Answers to questions families often have about caring for their child with constipation

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. Hard stools and pain/discomfort associated with passing them may cause children to “retain” stools. These retained stools get even harder and fresh stool may start leaking around these hard stools, causing “accidents” or encopresis.

Constipation can cause pain, a swollen belly, loss of appetite, gastro-esophageal reflux (heartburn), and even loss of ability to control the 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 appear to be diarrhea or soiling. Bulky hard poop can make small rips in the anus that leave spots of blood when the child wipes.

The primary care clinician may use specific criteria to diagnose constipation. Constipation generally includes more than one symptom including two or fewer bowel movements in a week, leaking stool once a week, holding back bowel movements, hard or painful bowel movements, or large stools that block the toilet.

Most children with functional constipation require prolonged treatment. In one study, after intensive initial medical and behavioral treatment, 60% of children were treated successfully after 1 year with follow-up care and 80% of children were treated successfully by 8 years of follow-up care. One-third of the children needing follow-up beyond puberty continued to have severe complaints of constipation. [van: 2003]

There are some conditions that lead to an increased risk of having constipation, such as diabetes, hypothyroidism, celiac disease, and specific protein allergies, although most children have constipation, not associated with other medical conditions. Families can ask their primary care clinician about the cause of their child's constipation and the risk of constipation in future children.

Parents can help prevent constipation by making sure that the child gets adequate fluids and fiber in the diet, exercise, appropriate positioning, and regular, unrushed toileting time after meals. These strategies are also good first steps to treat mild constipation as well.

In addition to fluids, diet, and lifestyle changes, the daily use of medications over a prolonged period may be necessary to keep some children regular; this is called “maintenance therapy.” In children, these medications are various kinds of laxatives. The child’s primary care clinician in the medical home can work with the family to develop a tailored plan for the child’s constipation if needed.

Changes in dietary, eating, and exercise habits are part of the routine needed to reduce constipation and can be supported by the whole family adopting the changes.

• Vomiting or dehydration related to the constipation or bowel problem
• Swollen, firm abdomen that is painful to the touch or associated with fever (seek immediate medical attention)
• Pain doesn’t go away or is getting worse
• Blood is in or around the stool (can be non-urgent, but check with your primary care clinician if this is new)
• Stool is not able to be passed despite appropriate medications
• An enema has not come back out

A typical bowel program will first clean out the large intestine and then continue to keep the stool mushy and easy to push out. This is the main mode of constipation treatment. The goal of the bowel management program is to produce 1-2 mushy, easy-to-pass, painless poops every day. It is important for the treatment to continue for several months, if not longer. If your child has any problems with their prescribed bowel program, or is not getting better with this program, you should contact your primary care clinician to tailor a program for your child’s specific needs. For more detailed information on medication, contact your primary care clinician. No medication, or clean out, should be initiated without consulting the child's physician first.

• Liquid – Inadequate liquid intake may contribute to constipation. 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. Avoid highly processed and carbohydrate-rich foods that lack fiber as these may decrease appetite. If using formula, consider switching to one with fiber.
• Stimulating foods – 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.
• Constipating foods – Many foods seem to contribute to constipation, at least in some children. Bananas and cheese are the most common. Again, this can vary among children.
• Refer to a nutritionist as needed (Dieticians and Nutritionists (see NV providers [4])).

• Meals – Regular meals are helpful in keeping the bowels moving. Sitting on the toilet following meals can enhance the ease of passing bowel movements.
• Fewer snacks – Snacking, particularly “grazing” (eating small amounts of food, usually low in fiber, through 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. Daily exercise also has benefits in terms of fitness and weight control. Time in a stander or walker may help with evacuation for kids who spend most of their time in a wheelchair or lying down.
• Behavioral issues – 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). During potty training, positively reinforce all passage of stool, and 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 until evening. (See Toilet Training Children with Complex Medical Conditions.)
• Positioning – Ensure the child is adequately supported in an upright position to allow optimal defecation. Placing the feet on stool can help for kids whose feet don’t reach the ground. If indicated, obtain an adapted toilet seat with adequate support. (Example: Squatty Potty).

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 letter of medical necessity. Less frequently, private payers can be convinced to do this.