Constipation is one of the most common reasons for a visit to the pediatrician. We separate constipation into functional and organic causes. Organic means there is something medically wrong that is leading to the withholding of stool and we will go into some of these possibilities. ‘Functional’ means there is nothing biochemically or physically wrong with a child’s body; the withholding of stool is caused by something behavioral, dietary, or emotional.
What is Constipation?
Everything we eat must pass through our stomach and move down into our small and large intestines. Along the way, food is broken down, digested and absorbed into the body. As our food moves down into the last portions of our GI tract, water is absorbed by the body. If this didn’t happen, every bowel movement would be diarrhea and we would always be thirsty. The longer stool sits in the colon and rectum, the more water is taken out and the harder and drier the stool gets. If the stool sits in there too long, the resulting bowel movement is hard and sometimes large and painful as well. This is constipation. This can lead to a host of problems in children and adults. It can lead to headaches and irritability, trouble with toilet training and, most commonly, abdominal pain. One of the worst features of constipation is the cyclic nature of the problem: having a bowel movement is hard and painful leading the child to withhold stool to avoid discomfort, thereby assuring each subsequent bowel movement will be harder and more painful.
This is very rare but it is also important not to miss. Certain genetic disorders, like Cystic Fibrosis, can affect the way we digest food and can lead to constipation. Conditions that affect the way the gut is controlled, like Hirschsprung disease can cause stool to build up in areas of the gut. Physical obstructions and abnormally functioning sphincters can also be causes. There are several other rare organic causes of constipation and that is why it should always be evaluated by your child’s doctor.
The vast majority of cases of constipation in children have something to do with behavior or diet. There are also key time periods when constipation often becomes a problem:
Babies: Introduction of Solids
Babies go through several changes in bowel movement consistency but often it is the introduction of solid foods that leads to constipation. All infants fuss and grunt a bit when having a bowel movement and some do so more than others. Gassiness and colic are frequently confused with constipation. The key is to look at the consistency of the stool: even if it is two or three days between bowel movements but the stool is soft, the infant probably isn’t constipated. If it is very hard (even if it has been less than a day since the last BM) it probably does represent constipation.
For infants who are truly constipated, an ounce of water, pear or prune juice in the morning and at night may do the trick. For infants under six months, talk to your pediatrician first to make sure this is OK. For more severe cases, a glycerin suppository or rectal stimulation with a lubricated thermometer may help but these strategies should be used very sparingly. An infant can come to pattern on the help of the suppository or rectal stimulation and this can aggravate the problem.
Stick with water and juice to create naturally softer bowel movements and only use the other options as a last resort.
Toddlers: Potty Training
The second common time for a child to develop constipation is during the toddler years around the time of toilet training. These children are newly mobile and have a lot of fun things to do. They may not want to bother taking the time to use the bathroom so they just hold it in. Couple this with a picky diet low in water, fresh fruits, vegetables and whole grains and constipation can develop quickly. After the first hard, painful bowel movement the child has good reason to avoid having another one. As they go day after day without a good bowel movement, the problem worsens. Remember, the longer the stool sits in the colon, the harder and more dried out it becomes. The colon begins to develop a ‘backlog’ (no pun intended) where the bowel movements the child does have just involve breaking the tip off the iceberg so to speak: they pass small hard stools but there is still a large mass in the colon that isn’t moving. Liquid stool tends to leak around this mass leading to encompresis (incontinence of stool and staining of the underwear). The child is having occasional liquid stool and occasional hard stools but is never fully evacuating the rectum and toilet training becomes stressful and ineffective.
Diet is always important but in the constipated toddler, particularly during potty training, there are some other points to make. First, take the pressure off. If a child is not doing well with toilet training, you may have started too early. Back off and give the diaper back. Regroup and try again in a few weeks. Second, get things moving. If things have already gone too far in the wrong direction and the toddler is now scared to go to the bathroom because of pain, you need to get them back on track. This means plenty of water, vegetables, fruits and whole grains. If the toddler adamantly refuses fiber, supplements can be given as a last resort. Juice is also helpful here.
Juice works because the high sugar content creates an osmotic load that causes more water to diffuse into and stay in the gut, moving along and loosening things up.
If these dietary changes don’t help, talk to your pediatrician about using one or two doses of a laxative to kick start the process but try not to get in the habit of reaching for the laxative. Use it to get the process going but, long term, it is much healthier to manage bowel movements with good diet.
Once the toddler is toilet trained and the acute case of constipation has been handled, encourage regular trips to the bathroom, usually just after meals to take advantage of the body’s natural urge to defecate after eating. Make it something fun and rewarding, regardless of whether or not the child has a bowel movement, not a chore the child comes to dislike. As a parent, it is important to talk to your child about bowel movements and give him regular opportunities to go.
Children: School Entry
These children are most likely to complain of a ‘tummy ache’ where the toddlers mentioned before may just be irritable. The problem is similar, however. Poor diet, and the new school environment may lead to stool withholding. Just as with toddlers, the process exacerbates itself: bowel movements are uncomfortable so the child avoids them, worsening the problem.
The school aged child is old enough that you can focus on diet and lifestyle changes. It is essential that these kids learn to eat right. I may sound like a broken record but it is all about adequate water, fresh fruits, vegetables and whole grains. The natural fiber content here helps to keep bowel movements regular. Parents pay the bills and buy the groceries. Parents are in control of what food is in the house.
Talk openly with kids about whether or not they are going and if it is hurting. Often times when a parent brings a child in to see me, I ask about the quality and time of the last bowel movement. The parent looks to the child and asks, ‘well, when was it?’ If a child has a history of constipation or is complaining of abdominal pain or just looks ‘blah,’ you should be trying to figure out right away if they are having any problems going to the bathroom! Again, take advantage of the gastro-colic reflex following a meal and get kids in the habit of going to use the bathroom regularly.
Sometimes a child's constipation has gone too far. They need help with a laxative and a 'clean out.' If fecal impaction has occurred, they may need a series of enemas and even a hospital stay to get things moving again. The important thing is to see these events as a wake up call and change the diet around after things are back to normal so they stay that way without more laxatives and enemas.
Finally, while not scientifically proven, I think exercise and movement promote good bowel habits in school aged children in two ways. First, athletics involve stretching and muscle flexion that get things moving. Sometimes when I see a child for abdominal pain, we need to do an x-ray and we see, literally pounds and pounds of stool all through the child’s abdomen. If this child was running and jumping and playing sports, this wouldn’t happen. The sedentary lifestyle of many children today allows them to build up an impressive amount of stool in their bellies before they actually feel it. Second, exercise makes children hungry and thirsty. If a parent has planned ahead and stocked a healthy pantry of food, the child will reach for good foods and eat them, because they are hungry and that’s all there is! It also stimulates a lot of thirst and children will learn to drink more water. Nine times out of ten, if the right stuff is going in, the right stuff will be coming out.
Matthew Toohey, MD. September 29, 2011