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). 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 into the infant's diet
During toilet training
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 (anal fissure). 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 and bed-wetting.
Causes of Constipation in Children
Common causes
In 95% of children, constipation results from
Dietary issues
Behavioral issues
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 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 (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 (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) or low level of potassium (hypokalemia) in the blood
Spinal cord problems (such as spina bifida)
Hormonal disorders, such as an underactive thyroid gland (hypothyroidism)
Intestinal disorders, such as a cow's milk protein allergy or celiac disease
Drugs, such as powerful pain relievers called opioids
Toxins, such as lead or those that cause infant botulism
Children with serious abdominal disorders (such as appendicitis or a blockage in the intestine) 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).
Warning signs
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
Decreased appetite
Blood in the stools
Fever
Vomiting
Abdominal swelling
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), 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 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).
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).
Testing
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 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
Modifying behavior
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.
Modifying behavior
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
Key Points
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.
