KidsMD Health Topics

Constipation

  • What is constipation?

    Constipation is a common concern among children and is commonly seen in toddlers as they potty train. School-aged children also commonly experience constipation. In fact, almost 3% of all pediatrician visits are in some way related to constipation. (At least 25% of visits to pediatric gastroenterology specialists are due to problems with constipation.)

    Constipation is when a child has either a decrease in the frequency of bowel movements or when moving the bowels is painful. Children ages 1 to 4 years typically have a bowel movement once or twice a day, and more than 90% will go at least every other day.

    Constipation is typically described as being either organic or functional. Organic constipation is caused by a diagnosed medical condition, like colon disease or a neurological problem. Functional constipation means there is no identifiable cause. Functional constipation is the most common form of the condition. While it still is a concern, there typically are no more serious medical conditions associated with it. 

    What causes constipation?

    Some infants experience difficulty moving their bowels, because their nervous systems are still developing.  Also worth noting, some healthy, breast-fed infants will go several days without having a movement.  

    In older children, constipation often begins with the introduction of changes in their diet, disruptions to their day-to-day routines, during toilet training or after becoming sick. Public bathrooms—especially unclean or less private ones—also can make a child reluctant to use the toilet, which can lead to a pattern of withholding or ignoring the need to move their bowels.

    If a child is constipated for several days, the retained stool can fill up the large intestine (the colon), causing it to stretch. An over-stretched colon will not function properly, and more stool is retained. Once this occurs, defecation becomes very painful. As a result, the child avoids the pain by withholding thus creating a cycle that can make constipation worse.

    How does Boston Children's Hospital treat constipation?

    To best understand the cause of your child's constipation, a clinician from the Division of Gastroenterology, Hepatology and Nutrition, will

    assess how serious your child's constipation is by asking if your child:

    • has hard or small stools that are difficult or painful to pass

    • consistently skips days without having normal bowel movements

    • has large, uncharacteristically large stools

    • has stomach pain, poor appetite, crankiness and/or bleeding from the anus

    In most cases, there is no need for testing prior to treatment for constipation. However, depending on the severity of the problem, your doctor may order x-rays or other tests to properly diagnosis the source of the constipation.

    Once the root and/or severity of your child's constipation have been determined, a treatment plan will be designed based on your child's age and personality. For some, constipation can be corrected by changes in diet, like increasing their intake of water, fiber or fresh fruit. Other children may need medications like laxatives or stool softeners to help them go. 

    In rare cases, children may need to have an excessive build-up of stool "flushed" from their colon. This usually is done with laxatives, suppositories or enemas if needed.  

    For more information on constipation or to speak with a member of Boston Children's Division of Gastroenterology, Hepatology and Nutrition, please call 617-355-6058.

  • What causes constipation? 

    Sometimes, there is no identifiable reason for constipation in children. However, some of the causes may include:

        •    Diet

      • Some children eat too much of foods that are high in fat and low in fiber (such as fast foods, "junk" foods, and soft drinks).
      • Some children do not drink enough water and liquids.
      • Infants changing from breast milk to formula or when introducing solid foods.

        •    Lack of exercise. Children who stay inside, watching TV and playing video games, do not get enough exercise. Exercise helps move digested food through the intestines.

        •    Emotional issues

      • Preschool- and school-aged children are sometimes embarrassed to use public bathrooms and hold in their bowel movements, causing constipation.
      • Toddlers can be overwhelmed by toilet training, especially when a parent is more anxious for the child to be out of diapers than the child is.
      • Toddlers can also become involved in power struggles with their parents as they learn to assert their independence, and may intentionally hold bowel movements in.
      • Some children who experience stress at school, with their friends, or in the family, may have constipation.

        •    Busy children

      • Some children ignore signals their intestines give them to have a bowel movement. This can happen when children are too busy playing and forget to go to the bathroom.
      • Constipation can also be a problem when children start a new school year, since they are no longer able to go to the bathroom whenever the urge strikes and have to change their bowel routine.
      • Once a child becomes constipated, a vicious cycle can develop. Hard, dry stools can be painful to push out, and the child can avoid using the bathroom to avoid the discomfort. Eventually, the intestine will not be able to sense the presence of stool.

    Physical problems that can cause constipation include the following:

        •    Abnormalities of the intestinal tract, rectum, or anus

        •    Problems of the nervous system, such as cerebral palsy

        •    Endocrine problems, such as hypothyroidism

        •    Certain medications (for example, iron preparations, some antidepressants, and narcotics such as codeine)

    Why is constipation a concern?

    Hard stools can irritate or tear the lining of the anus (fissure), making it painful to have a bowel movement. The child may avoid having a bowel movement, which can cause further constipation.

    What are the symptoms of constipation?

    The following are the most common symptoms of constipation. However, each individual may experience symptoms differently. Symptoms may include:

        •    Not having a bowel movement for several days, or passing hard, dry stools

        •    Abdominal bloating, cramps, or pain

        •    Decreased appetite

        •    Clenching teeth, crossing legs, squeezing buttocks together, turning red in the face as the child tries to hold in a bowel movement to avoid discomfort

        •    Small liquid or soft stool smears that soil the child's underwear

    The symptoms of constipation may resemble other conditions or medical problems. Always consult your child's health care provider for a diagnosis

  • How is constipation diagnosed?

    A health care provider will examine your child and get a complete medical history. Depending on the age of your child, you might be asked questions such as:

    • How old was your baby when he or she had their first stool?

    • How often does your child have a bowel movement?

    • Does your child complain of pain when he or she has a bowel movement?

    • Have you been trying to toilet train your toddler recently?

    • What does your child's diet consist of?

    • Have there been any stressful events in your child's life lately?

    • How often does your child soil his or her pants?

    Occasionally, in addition to a physical examination, your child's health care provider may want to perform other diagnostic tests to determine if there are any problems. These tests may include:

    • Digital rectal examination (DRE). In this procedure, a doctor or other health care provider inserts a gloved finger into the rectum to feel for anything unusual or abnormal.

    • Abdominal X-ray. A diagnostic test to evaluate the amount of stool in the large intestine.

    • Barium enema. A procedure done to examine the large intestine for abnormalities. A fluid called barium (a metallic, chemical, chalky liquid used to coat the inside of organs so that they will show up on an X-ray) is given into the rectum as an enema. An X-ray of the abdomen will show strictures (narrowed areas), obstructions (blockages), and other problems.

    • Anorectal manometry. This test measures the strength of the muscles in the anus, nerve reflexes, ability to sense rectal distention, and coordination of muscles during defecation.

    • Rectal biopsy. This test takes a sample of the cells in the rectum to be examined under a microscope for any problems.

    • Sigmoidoscopy. A diagnostic procedure that allows the health care provider to examine the inside of a portion of the large intestine. Sigmoidoscopy is helpful in identifying the causes of diarrhea, abdominal pain, constipation, abnormal growths, and bleeding. A short, flexible, lighted tube, called a sigmoidoscope, is inserted into the intestine through the rectum. The scope blows air into the intestine to inflate it and make viewing the inside easier.

    • Colorectal transit study. This procedure shows how well food moves through the colon. The child swallows capsules containing small markers which are visible on X-ray. The child follows a high-fiber diet during the course of the test, and the movement of the markers through the colon is monitored with abdominal X-rays taken several times 3 to 7 days after the capsule is swallowed.

    • Colonoscopy. A procedure that allows the health care provider to view the entire length of the large intestine. A colonoscopy can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It involves inserting a colonoscope, a long, flexible, lighted tube, in through the rectum up into the colon. The colonoscope allows the health care provider to see the lining of the colon, remove tissue for further examination, and possibly treat some problems that are discovered.

    When should you contact a health care provider?

    Do not hesitate to contact your child's health care provider if you have any questions or concerns about your child's bowel habits or patterns. The National Institutes of Health recommends that you talk to your child's health care provider if:

    • Episodes of constipation last longer than 2 weeks.

    • The child is unable to participate in normal activities because of constipation.

    • Normal pushing is not enough to expel a stool.

    • Liquid or soft stool leaks out of the anus.

    • Small, painful tears appear in the skin around the anus.

    • Hemorrhoids develop.

    • Abdominal pain, fever, or vomiting 

  • What are treatments for constipation?

    Specific treatment for constipation will be determined by your child's health care provider based on the following:

        •    Your child's age, overall health, and medical history

        •    Extent of the condition

        •    Type of condition

        •    Your child's tolerance for specific medications, procedures, or therapies

        •    Expectations for the course of the condition

        •    Your opinion or preference

    Treatment may include:

        •    Diet changes. Often, making changes in your child's diet will help constipation. Consider the following suggestions:

      • Increase the amount of fiber in your child's diet by:
        • Adding more fruits and vegetables.
        • Adding more whole grain cereals and breads (check the nutritional labels on food packages for foods that have more fiber).

    Foods
     Moderate fiber
    High fiber
    Bread Whole wheat bread, granola bread, wheat bran muffins, whole grain waffles, popcorn  
    Cereal
    Bran cereals, shredded wheats, oatmeal, granola, oat bran 100% bran cereal
    Vegetables
    Beets, broccoli, brussels sprouts, cabbage, carrots, corn, green beans, green peas, acorn and butternut squash, spinach, potato with skin, avocado  
    Fruits
    Apples with peel, dates, papayas, mangos, nectarines, oranges, pears, kiwis, strawberries, applesauce, raspberries, blackberries, raisins Cooked prunes, dried figs
    Meat substitutes
    Peanut butter, nuts
    Baked beans, black-eyed peas, garbanzo beans, lima beans, pinto beans, kidney beans, chili with beans, trail mix

      • Encourage your child to drink more fluids, especially water.
      • Limit fast foods and junk foods that are usually high in fats and offer more well-balanced meals and snacks.
      • Limit drinks with caffeine, such as cola drinks and tea.
      • Limit whole milk as directed by your health care provider.

    Plan to serve your child's meals on a regular schedule. Often, eating a meal will stimulate a bowel movement within 30 minutes to an hour. Serve breakfast early so your child does not have to rush off to school and miss the opportunity to have a bowel movement.

    • Increase exercise. Increasing the amount of exercise your child gets can also help with constipation. Exercise aids digestion by helping the normal movements the intestines make to push food forward as it is digested. People who do not move around much are often constipated. Encourage your child to go outside and play rather than watch TV or engage in other indoor activities.
    • Proper bowel habits. Have your child sit on the toilet at least twice a day for at least 10 minutes, preferably shortly after a meal. Make this time pleasant; do not scold or criticize the child if he or she is unable to have a bowel movement. Giving stickers or other small rewards, and making posters that chart your child's progress, can help motivate and encourage him or her. If these methods do not help, or if your health care provider notices other problems, he or she may recommend laxatives, stool softeners, or an enema. These products should ONLY be used with the recommendation of your child's health care provider. DO NOT use them without consulting with your child's health care provider first.

    What is the long-term outlook for a child with constipation?

    The outlook depends on what type of condition caused the constipation. Those children with diseases of the intestine, such as Hirschsprung's disease, may have chronic problems. However, most of the time, constipation is a temporary situation.

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