Constipation in children and infants – a basic chapter in pediatrics

What is the definition of constipation in children?

Actually, a clear-cut definition for constipation in children does not exist. When we discuss constipation in children we need to take several factors into account, including the consistency of the stool (soft or hard), the number of stools per day and the ease or difficulty at which the passing of stool occurs.
For example: a child who passes a soft stool every 3 days without any issues does not suffer from constipation. However, a child who passes a hard stool with great difficulty and pain once every two days, does indeed suffer from constipation.
Any efforts to tabulate the number of stools and age of the child will miss the main point behind the definition of constipation.
Theoretically speaking, according to the textbooks, constipation is defined as a symptom that has been ongoing for at least one month, or more, and includes some of the following criteria: decreased frequency of stooling, the passing of stools that are hard, painful or larger in diameter, the presence of a large volume of stool in the rectum, an underlying incontinence of stool, and more.
In my opinion, one does not need to wait for the symptoms to persist for one month before diagnosing constipation and starting treatment.

What are the main causes of constipation in children?

The causes of constipation are commonly divided into two:
1. Organic causes of constipation, i.e. due to a physical cause
2. Idiopathic or functional constipation, i.e. due to abnormal function

The first term, i.e. constipation due to an organic cause, refers to the child with a past medical history, where constipation is a secondary symptom or a result of their underlying medical problem. There could be many potential ‘problems’; from anatomical to metabolic issues, neurologic causes and to signs due to the adverse effects of drugs.
That is why, even in a healthy child, it is important to consult with a pediatrician when your child is experiencing constipation. The pediatrician will listen to your story, perform a good physical examination on the child and rule out organic causes of constipation.

But in most day-to-day cases of constipation that present at the clinic, the pediatrician usually encounters healthy children, without a clear cause of constipation, and that is when constipation is referred to as ‘functional constipation’.
Sometimes, parents will describe their child as one who has been suffering from constipation since infancy. Other times, the constipation will have just started, without any past medical history.

What are the causes of functional constipation?

There are many causes to functional constipation. These include:
– “Bad” dietary habits (low-fiber diet)
– Incorrect restraining/stool passage habits, sometimes involving significant life changes such as diaper weaning, use of public bathrooms or a traumatic event (anything from the birth of a sibling to physical abuse).
– Some children simply tend to suffer more from constipation
– Sometimes constipation is a result of a vicious cycle that develops right before our eyes – child does not pass stool because of an acute, unknown reason – whatever it may be. Their stool hardens, and this leads to pain in the child’s next attempt at defecation. This pain prevents them from trying to pass stool, the constipation worsens and the cycle starts all over again.

What starts the vicious cycle that leads to constipation?

If one were to simplify complex biological matters one could probably say that the mechanism behind defecation is common to us all.
The contraction of intestinal muscles allows soft stool to reach the rectum. This stimulates the body to pass stool, causes certain muscles to contract while others (around the anus) relax and allows for painless passage of stool.
If anything along this process goes wrong, for any reason whatsoever, hard stool accumulates in the rectum, the passage of stool becomes painful, both physically (pain and discomfort in the anal area that could lead to the formation of an anal fissure) and emotionally (children tend to remember painful events).
As a result, the child avoids defecating and learns how to retain stool. Intestinal contraction becomes less efficient, more dry stool accumulates in the sigmoid area (the last part of the gastrointestinal tract) and this turns into a vicious cycle. The child avoids defecating even more, there is more stool retention and so forth.
Sometimes, watery stool, which reaches the lower tract from the upper gastrointestinal tract, slides its way around the hardened stool and manages to pass through the anus, voluntarily or involuntarily (incontinence or soiling).

What are the symptoms of constipation in children? How can I tell that a child is experiencing constipation?

This sounds like a topic that could be easily noticed by parents. However, unfortunately, some of the signs of constipation could be misleading and puzzling.
In addition to hardened stool, decreased frequency of passage of stool, increased efforts in defecation and pain during defecation, there are several other symptoms that are important to elaborate on.
Non-specific abdominal pain – intermittent abdominal pain during the day that is relieved after the passage of stool (the bowel movement itself could be painful). However, it is important to make sure that there are no “red flags” – which means that the pain does not wake the child up at night.
Soiling – this is a very specific sign of constipation. This refers to the child who occasionally leaks stool into his/her underwear. This is the same stool I was referring to when I mentioned the watery stool that manages to bypass the hardened stool that has accumulated around the anus.
Paradoxical diarrhea – some of the children who suffer from constipation are actually taken to the doctor because their parents think their child is experiencing diarrhea. These children have soft stool leaking into their underwear or toilet several times a day, sometimes this passing of stool is voluntarily and at other times, involuntary.
For these children, the problem isn’t diarrhea but rather constipation, which should be appropriately treated for the resolution of their symptoms.
Urinary incontinence or retention – sometimes children avoid urinating. This is because the contraction of urinary muscles for urination also leads to the contraction of intestinal muscles, and for the child suffering from constipation this could be very painful. On the other hand, severe constipation can cause the leaking of involuntary urine.
Blood on defecation – small quantities of fresh blood can be seen on the stool (not mixed with the stool). Usually, this is a result of an injury to the anal region (fissure) or even a bleeding hemorrhoid.
Avoidance of eating and loss of weight – this is a symptom that is mentioned in our medical books. I’ve seen that children who suffer from constipation sometimes have a decrease in appetite since eating stimulates our intestines and activates them. However, I would like to emphasize, that despite what the textbooks propose, loss of weight is a “red flag” and is a sign to seek medical attention promptly.
Relief following stooling – typically, but not always, there is relief of most symptoms when there is passage of a large quantity of stool. The symptoms often return several hours or days later.
Encopresis – this is an important disorder that can present when a child experiencing severe constipation (and can sometimes present without any constipation) and it is the leakage of stools that is usually involuntary, in inappropriate places and situations. We have an entire chapter about this important topic on our website, and you can find it in the following link.
To summarize, it is very important to know the signs of constipation but more so to realize what the red flags are. These red flags include pain that wakes the child at night, abdominal pain with vomiting, loss of weight and passage of stool with blood or mucous.

What are the signs that the pediatrician will look for when examining the child with constipation?

The pediatrician will start by taking a detailed medical history. This will include questions about any underlying medical conditions and a series of questions about nutrition and bowel habits. The age at which the child began suffering from constipation is very important. It is also important that the pediatrician notes any signs of constipation immediately after birth. The child’s emotional state and the family’s response to their bowel habits and movements are to be noted as well.
The pediatrician will then go on to perform a physical examination which will focus on an abdominal examination, an examination of the lower vertebral column and observation of and sometimes examination of the anus.
In prolonged constipation the pediatrician can sometimes palpate fullness or lumps of stool (pebble-poop) in the abdomen.
Cuts or fissures can sometimes be seen around the anus, ‘pebble poop’ can be felt and the anal sphincter tone can be assessed.

Does the child with constipation need any labs or imaging tests?

Usually, these children don’t require further investigations, but this is at the physician’s discretion. Generally speaking, functional constipation does not require any laboratory workup.
Should the doctor decide to request any lab work it usually includes checking for calcium levels in the blood and thyroid function tests. Testing for Celiac Disease (gluten sensitivity – find out more in the link here) is to be considered, as these children tend to suffer more from constipation.
In the vast majority of cases, imaging tests and ultrasounds are unnecessary for the diagnosis of constipation.

How can we treat constipation?

First of all, it is important to emphasize that early treatment can really prevent severe disease. Treatment of constipation cannot be done in just one shot and requires the continued compliance and dedication of the child and their family.
The treatment is a combination of pharmacologist, behavioural, emotional, and para-medical therapy.

Psychological and emotional support for the child and their family – constipation causes a lot of frustration for their child. They could be in pain, afraid and disappointed from themselves. Parents can sometimes be supportive and understanding but at times they can also suffer from anxiety and express anger or disappointment towards the child. The entire topic of the child’s stooling becomes a central issue for the entire family. In such cases, calming the child and their family down and reassuring them that their problem will resolve soon is very helpful.

Behavioural therapy – note the fine difference between the emotional and behavioural aspects of treatment. Behavioural modifications include instilling healthy bowel habits in the child. Children are to learn that when they feel the need to defecate they are to do so and not postpone the act of defecation until their favorite tv show is over, for example.
Parents are to seat their child on the toilet, several times a day, preferably after meals. The act of simply sitting on the toilet seat is to be encouraged, regardless of the end result (i.e. whether or not stool is passed).
The placing of a stool beneath the child’s legs is recommended as it improves the child’s posture and allows for easier bowel movements.
Parents should not express anxiety. Instead, the parents and child are encouraged to pass this toilet-sitting time together by reading a book for example and waiting patiently until the stool is passed.
If the child has a specific problem, such as going to the toilet at school, one should try to find a solution for their specific problem. Healthy bowel habits could also include set times for defecation such as after dinner, at home. In addition, an increase in physical exercise is recommended as it allows for regular activity of the intestines.
As the child improves, it is important to encourage them and give them positive feedback.

Nutritional support – the right diet can lead to softer stool and easier bowel movements. Including dietary fiber, usually found in fruits and vegetables, cereals and more in the daily diet is recommended. Cutting down on products that worsen constipation such as rice, bananas, snacks, etc. is also important. The child should be encouraged to drink lots of fluids, preferably water.
It can be difficult to make nutritional changes to the child’s diet alone and sometimes change in the entire household’s dietary habits is needed.
Pelvic floor physiotherapy – the process of emptying the gastrointestinal system is complex and requires perfect synchrony between certain muscles that undergo contraction and others that undergo relaxation. A series of physiotherapy sessions by a physiotherapist that specialises in pelvic floor treatment allows the child to understand how the process works, to be aware of which muscles need to be contracted or relaxed. In addition, the therapy helps strengthen the core muscles and provides correct toilet-sitting habits. All of these contribute to successful treatment.

Pharmacological treatment of constipation in children:

These can be divided into several groups:
Lactulose-based therapies – this is a syrup that causes water retention in the stool and leads to the formation of soft stool and diarrhea. There are many reasons why this is not first-line treatment in healthy children. They are used in normally healthy children only in exceptional cases.
Fibers – treatment with fibers (fiber supplements that can be bought over the counter) softens the stool on one hand but prevents the stool from becoming watery on the other hand.
Paraffin oil – in the past we used to recommend paraffin oil as therapy, including frying an egg using this oil. It is no longer a first-line drug for constipation.
Polyethylene glycol based powders – this is usually first-line treatment. It is a substance that is not absorbed into the intestines but does cause the passage of fluids in the gastrointestinal system and the softening of stool. The powder is tasteless, odorless and colorless and can be added to any drink the child enjoys drinking. These powders are over the counter, but dosing ranges are wide, so it is best to refer to a doctor for dosing.
Ointment for the anal region – in cases of anal fissures the doctor will usually prescribe a topical ointment that allows for relaxation of the anal muscles and sometimes to anesthetize the region to allows for the passing of stool in a less painful manner.
Rectal therapies – enemas or glycerin suppositories. These are mainly used for children under the age of one. Enemas are not usually first line therapy, but they are important for the treatment of children who experience complex or persistent constipation.
Manual fecal disimpaction – in cases where there is an accumulation of hard fecal stones that the child is unable to pass despite treatment, sometimes a medical intervention is required and this is done by a surgeon or a gastroenterologist under anesthesia.
Additional therapies – these therapies will be prescribed in more complex cases, by a gastroenterologist. These medications are stimulants (they cause the contraction of the large intestine), pro-motility medications that promote the activity of the gastrointestinal system, or secretagogues medications which actively increase the secretion of fluids into the gastrointestinal system.

Which drug should I use and when? When should the drug be stopped in children?

When discussing pharmacological therapy, it is important to distinguish between the different goals of treatment.
Stool softeners causes stool coming from the upper tract to soften. This is an excellent choice of treatment and is the best option for prevention of constipation. However, if there is a large piece of hard stool in the intestine, sometimes it will need to be mechanically released before we can proceed. That is when your doctor may recommend a cleanout using substances that are prescribed prior to a colonoscopy, rectal therapies and in severe cases manual disimpaction under anesthesia.
Your gastroenterologist may choose to combine different therapies, in order to cater to the individual’s condition.
In other words, the pharmacological therapies can also be combined.
And of course, pharmacological therapy is always combined with behavioural/emotional therapy.

How long should I use the medications for?

This is an important topic as parents usually tend to stop treatment too early.
Assuming we are referring to treatment with polyethylene glycol powder, which is the basis of any pharmacological treatment, parents tend to stop administration of this medicine as soon as the child has had one day of good bowel movement.
It is important to understand that because constipation is a prolonged symptom, its treatment cannot be temporary.
It is a process that requires prolonged treatment (some believe treatment should be continued twice as long as the time the child suffered from constipation). If need be, the dosing can be reduced, but a sudden stop is not recommended.
Remember, the goal of the treatment is to have soft, painless stools (preferably daily).
Again, remember not to stop treatment early, because recurrence of constipation and failure of therapy will make treatment much harder in the long-run.
And most importantly, remember to combine pharmacological medications with all the other supportive therapeutic recommendations.

Constipation in infants under the age of one:

Constipation in infants under the age of one has several characteristics that we need to keep in mind.
Remember that in breastfed infants stool habits vary. Anywhere from seven stools a day to one per week can be considered normal.
In infants that are not breastfeed stool habits vary as well.
Throughout the first year of life, as the child grows, the number of stools passed per day decreases and the consistency of the stool slowly becomes harder.
Therefore, the best way to detect constipation in infants in these ages is by observing the consistency of the stool and the ease at which the infant passes it rather than the number of stools per day. If the infant seems to be suffering when passing the stool and the stool is hard and pebble-like – therapy should be considered.
Therapy in infants under the age of one is slightly different and more complex and depends on the suspected reason behind the constipation as well as the specific age of the child.

One of the less common causes of constipation includes cow-milk protein allergy. In such cases, the pediatrician will usually recommend switching the infant’s formula. It is important to consult with your doctor prior to switching to a different formula so as to not to reach a point where you are switching formulas every other day when there really is no actual need for it. Such changes can be very difficult for both the child and the family.
For infants that have been introduced to solid foods, the addition of tomato juice, peach juice or mashed fruits can be considered. Older infants can be treated with polyethylene glycol.
In any case, massaging the infant’s belly in a clockwise, and gentle manner and flexing the legs towards the belly can be beneficial.
In cases of fecal impaction, glycerin suppositories can be considered.

In summary, this is a super professional and important topic, and you really must keep in mind the points we have emphasized and the different therapeutic arms when considering the treatment of constipation in children.

Good luck.