Constipation

Constipation

Constipation is when your child has hard, infrequent poo - it's a common problem in childhood.

Key points to remember

  • constipation is when your child has hard, infrequent poo (stool, bowel motions)
  • it is a common problem in childhood
  • constipation often starts after 1 hard poo has caused pain and so your child has tried to avoid pain the next time by 'holding on' to the poo, resulting in a vicious cycle
  • increasing the fluid your child drinks and the amount of fibre in their diet can help prevent constipation
  • laxatives are often necessary - they work by softening the poo so it is easier to pass
  • a regular toileting habit is important
  • usually children need laxatives for months and sometimes years to manage the problem

What is it?

Constipation is when your child has hard poo or does not empty their bowel regularly. There is a lot of variation in the firmness and frequency of poo in normal babies and children:

  • breastfed babies may have a poo following each feed but some breastfed babies only have a poo every 7 to 10 days
  • bottle fed babies and older children will usually have a poo at least every 2 to 3 days

If your child over 1 year of age has a poo less frequently than every 3 days and the poo is firm, they are likely to be constipated.

What are the signs and symptoms?

Your child may be constipated if they have some of the following:  

  • hard and 'pebble-like' poo
  • no poos for 3 or more days 
  • pain or crying when having a poo
  • bright blood around the poo due to tears in the anal skin (anal fissures)
  • tummy pain, especially if it is relieved by having a poo
  • urinary tract infections, leaking urine (urine incontinence), and bedwetting - constipation can increase the risk of these 
  • soiling accidents (encopresis)

What causes it?

Constipation in children is common.

There are many possible reasons for your child's constipation. Often, it is a combination of factors:

  • a natural tendency to having a slower gut movement
  • a poor diet can make constipation worse in children who already have this natural tendency; a poor diet will be high in animal fat (meat, dairy products, eggs) and refined sugar (rich desserts and other sweets) but low in fibre (vegetables, fruits, whole grains). There is not much fibre in most packaged foods and takeaways
  • less activity and not eating and drinking as much, for example when your child is unwell
  • not drinking enough fluids
  • weaning from breastmilk to other types of milk
  • starting solids

Bowel habit can also be important. Your child can become constipated if they:

  • ignore the urge to have a poo or
  • fail to fully empty the bowel of poo when going to the toilet

How a vicious cycle can be established

Constipation often starts after 1 hard poo has caused pain. The natural response to a painful experience is to try and avoid or escape it in the future. Therefore, the next time the child feels the urge to poo, they 'hold on' in an attempt to avoid passing another painful poo. This results in the poo becoming firmer, larger and even more painful when it is eventually passed and the child becomes even more reluctant to poo in the future.

In this way a vicious cycle is established:

hard poo   -   pain   -   try to avoid pain by 'holding on' to poo   -   hard poo   -   pain etc.

What if constipation continues for a long time?

If constipation continues for a long time and the bowel is not emptied regularly, the bowel becomes overloaded and stretches (see 'How does my child get an overloaded bowel?' on the soiling page). The overloaded and stretched bowel means the feeling of needing to pass a poo is lost and can make soiling accidents more likely.

Could childhood constipation be due to an abnormal bowel?

Constipation is hardly ever due to an abnormal bowel. Most bowel problems show up in early life and are diagnosed within the first few months.

If your child passed meconium (the green/black poo newborn babies pass) within 24 hours of birth, it is unlikely your child has a bowel problem causing constipation.

What can I do to treat it?

Try simple measures first:

  • increase the water your child drinks daily - give them water at each meal time and extra water when it is hot
  • increase fruit and vegetables in your child's diet (and see the suggestions below in 'How can I increase the fibre in my child's diet?')
  • try giving your child 1 glass of undiluted apple juice or KiwiCrush (a kiwi fruit drink) daily – do not give juice to infants under 12 months of age
  • encourage a regular toileting habit (see 'What toileting habit should I encourage for my child?' below)
  • for bottlefed infants, consider experimenting with various infant formulas to find the one that makes the poos softer and easier to pass
  • encourage exercise

Fruit juice (and in particular KiwiCrush), and some of the medicines used to treat constipation, are high in sugar. Make sure your child's teeth are brushed after the juice or medicine, and at least twice a day.

If the above measures are not enough, your child will need laxatives (see 'What are laxatives?' below).

How can I increase the fibre in my child's diet?

Fibre makes the poo softer and easier to pass. Giving your child (aged over 15 months) more fibre in their diet can help prevent constipation and also treat short term or very mild constipation. Fibre is also important long term for regular bowel functioning. If your child has had constipation a long time, just increasing fibre without other treatment is unlikely to resolve the problem. 

To add more fibre to your child's diet, you can:

  • give at least 3 servings of fruits each day; fruits with the peel left on, such as plums, prunes, raisins, apricots, and peaches have a lot of fibre as do kiwifruit and corn
  • give at least 3 servings of vegetables each day; this includes potato, pumpkin, kumara
  • give cereals high in fibre, such as bran cereals, Weet-Bix, whole grain cereals, porridge; avoid refined cereals, such as corn flakes, rice bubbles or those with added sugar
  • give wholemeal breads instead of white bread (except in children under 12 months old)
  • try adding bran to muffins and other baking, or add it to your child's regular cereal
  • try adding 1 to 2 tablespoons of ground flax seed/linseed meal to cereals, soup or mixed into a smoothie 
  • give legumes (beans and peas), including baked beans, hummus, lentils
  • give strained prunes to babies, up to 3 tablespoons a few days each week

It is also important to give your child plenty of water with the increase in fibre.

What toileting habit should I encourage for my child?

Encourage your child to develop a regular toilet habit by sitting on the toilet for 5 minutes once or twice a day preferably after a meal (breakfast is best). Even if they don't do a poo, still encourage this habit.

  • make sure your child is comfortable on the toilet
  • get a stool for them to rest their feet on to make sure your child's knees are higher than their hips
  • the use of a toilet seat inner can be very useful for little bottoms. If your child is not relaxed because they're worried about falling in to the toilet they tend to tighten their pelvic floor muscle and this makes it difficult to have a relaxed successful poo
  • encourage your child to lean forward and rest their elbows on their knees
  • teach them to push their stomach (abdomen) out when pushing
  • make the toilet child friendly and fun with books, toys, a blackboard etc nearby; it's a lonely place and children get bored
  • incentive or 'star' charts are useful to reward your child for sitting on the toilet and doing a poo, and can help keep track of progress

When should I take my child to the doctor?

You should take your child to your doctor if:

  • the simple measures described above in 'What can I do to treat it?' (such as increasing fibre and the amount of water your child drinks) haven't worked, or
  • your child has had constipation for a long time, or
  • your child has tummy (abdominal) pain, or
  • your child is pooing their pants (soiling)

If any of the above apply to your child, it usually means their constipation is more severe.

Your doctor may refer your child to a paediatrician (specialist children's doctor) if:

  • your child's constipation is proving difficult to treat after standard treatments or,
  • your GP thinks there may be another condition underlying your child's constipation (if this is the case, some tests/investigations may be needed)

What are laxatives?

The aim is for 1 soft formed poo per day. Until the body can manage that alone, it will need help (from laxatives).

Laxatives are medications that help the body to get rid of poo. They are a standard and essential part of the treatment of constipation and have been shown to speed up improvement better than dietary changes alone. Most are available over the counter at a chemist (pharmacy) but advice about dosage from a nurse or doctor is helpful.

There are 2 main ways laxatives for childhood constipation work:

  • some soften the hard poo and make it easier to pass (poo softeners)
  • some help the bowel push the poo out (stimulants or emptiers)

For details about some of the laxatives that are available for the treatment of constipation, see the section 'Which laxatives are available?' on the laxatives page.

How long are laxatives for constipation necessary?

For as long as it takes. Children often need laxatives for months to years rather than weeks.

Remember that the purpose of laxatives is to allow your child to develop a normal habit of emptying their bowel regularly so that the overstretched bowel can return to a normal size. This recovery is often very prolonged.

Ideally a child should be aiming for 1 soft formed poo per day. Laxatives are necessary until the body can manage this without help. You may need to adjust the dose over time, but it is important to maintain the softening treatment. 

Often children get sick of taking medication, or dislike the taste. Try to make the medication taste better by serving it with milk or juice, or ask your doctor or nurse about an alternative laxative. Incentive or 'star charts' can be a good way of encouraging your child to take medicine regularly.

Bowel flush out to empty the lower bowel

If your child has had constipation for a long time, your doctor may recommend emptying the lower bowel (rectum) of poo. This is often necessary to allow the bowel to return to a normal size. It is called disimpaction - a flush out of the bowel contents. A bowel flush out is always just one part of your child's overall treatment – the first part. It is never a stand alone treatment. In fact, if your child requires a flush out, then they will usually need a long course of laxatives. Eventually, they can be weaned off the laxatives and on to a high fibre diet.

A bowel flush usually involves giving a powerful laxative solution (such as sodium picosulphate or macrogol). Your child will need to drink the solution until the bowel is emptied. Because of the volumes necessary for some of these treatments, your child may need to go to hospital to receive the laxative solution through a tube passed from the nose to the stomach (nasogastric tube).

Enemas and suppositories

These are medications given into the lower bowel (rectum) to help to empty it. This can be an unpleasant experience for children, causing pain and embarrassment. They are generally avoided in children and should only be used under medical direction.

References

  1. ESPGHAN and NASPGHAN. 2014. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN.
    http://www.naspghan.org/content/63/en/Clinical-Guidelines-and-Position-Statements [Accessed 14/05/2015]
  2. Royal Children's Hospital, Melbourne. Clinical Practice Guideline: Constipation.
    http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=11659 [Accessed 14/05/2015]
  3. National Institute for Health and Clinical Excellence, U.K. May 2010. Constipation in children and young people.
    http://www.nice.org.uk/guidance/CG99 [Accessed 14/05/2015]

This page last reviewed 24 November 2015.
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