Constipation in children

Constipation is relatively common in children aged over one year old.

It is generally due to a functional disruption of the healthy movement of food through the digestive tract. It is often associated with painful sensations when having a bowel movement.

Constipation is particularly likely to occur in pre-school aged children when they are in the process of toilet training. In most cases, it occurs due to a combination of several different factors, such as nutritional deficiencies, changes in the environment or stress.

Other causes of constipation in children are rarer. In newborn babies and infants in particular, it may be due to digestive system defects. Disorders of the thyroid, nervous system or spinal cord can also cause constipation.

Constipation in children can have various symptoms:

• Having fewer than three bowel movements per week (the exception to this is infants who are being breastfed)
• Stool is hard or lumpy
• Difficultly passing stool, with straining required
• Very bulky stools, which may block the toilet
• Masses of stool that can be felt inside the rectum
• Painful bowel movements
• Small tears in the skin around the anus
• Coating of blood on the stool
• Stool smears, which appear as traces of feces in the child’s underwear. This occurs when liquid stool leaks out of the rectum around the hard masses of stool that are impacted there. This can sometimes be confused with diarrhea.
• Fecal incontinence in children over the age of 4, occurring at least once a month. When this happens, the child is unable to stop themselves from having a bowel movement, even after they have been fully toilet trained.
• Temporary abdominal pain, which typically disappears once the child has been to the toilet
• Consciously withholding bowel movements, indicated by the child fidgeting or dancing around, while squeezing the buttocks together

The following symptoms indicate that the child is constipated as the result of an illness:

• A newborn baby’s first bowel movement is delayed and does not occur within the first 2 days of birth
• Constipation that becomes obvious within the first few weeks of life
• Failure to put on weight and failure to thrive
• Ribbon-like stool that is as narrow as a pencil
• Bloody stool, despite the absence of skin tears around the anus
• Additional vomiting of green liquid (bile)
• A severely bloated stomach

If these symptoms occur, the child should be examined by a doctor immediately.

Some children are more naturally susceptible to constipation than others. However, there are some typical triggers that cause a disruption in the functioning of the bowel.

Causes in infants and small children

Constipation can occur in infants when switching from breast milk to formula or cow’s milk. Possible causes in young children include a low-fiber diet, pressure from parents during toilet training, anxiety and deliberate withholding of bowel movements.

Causes in older children and teenagers

Older children will readily suppress the urge to have a bowel movement if the toilet facilities are unclean or if they are immersed in their play.

Pain when defecating is the most common reason why children try to avoid having another bowel movement. A single painful toileting experience is sometimes enough to cause this.

Among school-age children and adolescents, eating disorders like anorexia and use of prescription medication, such as anti-depressants, may also cause constipation.

Less common causes

In rare cases, constipation may be caused by physical illnesses and conditions. These include, for example, defects in the anus and rectum, a food intolerance or certain metabolic disorders.

Children are at an increased risk of constipation if they have a family member who also has constipation.

Fluid intake also plays a role – drinking too much or too little can cause constipation.

The following factors also increase the risk:

• a diet lacking in fiber, i.e., not eating enough fruit and vegetables and eating too many salty snacks, animal fats, sugary treats and sweetened drinks
• a lack of regular physical activity
• being overweight
• stressful life events, such as settling into pre-school or the birth of a younger sibling
• refusal to use the toilet at pre-school or school

Constipation is most common among small children and those of pre-school age.

In Germany, it affects around seven percent of children aged between 5 and 8 years old.

Constipation and fecal incontinence often occur together. Around two-thirds of children with fecal incontinence also experience constipation.

In cases where constipation is caused by another condition, this usually becomes evident within the first month of the child’s life.

The earlier constipation is treated, the quicker digestion becomes normalized again and the more effectively symptoms can be resolved.

What happens if constipation is left untreated?

If constipation is not treated, large, compacted masses of stool accumulate in the colon and rectum and can no longer be passed as a normal bowel movement without assistance.

Strong pushing during a bowel movement can cause the lining of the intestinal mucosa to bulge outwards. This is known as a prolapse.

The most common complication is fecal incontinence. This is often so distressing that quality of life for both parents and children is affected.

Other frequent complications are infections of the urinary tract and bedwetting. Psychological problems also often occur.

How long does it take for constipation to be resolved?

In order to see a sufficient improvement in symptoms, treatment generally needs to be continued over a period of several months or, in some cases, years.

Up to three-quarters of children affected are completely free of symptoms after 5 years and no longer need to use stool softeners.

Of the children who require treatment in hospital for constipation, around one quarter will continue to suffer with constipation as an adult.

For those who may be more susceptible to becoming constipated, the recommendations for prevention largely concern diet.

The following recommendations apply to children aged between 0 and 2 years old:

• Up to the age of 6 months, feed with breast milk only. In older babies, breast milk continues to be recommended as it promotes healthy digestion.
• From the age of 6 months, slowly introduce increasing amounts of solids into the diet.
• Feed regularly based on when the child is hungry. If the child becomes ill, respond with flexibility to changes in their intake.
• Offer as varied a diet as possible, with a variety of fruit and vegetables.
• Avoid sugar, soft drinks, salty snacks and processed or deep-fried foods.

To promote digestion in school-aged children, ensure that they drink at least three glasses of water a day and eat plenty of fruit and vegetables.

Before constipation can be diagnosed, a doctor will begin by asking about the specific symptoms the child is experiencing. They will then conduct a physical exam of the body and look for redness or small tears around the anus.

Next, an ultrasound examination will detect any stool masses in the colon.

By asking about behavioral patterns and eating habits as well as any relevant family circumstances, a doctor can often find more clues as to potential triggers of the child’s constipation. A special questionnaire is often used for this purpose.

If evidence is found that the constipation is being caused by another condition, blood tests, imaging techniques or tissue samples from the intestinal mucosa may be required.

If no improvement is seen despite the parents or, depending on their age, the child themselves strictly adhering to the recommended treatment measurements, further testing will be required.

The medication and treatment measures prescribed by a doctor to treat constipation will depend on the age of the child.

Treating children in the first year of life

If a child becomes constipated while they are still in their infancy, the reason is usually an illness or condition. This should be treated by a specialist.

Constipation can sometimes be caused by an allergy to cow’s milk protein. In this case, eliminating cow’s milk from the diet can help.

If there is no underlying illness, an infant can be given apple juice, plum juice or pear juice to help with constipation. These contain non-digestible carbohydrates, which draw water into the bowel and promote healthy digestion.

Stool softeners such as lactulose, sorbitol or polyethylene glycol (macrogol) have a laxative effect by drawing as much water as possible into the colon. Glycerin suppositories can also stimulate an evacuation of the bowel but may also cause irritation to the rectum and anus.

Treating pre-schoolers and school-aged children

Short-term constipation should be treated without delay to prevent it from becoming chronic. Stool softeners such as polyethylene glycol (macrogol) are ideally suited to this purpose.

If redness and small skin tears are found around the anus, painkilling and anti-inflammatory ointments can be used.

For chronic constipation, treatment aims to ensure that the child passes a soft stool every day or every second day.

Long-term treatment with stool softeners is generally required for this purpose:

• First, polyethylene glycol (macrogol) or an enema is used to empty the bowel completely. The bowel can only “learn” by itself how to function properly again once the bowel wall is no longer overstretched.
• Stool softeners are then used over an extended period to keep the stool soft and prevent it from building up in the bowel again. Macrogol or lactulose are generally used. Laxative agents such as bisacodyl or senna pods, which stimulate the action of the bowel, can also be used.
• It is important to use stool softeners consistently. If the child’s digestion becomes normalized for at least 6 months, the use of stool softeners can slowly be reduced. If the child doesn’t experience any constipation, they can be stopped entirely.

Toilet training is especially important to the treatment process:

• The child should become accustomed to sitting on the toilet for 5 to 10 minutes after meals two to three times a day, even if they don’t feel the urge to have a bowel movement.
• It is also important to adopt the correct sitting position when defecating. Sitting in a squatting position helps ensure that the bowel is fully emptied. To help children get into the squat position, they can use a small stool for their feet, which is placed in front of the toilet.

Making dietary changes is also beneficial:

• The diet should be rich in fiber, with lots of vegetables, fruit and wholegrain products.
• It’s also important to ensure that the child drinks enough fluids.

Treating adolescents

Constipation in adolescents is similarly treated over several months with stool softeners like polyethylene glycol (macrogol) or lactulose. It’s also important to ensure that older children are eating enough fiber in their diet and that they are drinking enough fluids.

Adolescents who have been suffering with constipation for an extended period usually also have another condition, such as diseases of the bowel, behavioral disorders, eating disorders or other mental health conditions. In this case, the underlying illness must be treated.

Medications that are actually approved for adult use only may be used to treat persistent constipation in adolescents. If an adolescent also experiences fecal incontinence, special training programs can be very beneficial.

To allow the bowel to “learn” to function as normal again, it’s important to use stool softeners for an extended period. This may take months or even years.

Keep a “poop diary”

It is helpful to keep a diary of daily bowel movements (a “poop diary”) for the child. Every day, the parent or older child records when they had a bowel movement, how hard or soft it was and which stool softeners were taken in which dosage. The dose can then be adjusted in accordance with the treatment plan if necessary.

Motivate, don’t punish

Parents can motivate small children to sit on the toilet by offering them a small reward. The reward should be earned by simply sitting on the toilet regularly, even if there is no bowel movement. For small children who are still in diapers, it is recommended that toilet training be postponed until the bowel is back to functioning as normal.

It’s important to understand that a constipated child is not being obstinate or defiant if they have an accident in their underwear. If the bowel is full of masses of stool and is overstretched, it is unable to hold in runny or semi-solid poop, which then leaks out. Children shouldn’t be punished or scolded.

Pack a change of clothes

If the child is already going to school, it’s useful to pack a spare change of clothes in their bag in case they have an accident. If the child refuses to use the school toilets and this is the reason for their constipation, it makes sense to speak to someone at the school. In some cases, there may be a separate, clean toilet that they can use instead.