Constipation in Children

Constipation in Children

Constipation is one of the most common complaints I hear in my practice. It’s so common that it almost seems like a rite of passage. Many children are placed on medication when they’re toddlers or have endured an ER visit related to constipation and related pain. 

What is constipation?

Constipation is complex. Often practitioners ask about daily bowel movements, implying that this frequency means nothing is problematic. In reality, “normal” stooling can range in frequency from 3 times daily to 3 times per week as long as the stool is soft, passes easily, and evacuation feels complete. Your child could be stooling daily, but if the poop is hard, dry, or painful to pass, then they could also be constipated.

The Rome Foundation defines constipation for children up to age four as follows:

  1. Two or fewer defecations per week
  2. History of excessive stool retention
  3. History of painful or hard bowel movements
  4. History of large diameter stools
  5. Presence of a large fecal mass in the rectum

In toilet-trained children, the following additional criteria may be used:

  1. At least one episode/week of incontinence after the acquisition of toileting skills
  2. History of large diameter stools which may obstruct the toilet

For older children and adults, the Rome criteria shifts as follows:

  1. Must include two or more of the following:
  2. Straining during more than ¼ (25%) of defecations
  3. Lumpy or hard stools (Bristol Stool Form Scale 1-2) more than ¼ (25%) of defecations
  4. Sensation of incomplete evacuation more than ¼ (25%) of defecations
  5. Sensation of anorectal obstruction/blockage more than ¼ (25%) of defecations
  6. Manual maneuvers to facilitate more than ¼ (25%) of defecations (e.g., digital evacuation, support of the pelvic floor)
  7. Fewer than three solid bowel movements per week
  8. Loose stools are rarely present without the use of laxatives
  9. Insufficient criteria for irritable bowel syndrome

If the criteria set by The Rome Foundation resonates with you, please discuss it with your medical provider. While dietitians and nutritionists can support healing through diet and lifestyle, we cannot diagnose or treat functional disorders. We are happy to be part of your complete care team!

Bristol stool chart
The Bristol Stool Chart is an easily accessible tool for caregivers to use in communicating with medical professionals about stool frequency and type. Printable versions are readily accessible online.

What causes constipation in children?

Most cases of constipation in children are functional, with only an estimated 5% of cases stemming from an organic, structural difference in the GI tract [1]. If this is a chronic problem for your child, your medical provider or specialist can rule out organic causes of constipation.

Functional constipation is complex and often involves a cycle of interrupted stooling, painful evacuation, and subsequent fear or withholding. There are common steps in development that align with the onset of chronic constipation, such as [2]:

  1. The introduction of solid food. Constipation is common during this time as the body adjusts from a liquid diet to increased solids.
  2. Starting school. Lots of kids are uncomfortable pooping in new or unfamiliar places, and this can be especially challenging when time limits and social distractions are present.
  3. Illness, especially involving fever. Febrile illness can cause dehydration, which can promote constipation.
  4. Travel. Sometimes children withhold stool when they are away from home, even for extended periods. 

Laxatives are often prescribed to break this cycle by making stooling more comfortable, but rarely are parents coached to address fear or withholding behaviors that exacerbate the problem. Unfortunately, many children use laxatives for extended periods to support stooling even though they are only meant to be taken in the short term. 

What can we try at home?

  1. Hydration. Offer water or juice diluted with water and take note that urine is light yellow in color. Educate older children to notice urine color and drink appropriately.
  2. Fruit, veggies, and whole grains. Eating whole foods and reducing processed foods is a great way to get more fiber. Fiber helps with motility and supports healthy stooling. Fiber can also provide bulk to stool, so maintaining hydration (and eating fresh, juicy fruits and vegetables) is an important complement to this dietary change.
  3. Eat healthy fats every day. Cook with quality oils and enjoy fatty fish, avocado, nuts, and seeds. Healthy fats can reduce inflammation and help to move things along in the GI tract.
  4. Provide a potty stool. Posture does make a difference when it comes to pooping! Potty stools can help to support a child’s feet and position our body for comfortable and complete evacuation. This can make a difference for teens and adults as well!
  5. Make time, especially after meals. Have you ever noticed that the family dog usually needs to go out after a meal? That’s because the act of eating triggers peristalsis – a wave of movement that pushes food through the GI tract. Humans work the same way, so making time to use the bathroom after meals is an excellent way to capitalize on this mechanism and develop healthy bathroom habits.

When is it time to get help?

If you feel like you’re doing everything you know for your child and they’re still struggling, it’s time to talk with their medical provider. Chronic constipation can influence digestion, growth, and healthy development, not to mention social health. I always tell parents to trust their instincts – if you feel like your child needs help, you’re probably right! The following indications can also help to know when to ask for support [1,2]:

  1. Discomfort
  2. History of impaction
  3. Developmental delays
  4. Frequent accidents
  5. Trust your intuition

Having your child’s doctor or gastroenterologist check for structural issues that might be contributing to constipation can provide a lot of peace of mind. Once those exams are clear, I work with families on any necessary shifts in diet and lifestyle. For complex cases, functional testing can be very insightful and offer a data-driven approach to resolving chronic constipation.

[1] https://pubmed.ncbi.nlm.nih.gov/32532657/

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7052003/

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