Constipation in children

Constipation in children is a common problem. A constipated child has infrequent bowel movements or hard, dry stools.

Common causes include early toilet training and changes in diet. Fortunately, most cases of constipation in children are temporary.

Encouraging your child to make simple dietary changes — such as eating more fiber-rich fruits and vegetables and drinking more water — can go a long way toward alleviating constipation. If your child's doctor approves, it may be possible to treat a child's constipation with laxatives.

Symptoms

Signs and symptoms of constipation in children may include:

• Less than three bowel movements a week
• Bowel movements that are hard, dry and difficult to pass
• Pain while having a bowel movement
• Stomach pain
• Traces of liquid or pasty stool in your child's underwear — a sign that stool is backed up in the rectum
• Blood on the surface of hard stool

If your child fears that having a bowel movement will hurt, he or she may try to avoid it. You may notice your child crossing his or her legs, clenching his or her buttocks, twisting his or her body, or making faces when attempting to hold stool.

When to see a doctor

Constipation in children usually isn't serious. However, chronic constipation may lead to complications or signal an underlying condition. Take your child to a doctor if the constipation lasts longer than two weeks or is accompanied by:

• Fever
• Not eating
• Blood in the stool
• Abdominal swelling
• Weight loss
• Pain during bowel movements
• Part of the intestine coming out of the anus (rectal prolapse)

Causes

Constipation most commonly occurs when waste or stool moves too slowly through the digestive tract, causing the stool to become hard and dry.

Many factors can contribute to constipation in children, including:

• Withholding. Your child may ignore the urge to have a bowel movement because he or she is afraid of the toilet or doesn't want to take a break from play. Some children withhold when they're away from home because they're uncomfortable using public toilets.

  Painful bowel movements caused by large, hard stools also may lead to withholding. If it hurts to poop, your child may try to avoid a repeat of the distressing experience.

• Toilet training issues. If you begin toilet training too soon, your child may rebel and hold in stool. If toilet training becomes a battle of wills, a voluntary decision to ignore the urge to poop can quickly become an involuntary habit that's tough to change.
• Changes in diet. Not enough fiber-rich fruits and vegetables or fluid in your child's diet may cause constipation. One of the more common times for children to become constipated is when they're switching from an all-liquid diet to one that includes solid foods.
• Changes in routine. Any changes in your child's routine — such as travel, hot weather or stress — can affect bowel function. Children are also more likely to experience constipation when they first start school outside of the home.
• Medications. Certain antidepressants and various other drugs can contribute to constipation.
• Cow's milk allergy. An allergy to cow's milk or consuming too many dairy products (cheese and cow's milk) sometimes leads to constipation.
• Family history. Children who have family members who have experienced constipation are more likely to develop constipation. This may be due to shared genetic or environmental factors.
• Medical conditions. Rarely, constipation in children indicates an anatomic malformation, a metabolic or digestive system problem, or another underlying condition.

Risk factors

Constipation in children is more likely to affect kids who:

• Are sedentary
• Don't eat enough fiber
• Don't drink enough fluids
• Take certain medications, including some antidepressants
• Have a medical condition affecting the anus or rectum
• Have a neurological disorder

Complications

Although constipation in children can be uncomfortable, it usually isn't serious. If constipation becomes chronic, however, complications may include:

• Painful breaks in the skin around the anus (anal fissures)
• Rectal prolapse, when the rectum comes out of the anus
• Stool withholding
• Avoiding bowel movements because of pain, which causes impacted stool to collect in the colon and rectum and leak out (encopresis)

Prevention

To help prevent constipation in children:

• Offer your child high-fiber foods. A diet rich in fiber can help your child's body form soft, bulky stool. Serve your child more high-fiber foods, such as fruits, vegetables, beans, and whole-grain cereals and breads. If your child isn't used to a high-fiber diet, start by adding just several grams of fiber a day to prevent gas and bloating.

  The recommended intake for dietary fiber is 14 grams for every 1,000 calories in your child's diet.

  For younger children, this translates to an intake of about 20 grams of dietary fiber a day. For adolescent girls and young women, it's 29 grams a day. And for adolescent boys and young men, it's 38 grams a day.

• Encourage your child to drink plenty of fluids. Water is often the best.
• Promote physical activity. Regular physical activity helps stimulate normal bowel function.
• Create a toilet routine. Regularly set aside time after meals for your child to use the toilet. If necessary, provide a footstool so that your child is comfortable sitting on the toilet and has enough leverage to release a stool.
• Remind your child to heed nature's call. Some children get so wrapped up in play that they ignore the urge to have a bowel movement. If such delays occur often, they can contribute to constipation.
• Be supportive. Reward your child's efforts, not results. Give children small rewards for trying to move their bowels. Possible rewards include stickers or a special book or game that's only available after (or possibly during) toilet time. And don't punish a child who has soiled his or her underwear.
• Review medications. If your child is taking a medication that causes constipation, ask his or her doctor about other options.

Diagnosis

Your child's doctor will:

• Gather a complete medical history. Your child's doctor will ask you about your child's past illnesses. He or she will also likely ask you about your child's diet and physical activity patterns.
• Conduct a physical exam. Your child's physical exam will likely include placing a gloved finger into your child's anus to check for abnormalities or the presence of impacted stool. Stool found in the rectum may be tested for blood.

More-extensive testing is usually reserved for only the most severe cases of constipation. If necessary, these tests may include:

• Abdominal X-ray. This standard X-ray test allows your child's doctor to see if there are any blockages in your child's abdomen.
• Anorectal manometry or motility test. In this test, a thin tube called a catheter is placed in the rectum to measure the coordination of the muscles your child uses to pass stool.
• Barium enema X-ray. In this test, the lining of the bowel is coated with a contrast dye (barium) so that the rectum, colon and sometimes part of the small intestine can be clearly seen on an X-ray.
• Rectal biopsy. In this test, a small sample of tissue is taken from the lining of the rectum to see if nerve cells are normal.
• Transit study or marker study. In this test, your child will swallow a capsule containing markers that show up on X-rays taken over several days. Your child's doctor will analyze the way the markers move through your child's digestive tract.
• Blood tests. Occasionally, blood tests are performed, such as a thyroid panel.

Treatment

Depending on the circumstances, your child's doctor may recommend:

• Over-the-counter fiber supplements or stool softeners. If your child doesn't get a lot of fiber in his or her diet, adding an over-the-counter fiber supplement, such as Metamucil or Citrucel, might help. However, your child needs to drink at least 32 ounces (about 1 liter) of water daily for these products to work well. Check with your child's doctor to find out the right dose for your child's age and weight.

  Glycerin suppositories can be used to soften the stool in children who can't swallow pills. Talk with your child's doctor about the right way to use these products.

• A laxative or enema. If an accumulation of fecal material creates a blockage, your child's doctor may suggest a laxative or enema to help remove the blockage. Examples include polyethylene glycol (GlycoLax, MiraLax, others) and mineral oil.

  Never give your child a laxative or enema without the doctor's OK and instructions on the proper dose.

• Hospital enema. Sometimes a child may be so severely constipated that he or she needs to be hospitalized for a short time to be given a stronger enema that will clear the bowel (disimpaction).

Alternative medicine

In addition to changes in diet and routine, various alternative approaches may help relieve constipation in children:

• Massage. Gently massaging your child's abdomen may relax the muscles that support the bladder and intestines, helping to promote bowel activity.
• Acupuncture. This traditional Chinese medicine involves the insertion and manipulation of fine needles into various parts of the body. The therapy may help if your child has constipation-related abdominal pain.

Preparing for an appointment

If your child's constipation lasts longer than two weeks, you'll likely first seek medical care from your child's doctor. If necessary, your child may be referred to a specialist in digestive disorders (gastroenterologist).

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared. Here's some information to help you get ready and know what to expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance, such as restrict your child's diet.
• Write down any symptoms your child is experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. It's also a good idea to write down your child's signs and symptoms. Record the date your child's constipation started and any other coinciding events. Include notes about stool frequency and appearance, and any changes you've noticed in stool patterns (frequency, volume and content), as well as what and how much your child eats and drinks.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins or supplements that your child is taking. Let your child's doctor know what steps you've taken to try to treat your child's constipation.
• Write down questions to ask your child's doctor.

For constipation in children, some basic questions to ask your doctor include:

• What's the most likely cause of my child's symptoms?
• Are there any other possible causes?
• What kinds of tests does my child need?
• How long might this condition last?
• What treatments do you recommend?
• Do I need to make any changes to my child's diet?
• Should we see a specialist?
• Is there a generic alternative to the medicine you're prescribing?
• Can this problem be treated without medication?
• Are there brochures or other printed material that I can take with me? What websites do you recommend?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

• When did your child first begin experiencing symptoms of constipation?
• Have your child's symptoms been continuous or occasional?
• How severe are your child's symptoms?
• What, if anything, seems to improve your child's symptoms?
• What, if anything, seems to worsen your child's symptoms?
• Do you see blood with your child's bowel movements, either mixed in with the stool, in the toilet water or on the toilet paper?
• Does your child soil his or her underwear?
• Does your child strain with bowel movements?
• Does your child have a family history of digestive problems?
• Has your child started any new medications or changed the dosage of current medications?
• Can you describe your child's toilet-training experience?

What you can do in the meantime

There are several things you can do that might help relieve your child's constipation before your doctor's appointment, for example:

• Give your child prune juice. Prune juice can be mixed with other juices (such as apple juice) if your child doesn't like the taste. It's also important to make sure toddlers and older children are drinking sufficient water.
• Cut back on constipating foods. Give toddlers and older children fewer foods that might lead to constipation, such as milk and cheese.
• If possible, take your child for a walk or run. Regular physical activity can encourage bowel movements.
• Ease up on toilet training. If you suspect that toilet training may be playing a role in your child's constipation, take a break from toilet training for a bit to see if the constipation improves.

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