Simple Constipation Fixes

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Dietary causes of constipation vary with the age of a child. For infants changing from breast milk to formula a decrease in stool frequency is common. This is also seen when there is a change from breast milk or formula alone to added cereal or a change from strained foods to table foods.

For children under age 4 years milk intake is often the cause. The first step is to decrease or stop all milk products for 1-2 months and use milk substitutes while continuing to provide vitamin and calcium supplementation. Always try to increase water intake as well as high water content foods such as fruits and vegetables.

Certain foods can also be constipating including carrots, banana, apples, and rice. Try to avoid cereals that are not whole grain. Use oatmeal, cheerios and granola and increase the amount of bran in your child’s diet. Bran is found in brown rice, oatmeal, whole wheat bread, shredded wheat and unmilled bran or bran muffins. You can add bran to many foods and your child will usually not notice. Children under 6 years can be given 2 teaspoons per day and older children 3-4 teaspoons. Raw vegetables and unpeeled fruits can be eaten throughout the day.

Remember that fruits, fiber and fluids are the best treatments for constipation.

Constipation in Children

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Constipation is defined as having fewer than 3 stools per week and most stools are hard and either pebble like or large and painful. Often constipation is accompanied by stool incontinence in children or abdominal pain.

Most breastfed infants under 3 months of age have 3 stools per day and formula fed infants 2 stools per day. As children reach age 12 months stool frequency decreases slightly and continues to decrease until over age 3 years 1 stool per day is the typical frequency. Infants without stools for up to 7 days are not unusual.

In the newborn period, delayed stool passage greater than 48 hours suggests an organic problem such as Hirschsprung’s Disease. Overall, newborn constipation issues suggest an organic or structural cause and constipation under age 12 months is usually dietary related. The onset of constipation after 18-24 months suggests behavioral causes and usually is functional. Constipation is considered to be functional if no organic cause is present. Acute constipation suggests an organic cause and chronic constipation suggests functional causes.

Common symptoms associated with constipation include diffuse colicky intermittent abdominal pain and rectal pain with defecation. Children with constipation will often be fidgety and uncomfortable and perform a “stool dance” when they feel this colicky pain. The child may clench teeth, cross legs, wiggle and squeeze the buttocks together and turn red in the face while trying to hold the bowel movement in to avoid discomfort.

Anal fissures are also common as is a small amount of bright red blood on the surface of stool that is passed. Rectal prolapse is much less common but can occur with chronic constipation and extended periods of “pushing” to have a bowel movement.

A family history of constipation is important as is a history of celiac disease, cystic fibrosis, thyroid disease or Hirschsprung’s Disease. A history of recent family or social-emotional stressors is also common as well as a history of developmental delay or special needs.

If there is a history of infrequent hard, large and painful stools as well as stool withholding behaviors (”stool dance”) and a normal physical examination then the cause is usually functional. If stools are small in caliber, associated with bloody diarrhea or bilious vomiting, weight loss, fever or persistent abdominal pain then organic causes need to be pursued. In cases of malabsorption constipation is common. This is seen in cystic fibrosis and celiac disease. As always a thorough history and physical examination will determine whether a functional or organic cause needs to be pursued.

Your child’s examination will include a growth evaluation with height and weight measurements as well as a general physical examination including an abdominal examination for distension, liver or spleen enlargement, abdominal masses including stool mass and an inspection of the anus. A rectal examination is common unless refused by a child. The rectal examination provides information about the anal sphincter tone and the amount of retained stool in the rectum. Stool can also be tested for blood. A neurologic examination including an inspection of the low back for any signs of spinal abnormalities such as sinus tracts or hair tufts or general asymmetry is performed and reflexes in the lower extremities will be checked to assess possible spinal cord abnormalities including a tethered spinal cord.

Laboratory and radiographic evaluations will be performed if medically indicated based on history and the examination. An abdominal x-ray may be obtained if a rectal examination is not done. This allows the amount of stool in the rectum and colon to be assessed.

Constipation Questions

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What is constipation?
If your child begins to have stools less frequently than his usual stool pattern or if he is aving less than 3 stools per week he is constipated.

What other signs and symptoms are seen in constipation?
Stools that are large, painful or difficult to push out are common in constipation.

How might my child act?
Your child may act fidgety and restless, squirm in his chair, sit on his foot and squeeze his buttocks together in an attempt not to have a bowel movement. He is trying to avoid having a bowel movement which he has learned causes him pain and discomfort. These behaviors are a sign of the colicky pain seen in a child who is constipated.

How common is constipation?
It is one of the most common gastrointestinal complaints in children.

Does diet cause constipation?
Often children eat food high in fat and low in fiber and do not take in enough water. These are common dietary causes of constipation as is a diet high in milk products.

Does exercise effect constipation?
Yes. Children who move more and live an active lifestyle have a shorter transit time for food to move through their intestines. This helps prevent constipation. Children who sit for extended periods and are inactive have more problems with constipation.

Do emotional concerns play a role?
Yes. Emotional concerns depend on the child’s age and developmental level. Some toddlers can develop anxiety and be overwhelmed by a toilet training program. Other toddlers or older children use it as a way to assert their independence and engage in a power struggle with their parent. Older children often avoid using the bathroom in school and this can cause them to stop responding to signals telling them to have a bowel movement. Over time this causes the typical stooling pattern to become disrupted. This is also seen in children who are very active and on the go and do not take time to use the bathroom.

Can stress cause constipation?
Yes. Children of all ages are prone to body complaints related to moderate or severe toxic stress at home or at school. Numerous functional complaints can be seen including stool retention.

What other symptoms are seen with constipation?
Your child may have a decreased appetite and sleep disruption. There may be smearing of underwear with a small amount of stool due to a leak of liquid or soft stool.

How does the pediatrician diagnose the cause of the constipation?
By taking a thorough medical history and performing a comprehensive examination your pediatrician will determine whether the cause is functional or is due to an organic problem.

What type of information should I collect to tell my pediatrician?
If your child is less than 1 year of age the time of his first stool in the newborn period will be important as will the pattern of stooling up to the time when stool frequency decreased. For older children the pattern of onset is important as is stool description, frequency and the way your child responds to signals of needing to have a bowel movement. Keep a food log for 1 week and see how much fluids your child drinks. Check his urine color to see if it is clear throughout the day or is yellow and concentrated. Check your child’s underwear for staining and look for behaviors that may signal he is holding back the urge to defecate.