Constipation in children

Constipation in children

Constipation in children is a common problem, and is not very easy for parents to deal with. The good news is that it usually clears up with time. Parents often worry that it means there is something seriously wrong, but this is very seldom the case.

What is normal?
Normal healthy children vary in how often they have their bowels open. Most children aged 1–4 years pass stools (faeces) once or twice a day. However, some children have their bowels open three times a day, whereas others have a bowel motion every other day. All this is quite normal. And a few perfectly healthy children have their bowels open once every 3 days.

The size and consistency of the stools will vary, depending on what your child has been eating and drinking.

How do I know my child is constipated?
Signs of constipation are:

your child seems to be straining hard to have a bowel movement
having a bowel movement is painful – suspect this if your child seems to be trying to hold the bowel motion in (e.g. by crossing the legs or sitting up on the heels) or if your child seems frightened of using the toilet
the stools are very hard and dry.

Causes of constipation in children
Not enough fluid and fibre in the diet is probably the commonest cause.

Anal fissure is another common cause. An anal fissure is a crack in the skin at the edge of the anus, and this makes a bowel movement very painful. Often the problem will have started after a the child was unwell with a viral infection. During the infection he/she might not have taken in enough fluids, so the stools became dry and difficult to pass. The hard, dry stools are then likely to have scratched the anus, causing the fissure.

Worries about using toilets, for example at nursery school or school where there might be a lack of privacy, can trigger a period of constipation.

A tummy upset, in which the child had diarrhoea that was difficult to control, can sometimes result in constipation afterwards. This could be because the child is worried about not being able to hold faeces in.

Emotional upset is another possible trigger – for example, if there has been a lot of family stress recently.

Medicines are not a common cause of constipation in children (unlike in adults), but some cough mixtures can have this effect.

Cows’ milk allergy seems to be a fashionable diagnosis at the moment for all sorts of gut problems in children. In a few children it may be the cause of constipation. If other people in the family have a tendency to asthma and eczema, it is worth considering. Constipation sometimes occurs when an infant is switched from breast milk to cows’ milk or formula milk.

How to help your child
Talk to your doctor if your child is less than 1 year old. If your child is over 1 year old, here are a few things you can try.

Encourage the child to drink plenty of fluids. Avoid sweet and fizzy drinks because they are bad for teeth. Offer a variety of drinks, such as water, diluted fruit juices and milk. (In some children, too much milk can have the opposite effect, making constipation worse.) Prune, pear and apple juices contain a sugar called sorbitol that is particularly good at keeping stools soft. In northern climates, children aged 4–6 years should drink about 2.5 pints (1.5 litres) in a day and children aged 7 years and older should drink about 3.5 pints (2 litres) in a day. Obviously, children in hot climates will need more.

Increase the amount of fibre in the diet. This can be difficult. A survey showed that 29–48% of children with constipation are ‘fussy eaters’, and 47% have a poor appetite. Eating often improves once the constipation has been dealt with. Meanwhile, you could explain to your child that you are changing the diet to make stools soft and easier to pass, but don’t make it into an issue. Give the whole family the same foods. Aim for five portions of fruit or vegetables a day. There is a list of high- and medium-fibre foods in the section on constipation in adults. With luck, this list contains some foods that your child will like.

Don’t exclude milk from the diet without talking to your doctor, it could result in nutritional deficiencies. About 50% of children with true cows’ milk allergy are also allergic to soya protein, so changing to soya might not be a simple solution.

Provide breakfast, and serve it early. For many children, breakfast seems to trigger a bowel movement. (This is called the gastro-colic reflex.) If you serve breakfast early, there will be plenty of time for the child to go to the toilet. Otherwise, because of the rush to get ready for school, the child may hold the stool in and then be reluctant to use the toilet at school.

Provide a child’s toilet seat (which fits over the normal seat), because it will make your child’s hip bend at the optimum angle for having a bowel movement.

Don’t give your child laxatives without talking to your doctor or health visitor. There are several different sorts of laxatives. Let your doctor or health visitor choose the most appropriate type if necessary.

When to see your doctor
You should see your doctor if your child is under 1 year old. If your child is older, you could try the measures outlined above for a couple of weeks, and then see your doctor if they have not solved the problem.

Another reason for seeing the doctor promptly is if you find yourself becoming angry with your child about it. A child with constipation can make you feel very frustrated, but the constipation is not the child’s fault, and is not being done deliberately. It is important to be patient.

The main reason for getting help is that constipation has to be sorted out, because if it continues for a long time the rectum enlarges. Then your child will miss a feeling that he/she needs to have a bowel movement, and the muscles of the bowel will not work properly to push the faeces out. Instead, liquid waste will dribble out from around the faeces, and there will be soiling of underwear. Then you will think that diarrhoea is the trouble, when in fact constipation is still the actual problem.

What your doctor can do
Your doctor will check that there is nothing physically wrong with your child. Your doctor might then decide that a laxative would be a good idea. Several types of laxative are available (see Constipation in adults). It is usual to start with lactulose to make the faeces soft, but other types may be needed. The laxative is often continued for about 3 months, and then very gradually reduced.

For further information see Useful contacts, particularly, the Children's Hospital of Iowa website.