How to tell if child is constipated

Constipation in Children | Johns Hopkins Medicine

What is constipation?

Constipation is when a child has very hard stools, and has fewer bowel movements than he or she normally does. It is a very common GI (gastrointestinal) problem.

Signs that a child has constipation include:

• Having fewer bowel movements than normal. Constipation is often defined as having fewer than 3 bowel movements a week. The number of bowel movements may be different for each child. But a change in what is normal for your child may mean there is a problem.
• Passing stool that is hard and sometimes large
• Having bowel movements that are difficult or painful to push out

What causes constipation?

Stool gets hard and dry when the large intestine (colon) takes in (absorbs) too much water.

Normally, as food moves through the colon, the colon absorbs water while it makes stool. Muscle movements (contractions) push the stool toward the rectum. When the stool gets to the rectum, most of the water has been soaked up. The stool is now solid.

If your child has constipation, the colon's muscle movements are too slow. This makes the stool move through the colon too slowly. The colon absorbs too much water. The stool gets very hard and dry.

Once a child becomes constipated, the problem can quickly get worse. Hard, dry stools can be painful to push out. So the child may stop using the bathroom because it hurts. Over time, the colon will not be able to sense that stool is there.

There are many reasons why a child may become constipated. Some common diet and lifestyle causes include:

Diet

• Eating too many foods that are high in fat and low in fiber. These include fast foods, junk foods, and soft drinks.
• Not drinking enough water and other fluids
• Having a change in diet. This includes when babies change from breastmilk to formula, or when they start eating solid foods.

Lack of exercise

• Children who watch a lot of TV and play video games don’t get enough exercise. Exercise helps move digested food through the intestines.

Emotional issues

• Not wanting to use public bathrooms. Children may then hold in their bowel movements, causing constipation.
• Going through toilet training. This can be a difficult time for many toddlers.
• Having power struggles with parents. Toddlers may hold in their bowel movements on purpose.
• Feeling stressed because of school, friends, or family

Busy children

• Some children don’t pay attention to signals that their body gives them to have a bowel movement. This can happen when children are too busy playing. They forget to go to the bathroom.
• Constipation can also be a problem when starting a new school year. Children can’t go to the bathroom whenever they feel the need. They have to change their bowel routine.

Underlying physical problem

 In rare cases, constipation can be caused by a larger physical problem. These physical issues can include:

• Problems of the intestinal tract, rectum, or anus
• Nervous system problems, such as cerebral palsy
• Endocrine problems, such as hypothyroidism
• Certain medicines, such as iron supplements, some antidepressants, and narcotics such as codeine

What are the symptoms of constipation?

Symptoms can occur a bit differently in each child. They may include:

• Not having a bowel movement for a few days
• Passing hard, dry stools
• Having belly (abdominal) bloating, cramps, or pain
• Not feeling hungry
• Showing signs of trying to hold stool in, such as clenching teeth, crossing legs, squeezing buttocks together, turning red in the face
• Small liquid or soft stool marks on a child's underwear

The symptoms of constipation can be like other health conditions. Make sure your child sees his or her healthcare provider for a diagnosis.

How is constipation diagnosed?

The healthcare provider will ask about your child’s symptoms and health history. He or she will give your child a physical exam. Depending on how old your child is, you might be asked questions such as:

• How old was your baby when he or she had their first stool?
• How often does your child have a bowel movement?
• Does your child complain of pain when having a bowel movement?
• Have you been trying to toilet train your toddler lately?
• What foods does your child eat?
• Have there been any stressful events in your child's life lately?
• How often does your child poop in his or her pants?

Your child’s provider may also want to do some tests to see if there are any problems. These tests may include:

• Digital rectal examination (DRE). Your child’s provider puts a gloved, greased (lubricated) finger into your child’s rectum. The provider will feel for anything abnormal.
• Abdominal X-ray. This test checks how much stool is in the large intestine.
• Barium enema. This is an X-ray exam of the rectum, the large intestine, and the lower part of the small intestine. Your child will be given a metallic fluid called barium. Barium coats the organs so they can be seen on an X-ray. The barium is put into a tube and inserted into your child’s rectum as an enema. An X-ray of the belly will show if your child has any narrowed areas (strictures), blockages (obstructions), or other problems.
• Anorectal manometry. This test checks the strength of the muscles in the anus and the nerve reflexes. It also checks your child’s ability to sense that the rectum is full (rectal distension) and a bowel movement is needed. And it looks at how well the muscles work together during a bowel movement.
• Rectal biopsy. This test takes a sample of the cells in the rectum. They are checked under a microscope for any problems.
• Sigmoidoscopy. This test checks the inside of part of the large intestine. It helps to find out what is causing diarrhea, belly pain, constipation, abnormal growths, and bleeding. A short, flexible, lighted tube (sigmoidoscope) is put into your child’s intestine through the rectum. This tube blows air into the intestine to make it swell. This makes it easier to see inside.
• Colorectal transit study. This test shows how well food moves through your child’s colon. The child swallows pills (capsules) filled with small markers that can be seen on an X-ray. The child eats a high-fiber diet for the next few days. X-rays will be taken 3 to 7 days after your child takes the pills. The X-rays will show how the pills moved through the colon.
• Colonoscopy. This test looks at the full length of the large intestine. It can help check for abnormal growths, red or swollen tissue, sores (ulcers), and bleeding. The test uses a long, flexible, lighted tube (colonoscope). The tube is put into your child’s rectum up into the colon. This tube lets the provider see the lining of the colon and take out a tissue sample (biopsy) to test it. The provider may also be able to treat some problems that are found.
• Lab testing. Several tests may be done. These include tests to check for issues such as celiac disease, urinary tract infection, thyroid  problems, metabolic problems, and blood lead level.

How is constipation treated?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Treatment may include diet and lifestyle changes, such as:

Diet changes

Often making changes in your child's diet will help constipation. Help your child to eat more fiber by:

• Adding more fruits and vegetables
• Adding more whole-grain cereals and breads. Check the nutrition labels on food packages for foods that have more fiber.

Other diet changes that may help include:

• Having your child drink more fluids, especially water
• Limiting fast foods and junk foods that are often high in fats. Offer more well-balanced meals and snacks instead.
• Limiting drinks with caffeine, such as soda and tea
• Limiting whole milk as directed by your child’s healthcare provider

It’s also a good idea to have your child eat meals on a regular schedule. Eating a meal will often cause a bowel movement within 30 to 60 minutes. Serve breakfast early. This will give your child time to have a bowel movement at home before rushing off to school.

Get more exercise

Having your child get more exercise can also help with constipation. Exercise helps with digestion. It helps the normal movements the intestines make to push food forward as it is digested. People who don’t move around much are often constipated. Have your child go outside and play rather than watch TV or do other indoor activities.

Good bowel habits

Try to get your child into a regular toilet habit. Have your child sit on the toilet at least twice a day for at least 10 minutes. Try to do this just after a meal. Be sure to make this a pleasant time. Don’t get mad at your child for not having a bowel movement. Use a reward system to make it fun. Give stickers or other small treats. Or make posters that show your child's progress.

In some cases these changes may not help. Or your child’s healthcare provider may detect another problem. If so, the provider may recommend using laxatives, stool softeners, or an enema. These products should only be used if recommended by your child's provider. Do not use them without talking with your child's provider first.

What are the complications of constipation?

Hard stools can irritate or tear the lining of the anus (anal fissures). This makes it painful to have a bowel movement. Your child may avoid having a bowel movement because it hurts. This can make constipation get worse.

Can constipation be prevented?

Constipation can be prevented by figuring out the times when it may occur, and making proper changes.

For instance, when babies start to eat solid food, constipation can result. This is because they don’t have enough fiber in their new diet. You can add fiber to your  baby’s diet by giving pureed vegetables and fruits. Or try whole-wheat or multigrain cereals.

Constipation can also happen during toilet training. Children who do not like using a regular toilet may hold in their stool. This causes constipation.

All children should get the right amount of fiber and fluids. Other preventative measures include  making sure your child has:

• Regular access to a bathroom
• Enough time to use the toilet
• Regular physical exercise

The same changes that can help treat constipation may also help to stop it from happening.

Living with constipation

Constipation can be either short-term (acute) or long-term (chronic). Children with intestinal diseases may have chronic constipation problems. But in most cases, constipation is a short-term condition. If your child has chronic constipation, work with his or her healthcare provider. Together you can create a care plan that is right for your child.

When should I call my child's healthcare provider?

Call your child's healthcare provider if you have any questions or concerns about your child's bowel habits or patterns. Talk with your child's provider if your child:

• Is constipated for more than 2 weeks
• Can’t do normal activities because of constipation
• Can’t get a stool out with normal pushing
• Has liquid or soft stool leaking out of the anus
• Has small, painful tears in the skin around the anus (anal fissures)
• Has red, swollen veins (hemorrhoids) in the rectum
• Has belly pain, fever, or vomiting

Key points about constipation

• Constipation is when a child has very hard stools, and has fewer bowel movements than they normally do.
• Constipation can be caused by a child’s diet, lack of exercise, or emotional issues.
• Once a child becomes constipated, the problem can quickly get worse.
• Making diet and lifestyle changes can help treat and help prevent constipation.
• Never give your child an enema, laxative, or stool softener unless the healthcare provider recommends this.

Next steps

Tips to help you get the most from a visit to your child’s health care provider:

• Before your visit, write down questions you want answered.
• At the visit, write down the names of new medicines, treatments, or tests, and any new instructions your provider gives you for your child.
• If your child has a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.

Symptoms & Causes of Constipation in Children

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What are the symptoms of constipation in children?

Symptoms of constipation in children may include your child

• having fewer than two bowel movements a week
• passing stools that are hard, dry, or lumpy
• having stools that are difficult or painful to pass
• telling you that he or she feels that not all stool has passed
• changing positions to avoid or delay having a bowel movement, including
  • standing on tiptoes and then rocking back on his or her heels
  • clenching his or her buttocks
  • doing unusual, dancelike movements
• having a swollen abdomen, or bloating
• having daytime or nighttime wetting
• having stool in his or her underwear that looks like diarrhea

If your child avoids or delays having a bowel movement, he or she may develop a fecal impaction.

When should my child see a doctor?

Your child should see a doctor if his or her symptoms last for more than 2 weeks or do not go away with at-home treatment.

Take your child to a doctor right away if he or she has constipation and any of the following symptoms

• bleeding from his or her rectum
• blood in his or her stool
• bloating
• constant pain in his or her abdomen
• vomiting
• weight loss

What causes constipation in children?

Children most often get constipated from holding in their stool to avoid or delay having a bowel movement. When stool stays too long in the colon, the colon absorbs too much fluid from the stool. Then the stool becomes hard, dry, and difficult to pass. Learn more about the digestive system and how it works.

Your child may delay or avoid a bowel movement because he or she

• feels stressed about potty training
• feels embarrassed to use a public bathroom
• does not want to interrupt playtime
• fears having a painful or an unpleasant bowel movement

Certain medicines

Medicines and dietary supplements that can make constipation in children worse include

• antacids that contain aluminum and calcium
• anticholinergics and antispasmodics
• anticonvulsants—used to prevent seizures
• iron supplements
• narcotic pain medicines
• some medicines used to treat depression

Certain health and nutrition problems

Certain health and nutrition problems can cause constipation in children

• not eating enough fiber
• not drinking enough liquids or dehydration
• Hirschsprung disease
• celiac disease
• disorders that affect your brain and spine, such as spina bifida
• spinal cord or brain injuries
• conditions that affect their metabolism, such as diabetes
• conditions that affect their hormones, such as hypothyroidism
• problems that can block or narrow the colon or rectum, including tumors

Last Reviewed May 2018

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This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.

Constipation in children. Prevention. Diet therapy

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Sabitova Vasily Ilyasovna Gastroenterologist

06/21/2019

Constipation is widespread among both adults and children (5-30% depending on the diagnostic criteria). Symptoms become chronic in more than 30% of patients, not only cause discomfort and pain to the child himself, but also disrupt the quality of life of his family.

CONSTIPATION - a condition manifested by an increase in the intervals between bowel movements (compared to the individual norm) or systematically slow, difficult and / or insufficient bowel movements. Constipation also includes stools with “gruel”, but after defecation was absent for up to 3 days.

Constipation can be related to functional or organic causes (abnormalities, inflammation). In children, 90-95% of constipation is functional. The peak incidence of functional constipation falls on 2-4 years, when they begin to accustom the child to the potty / toilet.

Main causes of functional constipation

• Pain
• Fever
• Dehydration
• Wrong diet of a nursing mother
• Insufficient drinking regime of a child with artificial feeding
• Insufficient drinking regimen of a breast-fed child with the introduction of complementary foods
• Early transition of the child to artificial feeding
• Fast transition of the baby from one mixture to another (less than 7 days)
• Irrational nutrition of the child (for a long time the child receives food with a large amount of proteins, fats and insufficient dietary fiber, abuse of drinks containing a large amount of astringents - tea, coffee, cocoa)
• Excessive use of baby hygiene products or the development of an allergic reaction of the skin of the perianal area
• Consequences of perinatal injuries of the nervous system
• Rickets, vitamin D deficiency
• Anemia
• Impaired thyroid function (deficiency - hypothyroidism)
• Food allergy, especially cow's milk protein allergy
• Forced potty training, period of adaptation to new conditions (nursery, kindergarten)
• Physical inactivity - a sedentary lifestyle
• Mental trauma or stress
• Systematic suppression of the urge to empty the bowels, associated, for example, with the beginning of attending a kindergarten, school, etc.
• Taking certain drugs
• Constipation in family members

Frequency of defecation in children of different ages

In addition to the frequency of the chair, you should pay attention to its nature. For a more objective assessment, the “Bristol fecal shape scale” is convenient, since it is the shape of the feces, and not the frequency of the stool, that is more consistent with the time of intestinal transit.

Bristol stool chart

In accordance with this scale, 3 and 4 form of feces is regarded as normal, and 1 and 2 indicate delayed transit (constipation). Quite often, in practice, there are situations when a child has a bowel movement frequency within the normal range, but the stool is dense, fragmented, in a meager amount. These signs indicate incomplete emptying of the bowels and are considered as manifestations of constipation.

The consistency of the stool in newborns and infants should be mushy. From 6 months to 1.5 - 2 years, feces can be both formalized and mushy. From the age of two, the chair must be decorated.

Signs and symptoms of constipation

• abdominal pain, often bursting, aching, sometimes colicky
• bloating
• change in the shape and consistency of the stool
• excessive flatulence
• unpleasant smell of flatus and stool
• may have pain during bowel movements
• straining during bowel movements
• there may be blood in the stool - on the surface of the feces or in the form of traces on a napkin (indicates an anal fissure)

If you do not eliminate constipation and do not establish bowel movements, then there is a risk of coprostasis (formation of fecal stones) and fecal intoxication:

• loss of appetite
• lack of energy
• general malaise
• depression, irritability
• nausea, vomiting
• skin symptoms - dryness, rash, peeling
• fecal incontinence, stool spotting
• urinary retention and incontinence due to pressure from a crowded bowel on the bladder
• bleeding from fissures, hemorrhoids

The treatment of constipation involves the following goals:

1. Normalization of stool consistency (soft, painless stools)

2. Regularity of bowel movements (prevention of re-accumulation of feces)

The treatment of constipation is a sequential, complex, individual process and consists of several stages:

• child and parent education
• correction of nutrition and drinking regimen
• elimination of existing coprostasis with the help of medications
• maintenance therapy

It is necessary to exclude factors that provoke and contribute to constipation (normalization of motor and nutritional regimen, discontinuation of medications that can cause constipation, identification of a food allergen, exclusion or confirmation of neuromuscular disease, celiac disease, etc.).

Lifestyle normalization includes:

• development of a conditioned reflex
• active lifestyle
• gymnastics
• light abdominal massage training
• for small children - laying out on the stomach, bending the legs to the stomach.

Education is the first step in the treatment of functional constipation. It must be remembered that episodes of fecal smearing and encopresis (fecal incontinence) are not arbitrary and should not be blamed on the child, who may already be frightened and disoriented. In some cases, when the intra-family situation is difficult, the help of a family psychologist may be needed.

It is important to understand that the treatment of functional constipation can be lengthy, based on trust, partnership and requires patience. Modern laxatives that are legal in children will not make the intestines “lazy”, will not cause “addiction”, they enter the bloodstream in minimal amounts or are not absorbed at all and are safe for long-term use.

Correction of the behavior of a child with constipation is based on the development of a routine of visiting the toilet, in order to achieve regular defecation. Defecation should be every time at the same time. The urge to defecate is based on the gastrocecal reflex, which manifests itself in the morning 1 hour after eating. A child with constipation needs to spend 3-10 minutes in the toilet (depending on age). It is necessary to plant the child on a potty or offer to visit the toilet after each meal.

A prerequisite for effective defecation is to provide a good support for the legs (a low bench on which the child can put his feet), which helps to increase intra-abdominal pressure.

If the defecation is not successful, the child should never be punished and vice versa. The daily frequency of bowel movements can be noted in a diary, which can be analyzed at a scheduled visit to the doctor.

Treatment of constipation should begin with lifestyle changes, which include dietary modification, drinking regimen and physical activity.

Calculation of fluid volume for healthy children

Children under the age of 1 year should drink at least 100 ml of water per day.

For healthy children weighing 10 to 20 kg the water requirement is calculated using the formula:

100 ml (volume of water for children under 1 year old) + 50 ml per kg for body weight over 10 kg.

For example, with a mass of 12 kg: 100 ml + 2 x 50 ml = 200 ml.

A child weighing 20 kg should drink water: 100 ml + 50 x 10 = 600 ml

For children weighing over 20 kg the following formula is suggested for calculation:

600 ml (volume of water for a child weighing 20 kg) + 20 ml for each kg over 20 kg.

For children over 3-5 years old you can use the calculation of the amount of water: 30ml / kg of weight

Principles of diet therapy for constipation:

• satisfaction of physical needs for nutrients and energy
• exclusion of excessive consumption of proteins and fats, which can inhibit intestinal motility
• enrichment of the diet with dietary fiber
• normalization of intestinal microflora with pro- and prebiotics

If the child is breastfed, then the mother's nutrition is corrected (restriction of products that promote gas formation). With artificial feeding, special mixtures are shown. For constipation associated with an allergy to cow's milk protein, therapeutic mixtures are prescribed if the child is bottle-fed. If the child is breastfed, cow's milk and products based on it are completely excluded from the mother's diet.

After the introduction of “thick” complementary foods, boiled water is necessary for all children, regardless of the type of feeding.

For older children, it is recommended to eat foods rich in vegetable fibers. It is not recommended to “smear food”, puree, “snacks”, “eating on the go”. Food should be crumbly, meat / poultry / fish - “piece”. A “bulk” breakfast is required to stimulate the “gastrocecal reflex”.

The main source of coarse-fiber vegetable fiber, containing a large amount of dietary fiber, is cereal bran, rye bread, as well as a number of vegetables and fruits. According to the principles of evidence-based medicine, a statistically significant increase in stool frequency and improvement in its consistency was demonstrated with the use of fiber compared with placebo.

Bran, as the main source of vegetable fiber, is recommended to be added to the second and third courses, after pouring boiling water over it and settling for 20 minutes. Bran can also be used in between meals, drinking plenty of fluids. For school-age children, the total amount of fluid when taking bran should be at least 1.5-2 liters per day, otherwise they mainly act as sorbents, absorbing fluid from the intestines, thereby increasing constipation. The dose is selected individually, it is recommended to start with 1 teaspoon 2-3 times a day, with a gradual increase to 40 g per day. When the effect is achieved, the dose is reduced and limited to one dose.

The American Academy of Pediatrics (2009) recommends a fiber intake of 0.5 g/kg/day (maximum 35 g/day) for all children. Fiber intake below the minimum recommended value has been shown to be a risk factor for chronic constipation in children.

However, long-term intake of a large amount of plant fibers due to fermentation by intestinal microflora is naturally accompanied by bloating and flatulence.

Children with constipation are shown to take cool liquids on an empty stomach (drinking and mineral water, juice, compotes, kvass), to enhance the laxative effect, it is possible to add honey, xylitol or sorbitol. It is very beneficial for bowel function to increase the intake of juices containing sorbitol/sorbitol, such as juice from plums, pears, apricots, peaches and apples,

With “sluggish” bowel function (hypomotor constipation), cool mineral water of medium and high mineralization is used, such as Essentuki 17, Batalinskaya, Arzni, Donat Magnesium, etc.; with spastic constipation (hypermotor constipation, stool form more often type 1) - warm and low mineralization (Essentuki 4). Calculation of mineral water - 3-5 ml / kg per day.

It is necessary to limit milk in its pure form and in dishes, as flatulence may occur with the appearance or intensification of abdominal pain. It is better to replace whole milk with sour-milk products - kefir, acidophilus, yogurt, yogurt, etc.

The diet of children with constipation includes dishes rich in vegetable fiber - salads from fresh vegetables, greens 2-3 times a day, baked apples, stewed vegetables, diluted vegetable and fruit juices with pulp. Food is cooked mostly unground, steamed or boiled in water.

It is preferable to take raw vegetables and fruits (in the absence of contraindications). Especially recommended are tomatoes, zucchini, pumpkin, carrots, beets, lettuce, cauliflower, apples. Dried fruits (prunes, dried apricots, figs) are given in soaked form and as part of cooked dishes. White cabbage, young green beans, green peas are allowed with good tolerance. Parsley, dill, celery are good to add to various dishes and salads.

If after reading the article you still have questions or you do not understand how to apply the recommendations in your particular case, we invite you and your child to be examined by a pediatric gastroenterologist at the DDC. For the convenience of parents, you can make an appointment with a pediatric gastroenterologist at the Children's Diagnostic Center on a weekday and on Saturdays.
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