Constipation is fairly common in children, affecting up to 10% at any given time, though many don’t seek medical attention.
Once a child is potty trained, parents might not be aware of what’s going on behind closed doors and may not know their child is constipated. We consider a child to be constipated if he or she experiences pain or straining while passing a bowel movement, and/or has large, hard, dry stools with (usually) more than a day between bowel movements.
The most common cause of constipation in young children is stool withholding. Also called stool retention, this can begin to be a problem for 2-5 year olds as they develop their independence and exert their will. They may try to avoid passing a bowel movement, especially if they’ve had a painful or uncomfortable experience passing a bowel movement in the past. This can make potty training difficult and frustrating, so we recommend treating any existing constipation before attempting to encourage them to have a BM on the toilet.
If a child does withhold stool, this causes the rectum to stretch. As the stool sits there, more and more water is reabsorbed, making the stool even drier and harder. The stool can become so large it may not pass without the help of enemas or medications. Sometimes liquid stool will overflow around the hard stool, causing diarrhea or soiling. After this stool does pass, it is important to treat the constipation aggressively to “retrain” the rectum back to its previous size and sensitivity, and to avoid the accumulation of more hard stool.
Other less common causes of constipation include dehydration, some medications, hypothyroidism, spinal cord disorders, and cerebral palsy.
When children are constipated, they may exhibit a variety of symptoms, including vague abdominal pain (often around the belly button), nausea, loss of appetite, and sometimes vomiting. They may also experience urinary incontinence, bedwetting, or frequent urination. You or they may notice blood in the stool, or on the toilet paper after wiping. This is often from a small fissure, or crack, in the skin due to the passing of hard stools.
If your child is experiencing constipation, the first place to start for treatment is the diet. Make sure your child drinks plenty of water. Add foods that are high in fiber, such as prunes, apricots, plums, peas, beans, whole grain cereals such as raisin bran and whole grain bread products. You can also try prune or pear juice. Avoid foods that make constipation worse, such as rice, bananas, applesauce, white bread, or cereals that are not high in fiber. (Think of the BRAT diet used to treat diarrhea — all these foods make constipation worse!). Make sure your child gets plenty of physical activity.
It’s important to establish a regular toilet routine. Take advantage of the body’s gastrocolonic reflex (the emptying of the colon after a meal) by encouraging your child to sit on the toilet after meals. Help your child relax there by reading a story, providing a footstool if needed, and allowing plenty of unrushed time. Remove any shaming or negative reinforcement associated with the constipation, such as punishment for soiling. If your child is in the middle of potty training and is constipated, put the training on hold until the constipation is resolved. Provide a diaper for bowel movements and lots of positive encouragement to help them through.
If the constipation is not relieved by dietary measures (including if your child is a picky eater and won’t touch any of the recommended foods!), or if he or she is having significant pain and/or has not had a bowel movement in several days, he or she should be evaluated in the office. There are several safe medications we can prescribe to soften the stool. Sometimes enemas are needed to clean out the rectum before further treatment is effective. We do not recommend giving a stimulant laxative to a child, especially without consulting a medical professional first.
Every child is different, and every child’s bowel habits are different too! If you’re concerned your child may be constipated, and dietary measures haven’t helped, be sure to call the office so we can help you.
Dr. Amy Maddalena, a Kids Plus Doc since 2006.