Disclaimer: This fact sheet is for educational use only. Please consult your doctor or other health professional to make sure this information is right for your child.

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 one 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 needed, which 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
soiling (encopresis) is when your child does poo in their pants after the age when you would expect them to be toilet-trained; this is usually caused by chronic constipation and an overloaded bowel
the treatment for soiling is the same as for constipation

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 seven to ten days
bottle-fed babies and older children will usually have a poo at least every two to three days

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

What are the signs and symptoms?

your child’s poo is hard and “pebble-like”
your child has not had a poo for four days or more
your child complains of pain or cries when having a poo
there is bright blood around the poo due to tears in the anal skin (anal fissures)
your child complains of tummy pain, especially if it is relieved by having a poo
constipation can increase the risk of urinary tract infections, leaking urine (urine incontinence), and bedwetting
there are soiling accidents

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 aggravate constipation 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 little fibre in most convenience or “junk” food
less activity and not eating and drinking as much, for example when your child is unwell
not drinking enough fluids

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 one 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? in the soiling fact sheet). The overloaded and stretched bowel means the sensation 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 - ensure they have a good drink at each meal time and extra drinks when it is hot
increase fruit and vegetables in your child’s diet (and see the suggestions in How can I increase the fibre in my child's diet?)
try giving your child one glass of undiluted apple juice or KiwiCrush (a kiwi fruit drink) daily – do not give undiluted juice to infants under six months of age
encourage a regular toileting habit (see What toileting habit should I encourage for my child?)
for bottlefed infants, consider experimenting with various infant formulas to find the one that makes the poos softer and easier to pass
encourage exercise

If these measures are not enough, your child will need laxatives (see What are laxatives?).

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 three 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 kiwi fruit and corn
give at least three 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 15 months old)
try adding bran to muffins and other baking, or add it to your child's regular cereal
try adding one to two 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 three tablespoons a few days each week

It is also important to increase your child’s intake of water with the increase in fibre.

What is the toileting habit I should encourage for my child?

Encourage your child to develop a regular toilet habit by sitting on the toilet for five 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 GP (general practitioner) if:

the simple measures described 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 soiling

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

Your GP 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 one soft but 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 two main ways in which 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? in the laxatives fact sheet.

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 one soft but formed poo per day. Laxatives are required 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

Emptying your child’s lower bowel (rectum) of poo is often required to return the bowel to a normal size, especially if your child has had constipation for a long time. This is called disimpaction, but could be seen as 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’s never a stand alone treatment. In fact, if your child requires a washout, then they will usually require a long course of laxatives. Eventually, they will be able to be weaned off the laxatives and on to a high fibre diet.

A bowel flush-out is usually done by giving a powerful laxative solution (such as ‘picoprep’, ‘movicol’ or ‘clean prep’) as a one-off dose. Your child will need to drink the solution until the bowel is emptied. Because of the volumes required 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.

Where to go for more information

On this website

Soiling (encopresis)

Laxatives

Children’s Health Camps www.healthcamps.org.nz

Children's Health Camps run a programme for children who have constipation and soiling problems.

KEEA (Kiwi Enuresis Encopresis Association) NZ www.keea.org.nz / 0800 533 269

The KEEA website provides information on constipation and soiling. Information and advice is also available via the KEEA 0800 number. An example of the information available from KEEA is the booklet “Tim’s problem” (there will be a small charge for this). Written for children, “Tim’s problem” is the story of a boy with an embarrassing problem of often soiling his pants. He and his mum discover that this is quite a common problem in children and that it can be treated.

Parent to Parent www.parent2parent.org.nz

Parent to Parent offers a support service to parents of children with a range of conditions and can put you in touch with parents experiencing similar situations.

Soiled pants: A guide for parents and children (at right)

This is a brochure (available in pdf format) with diagrams. It is designed for printing.

International websites

Bristol Stool Chart at Wikipedia en.wikipedia.org/wiki/Bristol_Stool_Scale

The Bristol Stool Scale / Chart is a medical aid, with diagrams, designed to classify poo into seven groups indicating constipation, normal poo or diarrhoea.

ERIC (Education and Resources for Improving Childhood Continence) www.eric.org.uk

ERIC has a number of leaflets that can be downloaded. It provides information for parents, children and adolescents and for health professionals.

University of Virginia Health System (U.S.)

The University of Virginia website provides the following tutorial for patients and families:

Chronic constipation and encopresis

Acknowledgements

This fact sheet was originally developed in consultation with:

The Royal Children’s Hospital (Melbourne) Kids Health Info. Adapted October 2006 by Child Development Centre, Waikato Hospital.

Paediatric Department, Christchurch Hospital
Paediatric Department, Nelson Hospital

References

NASPGHAN Constipation Guideline Committee. September 2006. Clinical practice guideline: Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
http://www.naspghan.org/user-assets/Documents/pdf/PositionPapers/constipation.guideline.2006.pdf [Accessed 4/03/2011]
Royal Children's Hospital, Melbourne. November 2010. Clinical Practice Guideline: Chronic constipation.
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=11659 [Accessed 4/03/2011]
National Institute for Health and Clinical Excellence, U.K. May 2010. Constipation in children and young people.
http://guidance.nice.org.uk/CG99 [Accessed 4/03/2011]

Your notes

Endorsement

This fact sheet was endorsed by PSNZ - 04/03/2011

Copyright

Fact sheets are subject to copyright. In the interests of information sharing they may be copied but acknowledgement must be given to PSNZ and Starship Foundation.
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