Management and Prevention of Constipation in Children

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Constipation is a pattern of delayed, painful, or hard bowel movements. Most people have an occasional hard poop, but if this happens frequently, it can cause problems. If the stools are thick, like clay, or hard and large, or like pebbles, then stool may get backed up in the GI tract. Constipation can cause pain, a swollen belly, loss of appetite, gastro-esophageal reflux (heart burn), and even loss of ability to control bowel movements. Pain from constipation in kids is usually crampy, sharp, or achy pain around the belly button or the sides of the belly. Usually this pain occurs while your child is awake and is worse after eating or with exercise. Although the cramps or aches may keep children from falling asleep, the pain does not usually wake them from sleep. Sometimes a child can accumulate so much poop in their rectum that it keeps the anus open, resulting in leaking, which can sometimes appear to be diarrhea or soiling.

Many children with special health care needs have trouble moving food and stool through their systems. Sometimes this constipation is obvious—when your child has painful, difficult-to-pass, hard, incomplete, or infrequent poops. Sometimes constipation is not obvious, but you may notice your child is having pain, nausea, or even vomiting, decreased appetite, a swollen abdomen, leaking stool or stool accidents, or bloody streaks around their stool. Constipation can happen for many reasons, including: high or low muscle tone, diets without enough fiber or liquid, immobility, developmental delays, problems with the nervous system, tube feedings or irregular meals, and use of certain medications, formulas, and supplements. Constipation can also sometimes occur as a result of illness, particularly if there has been fever, vomiting, diarrhea, or reduced fluid intake and dehydration.

Some children have fears of the toilet or bathroom. Some children have motor problems that make it hard for them to sit comfortably to poop; there are toilet chairs for children with special needs that can help with this problem. The best way to find the appropriate toilet chair for a child with limited motor function is to consult with a physical therapist who can evaluate and make suggestions. These chairs are also sometimes covered by insurance.

In newborns, meconium (the first, dark, tarry stool) should be passed promptly and completely within 2 days after birth. Once babies have established feeding, their bowel movements can vary significantly. Their patterns may be affected by nursing or formula use, how often and how much they feed, when they are having growth spurts, and when new foods are introduced. Many infants cry and appear to be in pain before they pass a stool. This is called infant dyschezia. However, typically, an infant should not have a persistent swollen, painful belly (abdominal distension). Infants should not routinely require assistance (suppository, rectal stimulation, or enema) to pass stool, although occasional episodes of constipation may occur after the newborn period. While infant stools can have a range of colors (most common are yellow, green, brown, and orange), blood in the stool, consistently tarry stools outside of the newborn period, or stools that remain pale (like clay) are abnormal and should be promptly discussed with the infant’s health care provider.

Most children are able to toilet train when they are developmentally between 2 and 4 years old, provided they have intact nerves and muscles and access to a toilet. (See Toilet Training.) This happens because around the age of 16–24 months, children start to learn how to hold the stool, and then learn how to let it go. If stool is held too long, it becomes larger and harder, making it too easy to hold, and it may result in constipation. If the rectum is frequently full of hard stool, the muscles can weaken and lead to stool leaking or incontinence. If there have been painful, difficult-to-pass, uncomfortable, or anxiety-provoking bowel movements, the sphincter may remain chronically contracted. This may establish a cycle of stool retention, with denser and larger difficult-to-pass stools, rectal pain, rectal fissures, and further retention.

Many chronic gastrointestinal complaints in children and adolescents can be explained by excessive stool retention. Despite being toilet-trained, entering school can make some children feel shy about asking to leave the room (embarrassed that it might take too long, afraid of a public restroom, etc.), which can result in a stool withholding pattern that leads to constipation. Parents may not realize this until the child has intermittent soiling, leaking, or non-intentional stool release (encopresis). This reaction is caused by stool that has stretched out the rectum, reducing the body’s ability to regulate bowel movements, and occasionally resulting in liquidy stool leaking around hard stool that is stuck in the rectum (think of flowing water passing around rocks in a river). When stool is stuck repeatedly in the colon, it can also lead to pain, nausea, or decreased appetite.

• Fluid intake—Inadequate fluid intake may contribute to constipation. Try to make sure your child drinks enough water every day. A child or teen should drink 5–8 cups of water per day; younger children should have 3–4 cups daily. Increasing water may be helpful, but can be difficult to do, particularly with a young child. Avoid using sweetened beverages, especially sodas, to increase fluid intake. 1–4 oz. per day of prune or apple juice can help with constipation in some children and infants.
• Fiber—Increasing fiber in the diet may reduce constipation. The best sources of fiber include whole grains, fruits, and vegetables. Avoiding highly processed and carbohydrate-rich foods that lack fiber may increase appetite and motivation to eat foods that are rich in fiber. If the child is tube-fed and using an enteral formula, consider switching to one with fiber.
• Stimulants—Some foods may stimulate the intestines to move more quickly. Prunes are the most common of these, but children may vary in which foods work best for them.
• Foods to avoid—Some foods can slow down digestion. Foods such as bananas, sweets, white breads, and fast food, foods that are high in fat, and large amounts of dairy products all tend to slow digestion and contribute to constipation. This varies among children.
• Refer to a nutritionist as needed (Nutrition Assessment Services (see NM providers [84]).)

• Meals—Regular meals are helpful in keeping the bowels moving. Timing opportunities to use the toilet to follow meals can enhance the ease of passing bowel movements.
• Less snacks—Snacking, particularly “grazing” (eating small amounts of food, usually low in fiber, throughout the day), can limit the amount of food eaten at meal times and result in a poor gastro-colic reflex, resulting in poor gut motility and constipation.
• Exercise—Kids who get plenty of exercise seem less likely to get constipated. Assuring daily exercise has other benefits in terms of fitness and weight control.
• Behavioral issues—Positively reinforce all passage of stool. For children who are toilet trained, ensure adequate time and privacy for defecation (e.g., it isn’t going to happen in a public school bathroom stall). Treat accidents with a neutral approach.
• Toileting routine—It is helpful if your child goes to the toilet and tries to poop after meals. This is particularly important after breakfast on school days, when he or she may not have another opportunity to poop till evening. See Toilet Training for CYSHCN
• Positioning—Ensure child is adequately supported in an upright position to allow optimal defecation. For children with mobility issues, time in a stander or at a standing table may help with evacuation. An adapted toilet seat may be necessary for proper positioning. Speak with your child’s physical therapist or primary care physician about the best options and how to obtain this equipment through insurance or Medicaid.
• Warm baths—A warm bath once a day can help to relax the muscles of the rectum and make it easier for your child to have a bowel movement.

If good diet and bowel habits fail to relieve your child’s constipation, he or she may need a prescribed bowel program, a “clean-out,” or medication to help produce regular stools. Consult your child’s primary care physician to talk about the treatment that is best for your child.

If your child has any problems with his or her bowel program or medication, contact the primary care physician to address and modify the treatment. No medication or clean-out should be initiated without consulting the child’s physician first.

Sometimes children need to take medications for long periods of time to manage constipation. In addition to fluids, diet, and lifestyle changes, the daily use of medications may be necessary to keep some children regular; this is called “Maintenance Therapy.” In children, these medications are usually various kinds of laxatives. The most commonly used laxative in children is polyethylene glycol (MiraLax, ClearLax, GlycoLax, etc.). Other laxatives include stool softeners, lubricating agents, osmotic laxatives, stimulating agents, rectal suppositories, and enemas. Your child’s primary care clinician in the Medical Home can work with you to develop a tailored plan for your child’s constipation if needed.

While the cost of over-the-counter (OTC) laxatives may be relatively low, when used chronically the cost adds up quickly. Check with your provider to obtain a prescription if there is a medication that your insurance will cover. Otherwise look for generics (store brands) or coupons, or shop online to compare prices.

Diapers are a huge health care expense. Generally, Medicaid will cover the cost of diapers for the incontinent child after age 3 through a home care company with a clinician’s prescription and Adaptive Equipment - Letters of Medical Necessity (Rifton). Less frequently, private insurers can be convinced to do this.