Constipation in Children: Causes, Symptoms and Remedies

A normal bowel pattern is thought to be a sign of good health but having issues with bowel movements once in a while is not uncommon.

Constipation is a very common problem in children and accounts for 3-5 % of all visits to Pediatric outpatient clinics but can cause significant distress to the child if left untreated.

If the child is having fewer than two bowel movements in a week, or if the stools are hard, dry or lumpy, or difficult and painful to pass, then it may be said that the child is suffering from constipation.^[1]

Children may suffer from different types of constipation based on the duration of the symptoms and the underlying cause.

When a child with normal bowel movements suddenly becomes constipated, e.g., when traveling, starting new school, after an acute illness etc., it is called acute constipation and usually resolves with simple remedies. But when the problem persists for 2 or more weeks, it is called chronic constipation which may or may not respond to home remedies alone.

Fortunately, most cases of constipation in children are of the acute type and temporary.

The most common cause of constipation in children accounting for 90 to 95 percent of all cases is functional or idiopathic meaning it is not caused by any serious medical disease. The remaining 5% are due to underlying medical conditions ranging from Hirschsprung disease, anorectal malformations, neuromuscular disease, metabolic to endocrine disorders.^[2][3]

Causes of Constipation in Children

Constipation may be due a number of factors, including-

Changes in diet. Insufficient fiber-rich fruits and vegetables or fluid in your child’s diet may be the cause of constipation. When a child switches from all-liquid to a solid food diet, then he is more susceptible to experience constipation.^[4]

Allergy from cow’s milk. An allergy to cow’s milk or consuming too many dairy products (cheese and cow’s milk) sometimes leads to constipation.^[5]

Family history of constipation. If there is a history of any family member suffering from constipation, then even the child is likely to develop constipation. This could be due to shared genetics or environmental factors.^[6]

Other Causes of Constipation–

Apart from the above-mentioned causes, there could also be a number of other causes for constipation. Though these causes do not have any scientific backing, but they have been reported by many to possibly being the underlying causes of constipation nonetheless.

Medical conditions. Sometimes, though it is quite rare, constipation in a child could be an indication of anatomic malformation, metabolic or digestive problem, or possible another underlying condition.

Medications. Common contributors include over-the-counter cold medications and antacids. Antidepressants, anticonvulsants, chemotherapy medications, or narcotic pain medications (such as codeine) can also cause constipation.

Withholding feces: Functional constipation is commonly the result of a child withholding feces to avoid painful defecation, for e.g., your child may ignore the urge to have a bowel movement because he or she is afraid of the toilet or doesn’t want to take a break from play. Some children also withhold and avoid using public toilet because they are not comfortable doing so when they are way from home.

Also, if it hurts to poop, then it is quite possible that your child would try to avoid repeating the distressing experience. So, if the child is facing painful bowel movements due to large, hard stools then it may lead withholding.

Changes in routine. If there are any changes in the child’s routine, due to maybe, travel, hot weather or stress, then it could also affect the bowel function. The chances of experiencing constipation are high when children first start school, away from home.

Early toilet training. One of the causes of constipation could also be early beginning of toilet training, it could lead the child to rebel and hold in stool. When it comes to rebelling against toilet training, a decision on the part of child to ignore the urge to poop could very quickly lead to habit that would be tough to change.

People with learning disabilities are more likely to suffer from constipation than people without learning disabilities.^[7]

Symptoms of Constipation in Children

Constipation is a symptom, not a disease. Children with constipation may present their problem in various ways, and the most common symptoms are pain while having a bowel movement, loss of appetite, nausea, abdominal pain, irritability, change in posture due to full/bloated abdomen, soiling accidents in a previously fully toilet trained child, itching in the bottom (specially in the child with soiling), fresh (bright red) blood on surface of hard stool, and vomiting in severe cases.

Sometimes a constipated child might actually appear to have diarrhea, which can be confusing and happens when a large mass of formed stool gets stuck in the child’s rectum whilst the soft/freshly formed liquid stool seeps around it, also known as constipation with overflow incontinence, often leading to soiling.

When to See a Doctor

Even though constipation in children is not usually serious, chronic constipation could either lead to further complications or could also be an indication of some underlying condition.

“We recommend encouraging the intake of fruits and vegetables as well as a good water intake to help with constipation. Exercise and physical activity also play a role in the motility of the GI tract, and we recommend this to our patients. However, sometimes when the issue has been ongoing for years, these changes might not be sufficient and consultation with the pediatrician might be necessary”, says Dr. Maria Stella Serrano, Chief, Division of Pediatric Gastroenterology, Hepatology and Nutrition, MedStar Georgetown University Hospital.

You would need to take your child to a doctor immediately if the constipation lasts more than two weeks, or worse if it is accompanied with either vomiting, blood in stool, abdominal swelling, weight loss, painful tears in the skin around the anus or intestinal protrusion out of the anus.

As a parent or guardian, it is crucial that you be aware of the sudden constipation that cannot be explained could also be a sign of abuse. Childhood constipation has often shown an association with physical, sexual and emotional abuse.^[8]

Prevention

To help prevent constipation in children:

High-fiber foods. To prevent constipation in children, it is a good idea to feed them more of high-fiber foods like fruits, vegetables, beans, whole-grain cereals and breads. If the child is not used to high-fiber diet, then you could start by adding several grams of fiber everyday in the meal to prevent gas and bloating.^[4]

Plenty of fluids. Encourage your child to drink plenty of fluids, for water is the best solution in almost every situation.

Physical activity. Regular physical activity helps stimulate normal bowel function.

Toilet routine. Set a fixed routine for your child to use the toilet. You can even provide your child a footstool so that your child may have enough leverage to comfortably release stool.

Remind your child to never ignore nature’s call. Sometimes children lose track of everything while playing and in fact, they might even ignore the urge to poop which could be a contributing factor to constipation.

Review medications. If a medicine that your child is taking is causing constipation, then you will need to ask the doctor for other options and avoid that medicine.

Although as a parent or guardian it is quite stressful for you to see your child in pain and discomfort, there are many simple and effective remedies as well as lifestyle changes that can help prevent as well as treat constipation and help alleviate your child’s discomfort.

1. Feed Your Child High-Fiber Foods

The very first thing that you can do to treat constipation in children is to increase your child’s dietary fiber intake. Fiber is a natural laxative that helps soften stool and encourage regular bowel movements.

For every 1000 calories in your child’s diet, 14 grams of fiber is the recommended daily intake.

Lack of dietary fiber may play an important role in causing chronic functional (idiopathic) constipation in children.^[9]

Adequate dietary fiber intake can increase stool frequency in patients with constipation.^[10]

But, fiber intake must only be taken in case of functional constipation, which should preferably be covered with the diet itself. In fact, fiber supplementation can only be prescribed in case of functional constipation.^[11]

You can include foods rich in both soluble and insoluble fiber in your child’s diet.

Some good sources of soluble fiber are oranges, apples, carrots, barley, oatmeal and flaxseeds.

Some good sources of insoluble fiber are nuts, seeds, beans, legumes, unprocessed grains and dark leafy vegetables like kale or spinach.

2. Increase Your Child’s Fluid Intake

Children tend not to think about drinking water in between playing, which can leave them dehydrated. Dehydration is one of the main causes of constipation in children.

Water is essential for the digestive system to function properly, and without enough water intake, stool becomes hard and difficult to pass.

Insufficient intake of dietary fiber and fluids are associated with aggravated constipation symptoms.^[12]

Make sure that your child drinks water, fruit juices and other healthy drinks as much as possible during the day.

Plain water or lukewarm water with a little juice can help your child stay hydrated. If your child does not like the taste of water, try flavored water, coconut water, fruit juice or vegetable juice. Apple, prune, and pear juices are usually recommended for constipation.^[13][14]

Breastfeeding is enough to keep babies below 6 months of age hydrated.

3. Massage Your Child’s Stomach

Stomach massage can be as effective as laxatives in the treatment of constipation. The advantage of the abdominal massage is there are no known side-effects.^[7]

Gently massaging your child’s stomach and lower abdomen stimulates bowel movements. It can help loosen the abdominal muscles and release the pressure, helping to promote bowel activity. It can even help relieve gas.

1. Ask your child’s permission to touch his or her tummy. If s/he doesn’t want the massage, s/he is likely to be too tense to benefit from it.
2. Place your child in a warm room before doing the massage, especially if you are removing the child’s clothing for massaging.
3. Use a hypoallergenic oil to rub in between your hands. Warm your hands by rubbing them together vigorously.
4. Gently massage the child’s stomach in a clockwise direction for 5 minutes. Apply firm but gentle pressure.
5. Do several massages throughout the day, until your child has a bowel movement.

4. Encourage Your Child to do Regular Exercise

Be it an adult or a child, doing exercises daily can help aid digestion and relieve constipation.

Exercising regularly will help food move faster through the large intestine and help the bowel muscles contract, moving the waste along.

On the other hand, lack of exercise leads to weakness in the intestines, making it hard to pass waste regularly.

Constipation can be prevented by promotion of physical activity.^[15]

For children, one of the best exercises is walking. Aim for 30 minutes of walking a day, especially after meals, to help with bowel movements.

Swimming, bicycling or doing yoga on a regular basis can also help the intestines and stimulate bowel movements.

5. Give Prunes to Your Child

One of the best ways to deal with constipation in children is to offer prunes.

Prunes are high in fiber and sorbitol, which helps soften the stool and add bulk to it for easy passage.

Dried plums are safe, palatable and more effective than psyllium for treating mild to moderate constipation, and should be considered as a first-line therapy.^[16]

• Give your child 3 or 4 prunes to eat daily.
• Blend 2 or 3 prunes into some warm almond milk, and make your child drink it at night before going to bed.

6. Make Fennel Tea for Your Child

Fennel seeds are also helpful in treating constipation in kids.

Early research suggests that drinking herbal tea containing a combination of fennel, anise, elderberry, and senna daily for 5 days can reduce constipation.^[17]

Fennel seeds encourage smooth muscle movement in the digestive tract, resulting in healthy digestion and regular bowel movements. Fennel seeds also prevent gas in children.

• Dry roast 1 cup of fennel seeds. Grind them and sieve the mixture. Store the powder in a jar. Give ½ teaspoon of this powder with warm water to your child daily.
• Alternatively, you can give your child fennel tea. Add 1 teaspoon of crushed fennel seeds to 1 cup of hot water. Let it steep for 5 minutes, then strain it. Give your child this tea to drink a few times a day.

7. Good Bowel Habits

For settling your child into a regular toilet habit^[18] make your child sit on the toilet at least twice a day for 10 minutes. Try to do this just after a meal. Be sure to make this a pleasant time. Don’t get angry at your child in case he/she doesn’t have bowel movement. Give stickers or other small treats. Or make posters that show your child’s progress.

As per Dr. Maria Stella Serrano, “a good amount of fiber intake with fruits and vegetables –the recommendation is 5 servings of fruits/ vegetables daily, and a good intake of water is important for healthy bowel habits. It is also important for kids to have an awareness of their bowel movements, and create a healthy habit of making time to go to the bathroom regularly in their busy days.”

Also, it is important to help small children sit in the right posture on the toilet. Give them a foot stool or step stool for supporting the legs.

When possible, help your child use squat toilets, as they are the best when experiencing constipation.

Keep telling your child not to hold back whenever there is an urge to use the bathroom.

Additional Tips

• If your child is taking medication that causes constipation, ask your doctor about other options.
• Incorporating Greek yogurt or other probiotics into your child’s diet is another safe and effective way to fight constipation.
• Include raw fruit, a vegetable or salad in all of your child’s meals.
• When suffering from constipation, give your child five or six small meals throughout the day, instead of three large meals.
• Whenever possible, encourage them to eat skins along with the fruits and vegetables.
• Avoid food that contain little or no fiber like cheese, meat or processed foods.
• Encourage your child to have regular three meals every day and to limit snacks between the meals so that his/her appetite is not affected during mealtimes. A child who is hungry would be more likely to eat vegetables than one who has been munching on crisps and cookies. Besides, full stomach will encourage healthy bowel movement. Therefore, children who are fussy eaters are more likely to experience constipation.

Resources:

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5. Intolerance of Cow’s Milk and Chronic Constipation in Children | NEJM. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJM199810153391602. Published October 15, 1998.
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7. Constipation. GOV.UK. https://www.gov.uk/government/publications/reasonable-adjustments-for-people-with-learning-disabilities/constipation.
8. Rajindrajith S, Devanarayana NM, Lakmini C, Subasinghe V, de DG, Benninga MA. Association between child maltreatment and constipation: a school-based survey using Rome III criteria. Journal of Pediatric Gastroenterology and Nutrition. https://www.ncbi.nlm.nih.gov/pubmed/24253365. Published April 2014.
9. Roma E, Adamidis D, Nikolara R, Constantopoulos A, Messaritakis J. Diet and chronic constipation in children: the role of fiber. Journal of Pediatric Gastroenterology and Nutrition. https://www.ncbi.nlm.nih.gov/pubmed/9932850. Published February 1999.
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11. Piccoli P, Eifer DA, Daniel E. Use of fibers in childhood constipation treatment: systematic review with meta-analysis. Jornal de Pediatria. https://www.ncbi.nlm.nih.gov/pubmed/29474804. Published February 21, 2018.
12. Mazlyn MM, Nagarajah LH, Fatimah A, Norimah AK, Goh KL. Stool patterns of Malaysian adults with functional constipation: association with diet and physical activity. Malaysian Journal of Nutrition. https://www.ncbi.nlm.nih.gov/pubmed/24800384. Published April 2013.
13. Bae SH. Diets for Constipation. Pediatric Gastroenterology, Hepatology & Nutrition. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4291444/. Published December 2014.
14. Bothe G, Coh A, Auinger A. Efficacy and safety of a natural mineral water rich in magnesium and sulphate for bowel function: a double-blind, randomized, placebo-controlled study. European Journal of Nutrition. https://www.ncbi.nlm.nih.gov/pubmed/26582579. Published March 2017.
15. Huang R, Ho S-Y, Lo W-S, Lam T-H. Physical Activity and Constipation in Hong Kong Adolescents. PLoS One. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938666/. Published February 28, 2014.
16. Attaluri A, Donahoe R, Valestin J, Brown K, Rao SS. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Alimentary Pharmacology & Therapeutics. https://www.ncbi.nlm.nih.gov/pubmed/21323688. Published April 2011.
17. Rawat AKS, Srivastava S, Ojha SK. Herbal remedies for management of constipation and its ayurvedic perspectives. https://www.researchgate.net/publication/289468603_Herbal_remedies_for_management_of_constipation_and_its_ayurvedic_perspectives. http://medind.nic.in/jav/t12/i1/javt12i1p27.pdf. Published January 2012.
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