Constipation refers to delay or difficulty in passing stool for a period of at least 1 month in infants and toddlers and a period of 2 months in older children (see also Constipation Constipation in Adults Constipation is difficult or infrequent bowel movements, hard stool, or a feeling that the rectum is not totally empty after a bowel movement (incomplete evacuation). (See also Constipation... read more in adults). Stools are harder and sometimes larger than usual and may be painful to pass. Constipation is very common among children. It accounts for up to 5% of children’s visits to the doctor.
Infants and children are particularly prone to developing constipation at three periods of time:
When cereals and solid food are introduced Starting Solid Foods in Infants The time to start solid food depends on the infant's needs and readiness. Generally, infants need solids when they are large enough to need a more concentrated source of calories than breast... read more into the infant's diet
Around the start of school
The frequency and consistency of bowel movements (BMs) vary throughout childhood, and there is no single definition of what is normal. Newborns typically have 4 or more stools per day. During the first year, infants have 2 to 4 a day. Breastfed infants typically have more BMs than formula-fed infants and may have one after each breastfeeding. The stools of breastfed infants are loose, yellow, and seedy. After a month or two, some breastfed infants have BMs less frequently, but the stools remain mushy or loose. After 1 year of age, most children have one or sometimes two soft but formed stools a day. However, some infants and young children typically have BMs only once every 3 to 4 days.
Guidelines for identifying constipation in infants and children include
No BMs for 2 or 3 more days than usual
Hard or painful BMs
Large stools that may clog the toilet
Drops of blood on the outside of the stool
In infants, signs of effort such as straining and crying before successfully passing a soft stool usually do not indicate constipation. These symptoms are usually caused by failure to relax the pelvic floor muscles during passage of stool and typically resolve spontaneously.
Parents often worry about their child's BMs, but constipation usually has no serious consequences. Some children with constipation regularly complain of abdominal pain, particularly after meals. Occasionally, passing large, hard stools may cause a small tear in the anus Rectum and Anus The rectum is a chamber that begins at the end of the large intestine, immediately following the sigmoid colon, and ends at the anus ( see also Overview of the Anus and Rectum). Ordinarily,... read more (anal fissure Anal Fissure An anal fissure is a tear or ulcer in the lining of the anus (the opening at the end of the digestive tract where stool leaves the body). Anal fissures may occur after passage of hard or large... read more ). Anal fissures are painful and may result in streaks of bright red blood on the outside of the stool or on toilet paper. Rarely, chronic constipation can contribute to urinary problems such as urinary tract infections Urinary Tract Infection (UTI) in Children A urinary tract infection is a bacterial infection of the urinary bladder ( cystitis), the kidneys ( pyelonephritis), or both. Urinary tract infections are caused by bacteria. Infants and younger... read more and bed-wetting Urinary Incontinence in Children Urinary incontinence is defined as the involuntary release of urine occurring two or more times per month after toilet training. Incontinence may be present During the day (daytime or diurnal... read more .
Causes of Constipation in Children
In 95% of children, constipation results from
Constipation that results from dietary or behavioral issues is called functional constipation.
Dietary issues that cause constipation include a diet that is low in fluids and/or fiber (fiber is present in fruits, vegetables, and whole grains).
Behavioral issues that may be associated with constipation include stress (as may be felt when a sibling is born), resistance to toilet training, and a desire for control. Also, children may intentionally put off having BMs (called stool withholding) because they have a painful anal fissure or because they do not want to stop playing. Sexual abuse Sexual abuse Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (for example, clergy, coach, or teacher)... read more may result in stress or injury that causes children to withhold stool.
If children do not move their bowels when the natural urge comes, the rectum eventually stretches to accommodate the stool. When the rectum has stretched, the urge to have a BM lessens, and more and more stool accumulates and hardens. A vicious circle of worsening constipation may result. If the accumulated stool hardens, it sometimes blocks the passage of other stool—a condition called fecal impaction. Looser stool from above the hardened stool may leak around the impaction into the child's underwear and lead to stool incontinence Stool Incontinence in Children Stool incontinence is the accidental passing of bowel movements that is not caused by illness or physical abnormality. Stool incontinence occurs in about 3 to 4% of 4-year-old children and becomes... read more (encopresis). Parents may then think that the child has diarrhea when the actual problem is constipation.
Less common causes
In about 5% of children, constipation results from a physical disorder, drug, or toxin. Disorders may be apparent at birth or develop later. Constipation that results from a disorder, drug, or toxin is called organic constipation and needs to be evaluated by a doctor.
In newborns and infants, the most common disorder that causes organic constipation is
Hirschsprung disease Hirschsprung Disease Hirschsprung disease is a birth defect in which a section of the large intestine is missing the nerve network that controls the intestine's rhythmic contractions. Symptoms of intestinal obstruction... read more (an inadequate nerve supply to the large intestine)
Other causes of organic constipation include
Metabolic and electrolyte disorders, such as an abnormally high level of calcium (hypercalcemia Hypercalcemia (High Level of Calcium in the Blood) In hypercalcemia, the level of calcium in blood is too high. A high calcium level may result from a problem with the parathyroid glands, as well as from diet, cancer, or disorders affecting... read more ) or low level of potassium (hypokalemia Hypokalemia (Low Level of Potassium in the Blood) In hypokalemia, the level of potassium in blood is too low. A low potassium level has many causes but usually results from vomiting, diarrhea, adrenal gland disorders, or use of diuretics. A... read more ) in the blood
Hormonal disorders, such as an underactive thyroid gland (hypothyroidism Hypothyroidism Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormones and a slowing of vital body functions. Facial expressions become dull, the voice... read more )
Intestinal disorders, such as a cow's milk protein allergy Lactose Intolerance or celiac disease Celiac Disease Celiac disease is a hereditary intolerance to gluten (a protein found in wheat, barley, and rye) that causes characteristic changes in the lining of the small intestine, resulting in malabsorption... read more
Drugs, such as powerful pain relievers called opioids Side effects of opioids Pain relievers (analgesics) are the main drugs used to treat pain. Doctors choose a pain reliever based on the type and duration of pain and on the drug's likely benefits and risks. Most pain... read more (for example, codeine and morphine)
Toxins, such as lead Lead Poisoning Lead poisoning affects many parts of the body, including the brain, nerves, kidneys, liver, and blood. Children are particularly susceptible because their nervous system is still developing... read more or those that cause infant botulism Infant Botulism Infant botulism is a potentially life-threatening infection that causes muscle weakness. It develops in infants who eat food containing spores of Clostridium botulinum bacteria. (See... read more
Children with serious abdominal disorders (such as appendicitis Appendicitis Appendicitis is inflammation and infection of the appendix. Often a blockage inside the appendix causes the appendix to become inflamed and infected. Abdominal pain, nausea, and fever are common... read more or a blockage in the intestine Intestinal Obstruction An obstruction of the intestine is a blockage that completely stops or seriously impairs the passage of food, fluid, digestive secretions, and gas through the intestines. The most common causes... read more ) often do not have BMs. However, these children typically have other, more prominent symptoms, such as abdominal pain, swelling, and/or vomiting. These symptoms typically lead parents to seek medical care before the number of BMs decreases.
Evaluation of Constipation in Children
Doctors first try to determine whether constipation results from dietary or behavioral issues (functional) or from a disorder, toxin, or drug (organic).
Certain symptoms are cause for concern and should raise suspicion for an organic cause of constipation:
No bowel movements (BMs) during the first 24 to 48 hours after birth
Weight loss or poor growth
Blood in the stools
Abdominal pain (in children old enough to communicate this)
In infants, loss of muscle tone (the infant appears floppy or weak) and reduced ability to suck
In older children, an involuntary release of urine (urinary incontinence Urinary Incontinence in Children Urinary incontinence is defined as the involuntary release of urine occurring two or more times per month after toilet training. Incontinence may be present During the day (daytime or diurnal... read more ), back pain, leg weakness, or problems with walking
When to see a doctor
Children should be evaluated by a doctor right away if they have any warning signs. If no warning signs are present but the child is passing infrequent, hard, or painful BMs, then the doctor should be called. Depending on the child's other symptoms (if any), the doctor may advise trying simple home treatments Treatment Constipation refers to delay or difficulty in passing stool for a period of at least 1 month in infants and toddlers and a period of 2 months in older children (see also Constipation in adults)... read more or ask the parents to bring the child for an examination.
What the doctor does
Doctors first ask questions about the child's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the constipation and the tests that may need to be done (see table Some Physical Causes and Features of Constipation in Infants and Children Some Physical Causes and Features of Constipation in Infants and Children ).
Doctors determine whether newborns have ever had a BM (the first BM is called meconium). Newborns who have not had a BM within 24 to 48 hours after birth should have a thorough examination to rule out the possibility of Hirschsprung disease, anorectal malformations, or other serious disorder.
For infants and older children, doctors ask whether constipation began after a specific event, such as introducing cereal or other solid foods, eating honey under 12 months of age, beginning toilet training, or starting school. For all age groups, doctors ask about diet and about disorders, toxins, and drugs that can cause constipation.
For the physical examination, doctors first look at the child overall for signs of illness and measure height and weight to check for signs of delayed growth. Doctors then focus on the abdomen, the anus (including examination of the rectum using a gloved finger), and nerve function (which can affect how the digestive tract functions).
If the cause of constipation appears to be functional, no tests are needed unless children do not respond to treatment. If children do not respond or if doctors suspect that the cause is another disorder, an x-ray Plain X-Rays X-rays are high-energy radiation waves that can penetrate most substances (to varying degrees). In very low doses, x-rays are used to produce images that help doctors diagnose disease. In high... read more of the abdomen is taken, and tests for other disorders are done based on the results of the examination.
Treatment of Constipation in Children
Treatment of constipation depends on the cause.
For organic constipation, the causative disorder, drug, or toxin is treated, corrected, or removed.
For functional constipation, measures include
Changing the diet
Sometimes using stool softeners or laxatives
Changing the diet
Dietary changes for infants include giving them 1 to 4 ounces (30 to 120 milliliters [mL]) of prune, pear, or apple juice each day. For infants younger than 2 months, 1 teaspoon (5 mL) of light corn syrup can be added to their formula in the morning and evening.
Older infants and children should increase their consumption of fruits, vegetables, and high-fiber cereals and decrease consumption of constipating foods, such as milk and cheese.
Behavioral modification can help older children. Measures include
Encouraging children who are toilet trained to sit on the toilet for 5 to 10 minutes after meals and encouraging them when they make progress (for example, noting progress on a wall chart)
Giving children who are being toilet trained a break from toilet training until constipation resolves
Sitting on the toilet after a meal can help because eating a meal triggers a reflex to have a BM. Frequently, children ignore the signals from this reflex and put off having a BM. This technique uses the reflex to help retrain the digestive tract, establish a toilet routine, and encourage more regular BMs.
Stool softeners and laxatives
If constipation does not respond to behavioral modification and changes in diet, doctors may recommend certain drugs that help soften stool (stool softeners) and/or increase the spontaneous movement of the digestive tract (laxatives). Such drugs include polyethylene glycol, lactulose, mineral oil, milk of magnesia (magnesium hydroxide), senna, and bisacodyl. Many of these drugs are now available over the counter. However, doses should be based on the age and body weight of the child as well as the severity of constipation. Thus, parents should consult a doctor regarding the appropriate dose and number of doses per day before using these treatments. The goal of treatment is the passage of one soft stool per day.
If children have a fecal impaction, options include gentle enemas and agents (such as mineral oil or polyethylene glycol) taken by mouth with large amounts of fluid. If these treatments are ineffective, children may need to be hospitalized to have the impaction removed.
Infants do not usually require any of these treatments. Typically, a glycerin suppository is adequate.
To maintain regular BMs, doctors may recommend that children use fiber supplements (such as psyllium), which may be obtained without a prescription. For these supplements to be effective, children must drink 32 to 64 ounces (about 1 to 2 liters) of water a day.
Usually, constipation is caused by behavioral or dietary issues (called functional constipation).
Children should be evaluated by a doctor if the interval between BMs has been 2 or 3 days more than usual, if their stools are hard or large, if stools cause pain or bleeding, or if children have other symptoms.
If a newborn does not have a BM within 24 to 48 hours after birth, a thorough evaluation should be done to rule out the presence of Hirschsprung disease or another serious disorder.
Addition of fiber to the diet or behavioral modification can help when dietary or behavioral issues are the cause.