High Milk Diet. Milk and cheese are the only foods that in high amounts can cause constipation. It causes hard pale stools. This is why you want your child to eat a well-balanced diet.
  • Low Fiber Diet. Fiber is found in vegetables, fruits and whole grains. Fiber keeps stools soft, bulky and easy to pass. A low fiber diet causes hard, small stools.
  • Low Fluid Intake. This can also cause stools to be dry and harder to pass. It's rarely the only cause of constipation.
  • Lack of Exercise. Exercise also keeps the bowel from slowing down. Not a cause in children unless they are confined to bed.
  • Holding Back Stools Because of Pain. If passing a stool causes pain, many children will hold back the next one. This can happen with a Strep infection around the anus. It can also occur with a bad diaper rash or anal fissure (tear).
  • Holding Back Stools Because of Power Struggles. This is the most common cause of recurrent constipation in children. Most often it's a battle around toilet training. If they are already trained, it may begin with the start of school. Reason: some children refuse to use public toilets. Some children postpone stools because they are too busy to sit down.
  • Slow passage of food through the intestines. Most often, this type runs in families. Called slow transit time.

Stools: How Often is Normal?

  • Normal Range: 3 per day to 1 every 2 days. Once children are on normal table foods, their stool pattern is like adults.
  • Kids who go every 4 or 5 days almost always have pain with passage. They also have a lot of straining.
  • Kids who go every 3 days often drift into longer times. Then, they also develop symptoms.
  • Passing a stool should be free of pain.
  • Any child with pain during stool passage or lots of straining needs treatment. At the very least, the child should be treated with changes in diet.

Imitators of Constipation: Normal Patterns and Stools

  • Breastfed and Over 1 Month Old. Stools every 4-7 days that are soft, large and pain-free can be normal. Caution: before 1 month old, not stooling enough can mean not getting enough breast milk.
  • Straining in Babies. Grunting or straining while pushing out a stool is normal in young babies. They are learning to relax their anus after 9 months of keeping it closed. It's also hard to pass stool lying on their back with no help from gravity. Babies also become red in the face and draw up their legs during straining. This is normal. Key: they continue to pass normal size stools every day. Just not every time they have some straining.
  • Brief straining under 10 minutes can occur at times at any age.
  • Large Stools. Size relates to the amount of food eaten. Large eaters have larger stools.
  • Hard or Dry Stools. Also can be normal if passed easily without too much straining.  Often, this relates to poor fiber intake. Some children even have small, dry rabbit-pellet-like stools.
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When To Call

Go to ER Now

  • Vomiting bile (green color). Exception: stomach juice which is yellow.

Call Doctor or Seek Care Now

  • Stomach pain goes on more than 1 hour (includes crying) after using care advice
  • Rectal pain goes on more than 1 hour (includes straining) after using care advice
  • Vomits 2 or more times and stomach looks more swollen than normal
  • Age less than 1 month old and breastfed
  • Age less than 12 months with recent onset of weak suck or weak muscles
  • Your child looks or acts very sick
  • You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

  • Age less than 2 months. Exception: normal straining and grunting.
  • Bleeding from anus
  • Needs to pass a stool but afraid to or refuses to let it out
  • Child may be "blocked up"
  • Suppository or enema was given but did not work
  • You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

  • Leaking stool
  • Suppository or enema was needed to get the stool out
  • Infrequent stools do not get better after changes to diet. Exception: normal if breastfed infant more than 1 month old and stools are not painful.
  • Stool softeners are being used and have not been discussed with your doctor
  • Toilet training is in progress
  • Painful stools occur 3 or more times after changes to diet
  • Constipation is a frequent problem
  • You have other questions or concerns

Self Care at Home

  • Mild constipation
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Care Advice

What You Should Know about Constipation:

  • Constipation is common in children.
  • Most often, it's from a change in diet. It can also be caused by waiting too long to stool.
  • Passing a stool should be pleasant and free of pain.
  • Any child with pain during stool passage or lots of straining needs treatment. At the very least, they need changes in diet.
  • Here is some care advice that should help.

Normal Stools:

  • Normal range: 3 per day to 1 every 2 days. Once children are on a regular diet, their stool pattern is like adults.
  • Kids who go every 3 days often drift into longer times. Then symptoms start.
  • Kids who go every 4 and 5 days almost always have pain with passage. They also have lots of straining.

Diet for Infants Under 1 Year Old:

  • Age over 1 month old only on breast milk or formula, add fruit juice.
  • Amount. Give 1 ounce (30 mL) per month of age per day. Limit amount to 4 ounces (120 mL).
  • Pear and apple juice are good choices. After 3 months, can use prune (plum) juice. Reason for fruit juice: approved for babies in treating a symptom.
  • If on baby foods, add those high in fiber. Do this twice a day. Examples are peas, beans, apricots, prunes, peaches, pears, or plums.
  • If on finger foods, add cereals and small pieces of fresh fruit.

Diet for Children Over 1 Year Old:

  • Increase fruit juice (apple, pear, cherry, grape, prune). Note: citrus fruit juices are not helpful.
  • Add fruits and vegetables high in fiber content. Examples are peas, beans, broccoli, bananas, apricots, peaches, pears, figs, prunes, or dates. Offer these foods 3 or more times per day.
  • Increase whole grain foods. Examples are bran flakes or muffins, graham crackers, and oatmeal. Brown rice and whole wheat bread are also helpful.  Popcorn can be used if over 4 years old.
  • Limit milk products (milk, ice cream, cheese, yogurt) to 3 servings per day.
  • Fluids. Give enough fluids to stay well-hydrated. Reason: keep the stool soft.

Stop Toilet Training:

  • Your child may be starting to hold back stools. Talk to your doctor about a treatment plan.
  • Put your child back in diapers or pull-ups for a short time.
  • Tell him that the poops won't hurt if he helps them come out every day.
  • Praise him for passing poops into a diaper.
  • Holding back stools is harmful. Use rewards to help your child give up this bad habit.
  • Avoid any pressure or punishment. Also, never force your child to sit on the potty against his will. Reason: it will cause a power struggle.
  • Treats and hugs always work better.

Encourage Sitting on the Toilet (if toilet trained):

  • Set up a normal stool routine, if your child agrees to sitting.
  • Have your child sit on the toilet for 5 minutes after meals.
  • This is especially important after breakfast.
  • If you see your child holding back a stool, also take to the toilet for a sit (if cooperates).
  • During sits, stay with your child and be a coach. Just focus on helping the poop come out.
  • Do not distract your child. Do not allow your child to play with video devices, games or books during sits.
  • Once he passes a normal size stool, he doesn't need to sit anymore that day.

Warm Water to Relax the Anus:

  • Warmth helps many children relax the anus and release a stool.
  • For straining too long, have your child sit in warm water.
  • You can also put a warm wet cotton ball on the anus. Vibrate it side to side for about 10 seconds to help relax the anus.

Flexed Position to Help Stool Release for Babies:

  • Help your baby by holding the knees against the chest. This is like squatting for your baby. This is the natural position for pushing out a stool. It's hard to have a stool lying down.
  • Gently pump on the lower belly with your fingers. If no stool release in a few minutes, stop.
  • Gently pumping the left side of the belly also helps.

Squatting Position to Help Stool Release for Older Children:

  • The squatting position gives faster stool release and less straining.
  • Squatting means that the knees are above the hips.
  • For most children who sit on the toilet, a foot stool is needed.
  • It is an important part of treating constipation.

Stool Softeners (Age Over 1 Year Old):

  • If a change in diet doesn't help, you can add a stool softener. Must be over 1 year of age.
  • Use a stool softener (such as Miralax). It is available without a prescription. Give 1-3 teaspoons (5-15 mL) powder each day with dinner.
  • Mix each 1 teaspoon (5 mL) of Miralax powder to 2 ounces (30 mL) of water.
  • Fiber products (such as Benefiber) are also helpful. Give 1 teaspoon (5 mL) twice a day. Mix it in 2 ounces (60 mL) of water or fruit juice.
  • Stool softeners and fiber should produce regular soft stools in 1 to 3 days.
  • Discuss dosage and how long to use with your doctor.

What to Expect:

  • Most often, changes in diet helps constipation.
  • After your child is better, be sure to keep him on high fiber foods.
  • Also, have your child sit on the toilet at the same time each day.
  • These tips will help to prevent the symptoms from coming back.

Call Your Doctor If:

  • Constipation lasts more than 1 week after making changes to diet
  • You think your child needs to be seen
  • Your child becomes worse

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Barton Schmitt MD, FAAP
Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.
Copyright 2000-2024. Schmitt Pediatric Guidelines LLC.
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