Constipation in Children

Constipation is a common problem in children. It occurs in up to 10%, although only 3% of parents actually seek advice from the doctor. Constipation is generally described as the infrequent passage of stools (bowel movements) or the passage of hard stools. Any definition of constipation depends on how often the child normally passes stools and the normal consistency of his or her stools.

For some children, it may be normal to pass stools as far apart as every few days. But you should treat hard stools that are difficult to pass and those that happen only every 3 days as constipation.

Infants and children with constipation are treated differently than adults because patterns of bowel movements change from the time they are born until they are age 3 or 4 years. The majority of children with constipation do not have a medical disease or disorder causing the constipation. Rarely, a disorder causes infants and children to have significant problems moving their bowels.

Many things can contribute to constipation.

• The most common cause in a child older than 18 months is the avoidance of going to the bathroom for various reasons. For example, toddlers are often too involved in their play and lack the time or patience for bathroom breaks.
  
  
• At school they may be concerned with lack of privacy or cleanliness of the bathroom.
  
  
• They may have had a prior painful or frightening experience that makes them want to avoid going to the bathroom. Over time, their brain learns to ignore repeated urges by the colon to go to the bathroom. As stool remains in the colon, the colon will absorb water out of the stool, making it hard and dry. This makes it even more difficult or painful to pass and causes the child to continue "holding it."
  
  
• Diet or changes in diet have been thought to have an effect on bowel habits. In adults, high-fiber diets have been shown to improve bowel function. In children, however, high-fiber diets have not been proven to improve constipation. Infants and children who eat well-balanced meals typically are not constipated.
  
  
• Breastfed infants will generally have more stools per day. Their stools vary more in their frequency when compared to bottle-fed infants. For example, breastfed infants have anywhere from 5-40 bowel movements per week; whereas formula-fed infants have 5-28 bowel movements per week. Also, switching the type of milk or formula a child is taking can also cause constipation.
  
  
• Teenagers and toddlers who eat a lot of sugar and desserts are also prone to difficulties in passing their bowels.
  
  
• Any intense changes in a child, such as illnesses causing fever, a long time in bed, eating less, or dehydration may cause decreased frequency of stools or may harden stools.
  
  
• A number of medical disorders can cause chronic constipation.
  
  
  • Hypothyroidism (lowered activity of the thyroid gland) is a condition that causes decreased activity of the intestinal muscles along with many other symptoms. Most newborns are tested for it at birth as part of the newborn screening blood test. This condition is usually diagnosed when a baby is very young.
    
    
  • True constipation in infants and children that has been present since birth may be Hirschsprung disease. This is a congenital condition that is uncommon. It is a condition in which there are no ganglion cells (a type of nerve cell) located in a segment of the colon. As a result, the colon cannot receive directions from the brain to go to the bathroom properly. Most infants with Hirschsprung disease generally will have symptoms within the first few weeks of life. They may be underweight or small for their age. They may vomit and have small stools, which are described as ribbonlike. Hirschsprung disease is generally more common in boys and in babies with Down syndrome. If Hirschsprung is suspected, you need to take the child to see a specialist (gastroenterologist) or pediatric surgeon for further tests.
    
    
  • Diabetes is another common medical problem that is associated with constipation.
    
    
  • Alterations of electrolytes, such as calcium or potassium, can produce changes in bowel habits.
    
    
  • Although other symptoms of lead poisoning will be more obvious, children with chronic lead exposure may have constipation.
    
    
  • Cystic fibrosis, for many reasons, causes constipation in children.
    
    
  • Children with disorders of the nervous system such as cerebral palsy, mental retardation, or spinal cord problems have a high rate of constipation because they have prolonged time in one position, abnormal colon movement, and lack coordination in moving their bowels.
  
  
• Medications can make children more likely to be constipated. Over-the-counter cold medications and antacids are common causes. Antidepressants, anticonvulsants, chemotherapy medications, or narcotic pain medications, such as codeine, can contribute to the problem.
  
  
• Other possible causes of constipation are depression, coercive toilet training, attention deficit disorders, and sexual abuse.

Generally, if a child has fewer than 3 bowel movements per week and they are hard and difficult to pass, he or she may have constipation.

• Children often exhibit characteristic behaviors while trying to keep from having a bowel movement.
  
  
  • Infants having painful bowel movements may extend their legs and squeeze their anal and buttock muscles to prevent passage of stool.
    
    
  • Toddlers often rise up on their toes, rock back and forth, and hold their legs and buttocks stiffly.
  
  
• Sometimes school-age children (older than 4 years) are taken to the doctor for what is mistaken as diarrhea. These constipated children often have encopresis, or accidental fecal soiling. Often if hard stool is present in the rectum, liquid feces can leak around the hard stool and pass out the anus without the child’s control. It can happen as often as once to several times a day. The child cannot do anything to prevent or withhold it. Parents, unaware that their child is constipated, don't relate the soiling to constipation, making it hard to make the diagnosis.
  
  
• Other signs that children are constipated are these:
  
  
  • Vague abdominal pain around the navel (belly button) or even severe attacks of abdominal pain
    
    
  • Decreased appetite, nausea, or vomiting
    
    
  • Urinary incontinence, frequent urination, or bed-wetting
    
    
  • Reappearing urinary tract infections

If none of the home care measures is working, call your doctor. He or she may prescribe a laxative. The type of laxative depends on the age of the child and the exact problem. You may need to make an appointment with your doctor.

If the child has significant abdominal pain, nausea, vomiting, decreased appetite, fever, or bloody diarrhea, he or she needs to see a doctor immediately. Many of these symptoms can be related to constipation. Some of them, however, can indicate a serious medical condition.

• A doctor will perform an examination to assess the child’s general appearance and growth. The doctor will look for signs of diseases that may cause constipation.
  
  
  • Close attention to the abdominal exam may reveal distention, tenderness, or hard stool that can be felt.
    
    
  • Anal inspection will be performed to check for problems. The doctor may perform a digital rectal exam with his or her finger to check for hard stool in the rectum or to see if the rectum is dilated.
    
    
  • The stool may need to be tested for blood.
  
  
• Usually no diagnostic tests or x-rays have to be performed if the history and exam suggest constipation. Sometimes an abdominal x-ray is obtained and shows stool in the colon. If a medical problem is suspected as the cause of constipation, blood tests or other abdominal imaging studies may need to be performed.
  
  
• The most useful tool the doctor can use to diagnose constipation is the history given by the parents. A doctor needs to know the following:
  
  
  • What is meant when parents use the term constipation and how long has the condition been present?
    
    
  • What is the size and consistency of the stools?
    
    
  • How frequent are the bowel movements?
    
    
  • Is pain present with stooling and is there blood present?
    
    
  • Is abdominal pain a problem?
    
    
  • Is there poor appetite, weight loss, or poor weight gain?
    
    
  • Are episodes of fecal soiling present?
    
    
  • Does the child use the bathroom at school?
    
    
  • What over-the-counter, herbal, or prescription medications are being taken?
    
    
  • What type of diet is the child on?

|Self-Care at Home|

A few important steps at home can keep constipation from becoming a continuous problem:

• Positive reinforcement is the first step in giving children the desire to begin regulation of their bowels. It is important to remove any negative thoughts about being constipated, especially if fecal soiling is present.
  
  
• Bowel retraining is the next step. The body has a natural reflex called the gastrocolonic reflex. After a meal, the colon undergoes peristalsis and attempts to clear the bowels. Have your child take advantage of the gastrocolonic reflex after each meal. Have him or her sit on the toilet for at least 10 minutes. It is often easier for the child if the feet are on the floor or on a footstool.
  
  
• Give your child plenty of fluids and juices, such as prune juice.
  
  
• A well-balanced meal consisting of whole bran cereals, fruits, and vegetables with less candy and dessert also helps.

|Medical Treatment|

Treatment usually consists of educating parents about the cause of the constipation. It is important for the doctor to reassure parents that it is neither their fault nor the child’s and that nothing is psychologically wrong. If fecal soiling is present, negative attitudes about the condition need to be removed.

• Treatment can begin after education. If a child has a large amount of hard stool present in the colon, disimpaction will need to be done. In other words, the stool needs to be removed. This is done using either oral or rectal medications, or a combination of both. The type of medication used also depends on the child’s age and exact problem.
  
  
• After disimpaction, preventing the reaccumulation of hard stools is the key to maintaining good bowel habits. This usually has to be done with long-term medication.

|Follow-up|

After the initial diagnosis, regular scheduled visits to the doctor should be made in order to ensure that the therapy continues to work and to prevent relapses. As soon as a problem develops, call the doctor.

|Prevention|

To prevent constipation from returning, the child should make changes in behavior, diet, and fluid intake.

• Long-term use of laxatives may be indicated for several months or up to a full year.
  
  
• Regular toilet habits have to be started after each meal to take advantage of the body’s normal urge to empty the bowel.
  
  
• Continued use of positive reinforcement with verbal or other rewards or both often contributes to long-term bowel success.

|Outlook|

• Acute constipation can be corrected easily. After dehydration or illness improves, bowel function improves.
  
  
• Chronic constipation, however, often requires long-term therapy with oral medication. Most children respond to therapy and are off medications within a year. Relapses can be common, however, especially if the child or parents do not follow the doctor’s instructions or medical intervention is not present. If therapy fails, the child may need to see a pediatric gastroenterologist (a doctor who specializes in the stomach and intestines).

constipation, hard stools, straining with defecation, infrequent bowel opening, impaction, laxative, bowel movement, BM, bowel, elimination of stool, poor bowel habits, fiber, diarrhea, constipated,  irregularity, encopresis, Hirschsprung disease, disimpactation, bowel retraining, acute constipation, chronic constipation, abdominal pain, constipation in children

Author: Victoria NH Wilson, MD, Resident Physician, Department of Emergency Medicine, Wake Forest University Baptist Medical Center.

Coauthor(s): Nancy A Wick, MD, Instructor, Department of Emergency Medicine, Section of Pediatrics, Wake Forest University and Baptist Medical Center.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Steven L Bernstein, MD, Vice-Chair, Academic Affairs, Department of Emergency Medicine, Newark Beth Israel Medical Center; Assistant Professor, Department of Emergency Medicine, Mt Sinai School of Medicine.