Diagnosis and Treatment of Constipation in Children

Four year old on the toilet
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Constipation is very common in children between infancy in adulthood. In fact, up to three percent of visits to the pediatrician are because of constipation.

There are many possible causes of constipation in toddlers and grade school children ranging from easy-to-remedy problems like dehydration or eating habits to underlying medical conditions such as the disorder Hirschsprung's disease.

Be aware that the causes and treatment of constipation in infants is somewhat different than in toddlers and older children.

Symptoms of Constipation in Children

What we envision as constipation in adults can be quite different from that in children. In adults, the most common symptom associated with constipation is infrequent bowel movements. While this may occur in children as well, it is less important.

In fact infrequent stools in a child—if they are of a normal soft consistency—don’t necessarily mean constipation at all.

Possible symptoms of constipation in a child may include:

  • Large stools (the kind that can plug up a toilet.)
  • Hard stools: The texture of bowel movements is more important than the frequency.
  • Small pellet-like stools ("rabbit" pellet stools.)
  • Painful bowel movements.
  • Straining or other signs of difficulty having a bowel movement.
  • Fear of going to the bathroom: If your child is past the potty training age, she may not tell you the consistency of her the stool. That said, you may notice that she spends long periods of time in the bathroom, comes out of the bathroom breathless, teary or in pain, or refuses to go to the bathroom.
  • Abdominal pain: Your child may claim that her tummy hurts, and you may notice that there is a pattern to her "stomach aches."
  • Infrequent stools: Again, infrequent stools may not indicate constipation unless the consistency is hard, your child appears uncomfortable, or strains to pass them.

In general, constipation in children is usually defined as having "difficulty with defecation for at least two weeks, which causes significant distress to the patient."

Keep in mind that parents often don't know how often their school-age children are having bowel movements, which often delays the diagnosis of constipation.

Causes of Constipation in Children

A search for causes of constipation is often the first step in making the correct diagnosis and choosing the best treatment or dietary change.

Possible causes may include:

  • Dehydration
  • A diet with too little fiber
  • A diet consisting of highly constipating foods such as milk, cheese, and bananas
  • Some medications, especially antacids and narcotic pain medications
  • An emotionally difficult experience which causes the child to retain stool, or an attempt to avoid public restrooms
  • A reduction in physical activity
  • Bowel obstruction
  • Endocrine problems such as hypothyroidism
  • Conditions such as Down's syndrome and cerebral palsy

Diagnosing Constipation in Children

If you are concerned that your child may be constipated, it's important to talk to your pediatrician. A careful history can often reveal the patterns that go with constipation. If the cause is clear from the history and physical, further testing is usually not necessary.

Sometimes further studies, such as blood work, imaging studies, or endoscopy may be needed to figure out the cause of constipation in children.

Treatments for Constipation in Children

The treatments recommended for constipation in children depend on an accurate history and physical exam. Sometimes all that is needed is increased fluids in her diet or slight changes in her food intake. That said, if a child is uncomfortable, you may need to use a stool softener or laxative to "get things going" while making changes in her diet.

If her diet is too low in fiber, adding fiber is a good idea, but unlike adults, seems to have little effect on reducing constipation in children. It's important to increase dietary fiber slowly if you choose to do so, as a rapid increase can lead to bloating and abdominal pain.

Reducing constipating foods such as highly processed foods, sugary snacks, and dairy products such as cheese may be helpful, and may also encourage your child to make healthier choices. If your child has been inactive, trading active playtime for screen time is a good idea in many ways.

Laxatives may need to be used sparingly. Polyethylene glycol (Miralax) is often tolerated well by children and is frequently recommended by pediatricians. Unlike laxatives, stool softeners are not usually addictive and can be given often if needed.

A common mistake is for parents to stop stool softeners as soon as a child begins having soft bowel movements, only to have the child develop constipation again.

Sometimes, if a child is backed up, an enema or digital evacuation may be needed. Make sure to rule out any serious causes of constipation before taking this route (in other words, avoid these if your child is having abdominal pain.)

There are other options as well, though it's best to talk to your pediatrician before trying these. A pediatric gastroenterologist can provide extra help if your child has chronic constipation that is hard to treat.

Complications of Constipation in Children

Some children with severe constipation develop a blockage, past which liquid stool leaks. This can lead to soiling accidents, a condition called encopresis.

Anal fissures may also occur due to constipation and can worsen symptoms if children then avoid using the bathroom.

Bottom Line on Constipation in Children

Most of the time, constipation in children can be managed with a change in diet and an increase in physical activity. That said, stool softeners and sometimes a laxative will be needed to get a child's bowels moving. There is little risk associated with using stool softeners in children, and if this is needed they should be continued until a child is having regular and soft bowel movements.

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