Constipation means that the bowel is healthy but not working properly. Constipation is defined as having a bowel movement fewer than three times per week. Stools are usually hard, dry and difficult to eliminate. Some children who are constipated find it painful to have a bowel movement and often experience straining, bloating and the sensation of a full bowel.
In most cases, the cause of constipation is functional; in other words, there is no physical abnormality causing constipation. Some children experience functional constipation for the following reasons:
- Dietary changes. Constipation following dietary changes usually occurs during the first year or two of life. This often happens after the introduction of rice cereal, solid foods or during the change from breast milk or formula to cow's milk.
- Stool avoidance behavior. Stool avoidance behavior occurs when children experience painful bowel movements or fear having a bowel movement. Other reasons a child may avoid a bowel movement include fear of toilet training, anxiety in public restrooms and being too distracted by school work or play to go to the toilet. The child is able to hold the stool in, but over time it becomes too large. The passage of a large stool is painful and can perpetuate the cycle of pain leading to stool withholding. A large stool may also cause small tears in the anus that result in blood on the toilet paper or in the toilet water. Over time, the rectum becomes stretched and the child cannot feel the urge to have a bowel movement. In some cases, children with constipation begin to experience fecal soiling of their underpants. This is called encopresis. Children who are trying to withhold stool will often be quiet and still while assuming an unusual posture. Some children will stand stiffly while others hide. Infants and toddlers often cry while straightening their legs.
The good news is that, most of the time, constipation in childhood is not serious.
Symptoms of constipation include:
- Avoidance of bowel movements
- Abdominal pain
- Dry, hard stool
- Encopresis(soiling of the underpants)
- Lack of appetite
- Passage of large stool that clogs or almost clogs the toilet
Children with constipation may pass a large amount of liquid stool, even if they are not sick. Parents may misinterpret this as diarrhea.
Diagnosis of Constipation
If your child has symptoms of constipation, a pediatric gastroenterologist will talk with you and your child and complete one or more of the following exams and tests to confirm a diagnosis:
- Physical exam. The pediatric specialist will ask you about your child's symptoms and conduct a physical examination.
- Rectal exam. The physical exam may include a rectal examination to check for impacted stool. During this exam, the doctor inserts a lubricated, gloved finger into your child's rectum.
- X-ray. Your child's pediatric gastroenterologist may also recommend an abdominal X-ray to confirm the presence of impacted stool.
- Fluoroscopy. In rare cases, a pediatric radiologist will perform a type of fluoroscopy called a barium enema to look for structural abnormalities of the large intestine (colon).
- Motility test. A pediatric gastroenterology specialist can perform a motility test called anorectal manometry to test the sphincter muscles that control bowel movements.
There are four equally important parts of treating children with constipation:
- Disimpaction. If your child has a fecal impaction, this stool must be removed before therapy can be successful. An enema or a high dose of medicine such as MiraLAX may be used.
- Maintenance medicine. Once the rectum is cleared of stool, long-term therapy can begin. Stool softeners such as MiraLAX, lactulose, Milk of Magnesia or mineral oil are most often used. Occasionally, stimulant laxatives are used in addition to stool softeners. Maintenance medications usually are continued for several months.
- Dietary modifications. Increasing fiber in the diet and drinking plenty of fluids may help manage your child's symptoms once a regular bowel habit is established. A pediatric gastroenterologist will give your child a goal for daily fiber intake. In some cases, it may be necessary to use a fiber supplement.
- Behavioral modifications. This part of the treatment is key. In order for the above treatments to work, a regular bowel habit must be established and maintained. To promote a regular bowel habit, children who are toilet trained (or in the process) should sit on the toilet for five to 10 minutes following their morning and evening meals. Meals are often followed by contractions in the colon that are meant to rid the colon of stool (the gastrocolic reflex). Sitting on the toilet takes advantage of this natural reflex.
Key Points to Remember
Key Points to Remember
- Constipation is defined as fewer than three bowel movements per week.
- Stool avoidance behavior is a common cause of constipation. Infants may experience constipation due to dietary changes.
- Treatment for constipation includes dietary and behavior modifications along with the use of stool softeners.
Support Services & Resources
Support Services & Resources
Visit the websites below to find support groups and services and learn more about constipation.
Riley at IU Health offers a broad range of supportive services to make life better for families who choose us for their children's care.
The Gastroenterology, Hepatology & Nutrition Department at Riley at IU Health is involved in research for constipation. If you would like to learn more, please ask your child's provider about available research opportunities.