Child Constipation: Symptoms, Causes & Treatment

What Is Constipation in Children?

Constipation in children means having fewer than three bowel movements per week, passing hard or painful stools, or having difficulty emptying the bowels completely. It is one of the most common gastrointestinal problems in childhood, affecting approximately 3-5% of all children who visit a doctor.

Constipation is an extremely common condition in children of all ages, from infants to teenagers. The medical term for constipation that occurs without an underlying disease is functional constipation, which is by far the most common type. Understanding what constipation actually means is the first step toward helping your child feel better and preventing future episodes.

When we eat food, it travels through the digestive system where nutrients and water are absorbed. In the large intestine (colon), the body absorbs most of the remaining water from the digested material. When stool remains in the colon for too long, too much water is absorbed, making the stool hard, dry, and difficult to pass. This is how constipation develops in most children.

The rectum (the last part of the colon before the anus) sends signals to the brain when it becomes full, creating the urge to have a bowel movement. However, if a child repeatedly ignores or suppresses this urge, because it hurts to defecate or for other reasons, these signals become weaker over time. This creates a vicious cycle where more stool accumulates, becomes harder, and is even more difficult and painful to pass.

Normal Bowel Habits in Children

Normal bowel frequency varies significantly depending on a child's age and diet. Understanding what is normal can help you identify when your child may be constipated. Breastfed infants may have bowel movements after every feeding or as infrequently as once a week, as breast milk is so well absorbed. Formula-fed infants typically have one to three bowel movements per day. Once children start eating solid food, they usually have one to two bowel movements daily, though this can vary considerably from child to child.

It is important to remember that the frequency of bowel movements alone does not define constipation. The consistency of the stool and whether the child has difficulty or pain during defecation are equally important factors. A child who has a bowel movement every other day but passes soft stool easily is not constipated, while a child who has daily bowel movements but strains and produces hard, pellet-like stool may well be constipated.

Types of Constipation

There are two main categories of constipation in children. Functional constipation, which accounts for over 95% of cases, occurs without any underlying medical condition. It is typically related to diet, fluid intake, toilet habits, or behavioral factors. Organic constipation is caused by an underlying medical condition such as Hirschsprung's disease, hypothyroidism, celiac disease, or anatomical abnormalities. This type is much less common but is important to rule out, especially in infants or when constipation does not respond to standard treatment.

What Are the Symptoms of Constipation in Children?

Children with constipation may have fewer than three bowel movements per week, pass hard or painful stools, experience abdominal pain, show withholding behavior, have blood on the stool surface from anal fissures, or have fecal soiling (loose stool in underwear). They may also have decreased appetite and a distended abdomen.

Recognizing the symptoms of constipation is essential for parents to help their children as early as possible. Constipation can manifest in various ways, and some symptoms may be surprising or even misleading. For example, many parents are unaware that loose stool in a child's underwear can actually be a sign of constipation rather than diarrhea. Learning to recognize these signs helps ensure your child receives appropriate care.

The symptoms of constipation can affect not only the digestive system but also other aspects of a child's health and well-being. Chronic constipation can lead to decreased appetite, as the child feels full from the accumulated stool. It can cause irritability, mood changes, and even behavioral problems. Physical activity may decrease as the child feels uncomfortable. Understanding the full range of symptoms helps parents take a comprehensive approach to treatment.

Common Symptoms

The most recognizable symptoms of constipation include infrequent bowel movements, typically fewer than three per week. The stool is often hard, dry, and may resemble small pellets or balls. Children frequently experience pain during defecation, which can lead to crying, reluctance to use the toilet, or avoidance of bowel movements altogether. When the child does pass stool, there may be a large amount that can even clog the toilet.

Abdominal pain is another common symptom, particularly in the lower left side of the abdomen where the descending colon is located. This pain may come and go and is often relieved after a bowel movement. The abdomen may appear bloated or distended. Children may lose their appetite because the full feeling from accumulated stool reduces their desire to eat.

• Fewer than 3 bowel movements per week
• Hard, dry, or pellet-like stools
• Pain or difficulty during defecation
• Abdominal pain, especially in the lower left area
• Decreased appetite
• Bloated or distended abdomen
• Blood on the surface of stool or on toilet paper (from anal fissures)

Withholding Behavior

One of the most important symptoms to recognize is withholding behavior, where children actively try to avoid having a bowel movement. This often develops after a child has experienced painful defecation and associates the toilet with discomfort. Withholding behavior can be subtle or quite obvious. Signs include standing on tiptoes, crossing legs, squeezing the buttocks together, rocking back and forth, or hiding in corners. The child may become red-faced and appear to be straining, but they are actually trying to hold the stool in rather than push it out.

Withholding behavior creates a significant challenge in treating constipation because the more the child holds stool, the more it accumulates and hardens in the rectum, making eventual defecation even more painful. This perpetuates the cycle of constipation. Breaking this cycle requires patience, sometimes medication to ensure soft stools, and often behavioral support to help the child overcome their fear of using the toilet.

Fecal Soiling (Encopresis)

Perhaps the most confusing symptom for parents is fecal soiling, medically known as encopresis. This occurs when loose or liquid stool leaks around a hard mass of impacted stool in the rectum and ends up in the child's underwear. Many parents initially believe their child has diarrhea, when in fact the underlying problem is severe constipation. The child often has no control over this leakage and may not even be aware it is happening.

Fecal soiling can be extremely distressing for children and families. It may lead to social problems, embarrassment at school, and psychological distress. Understanding that this is a medical symptom rather than a behavioral problem is crucial. With proper treatment of the underlying constipation, fecal soiling typically resolves completely.

Urinary Problems

Constipation can also cause urinary symptoms that parents may not immediately connect to bowel problems. A large amount of hard stool in the rectum can press on the bladder, reducing its capacity and causing frequent urination, urinary urgency, or daytime wetting accidents. Some children may experience nighttime bedwetting that improves once constipation is treated. Recurrent urinary tract infections can also be associated with chronic constipation in children.

When Should You See a Doctor for Child Constipation?

Seek medical care if your child's constipation lasts more than one week, if there is blood in the stool, if your child has severe abdominal pain, vomiting with a distended abdomen, weight loss, or if constipation occurs in a breastfed infant. Also consult a doctor for recurring episodes or if home treatments are not working.

While most cases of mild, temporary constipation can be managed at home with dietary changes and adequate fluids, there are situations where medical evaluation is important. Knowing when to seek care helps ensure your child receives appropriate treatment and that any underlying conditions are identified promptly. Early intervention can also prevent constipation from becoming a chronic problem that is more difficult to treat.

Parents should trust their instincts about their child's health. If something seems wrong or if you are concerned about your child's symptoms, it is always appropriate to consult a healthcare provider. Better to seek advice and be reassured than to delay care for a condition that may need treatment.

Contact Your Doctor If

• Your breastfed infant shows signs of constipation
• Constipation persists for more than one week despite home treatment
• Your child has recurring episodes of constipation
• There is blood in the stool or on the toilet paper
• Your child alternates between constipation and diarrhea
• Your child is in significant distress during bowel movements
• Your child is not gaining weight appropriately
• Fecal soiling is occurring

What Causes Constipation in Children?

Constipation in children is most commonly caused by dietary factors (low fiber, inadequate fluids), withholding behavior due to fear of pain or bathroom anxiety, lack of physical activity, changes in routine, and toilet training issues. Less commonly, it may be related to food allergies, medications, or underlying medical conditions.

Understanding what causes constipation helps parents both treat current symptoms and prevent future episodes. In the vast majority of children, constipation develops due to a combination of factors rather than a single cause. Diet, hydration, physical activity, toilet habits, emotional factors, and timing of life changes all play important roles. Identifying which factors are relevant for your child allows for more targeted and effective treatment.

It is important to note that functional constipation, while common and often frustrating, is not caused by anything parents did wrong. Many factors contributing to constipation are part of normal child development, such as learning to use the toilet or becoming more independent in food choices. Understanding this can help reduce parental guilt and focus energy on practical solutions.

Dietary Factors

Diet is one of the most significant factors in childhood constipation. Children who do not eat enough fiber-rich foods such as fruits, vegetables, and whole grains are more likely to develop constipation. Fiber adds bulk to stool and helps it retain water, making it softer and easier to pass. Many children prefer refined foods like white bread, white rice, pasta, and processed snacks that contain little fiber.

Inadequate fluid intake compounds the problem. Water is essential for fiber to work properly in the digestive system. Without enough fluids, even fiber-rich diets may not prevent constipation and can actually make it worse. Children often prefer sugary drinks or may not drink enough throughout the day, especially when busy with activities or at school.

Excessive consumption of binding foods can contribute to constipation. These include foods made with white flour (white bread, pasta, pastries), white rice, bananas, and excessive dairy products. While these foods are not harmful in moderation, large amounts can contribute to harder stools.

Withholding and Behavioral Factors

Children often learn to suppress the urge to have a bowel movement for various reasons. Pain from passing hard stool is a common trigger that makes children afraid to defecate. This withholding creates a vicious cycle: stool accumulates and hardens, making the next bowel movement even more painful, reinforcing the child's fear and avoidance.

Environmental factors also play a role. Many children do not want to use unfamiliar toilets, such as those at school, daycare, or friends' houses. They may find public restrooms unpleasant, worry about privacy, or simply prefer the comfort of their home bathroom. If a child suppresses the urge to defecate during the day, constipation can develop over time.

Being too busy or engrossed in play is another common reason children ignore signals to use the bathroom. Young children especially may be so focused on activities that they don't want to stop, leading them to postpone bowel movements until the urge passes.

Toilet Training Issues

Constipation commonly develops during toilet training, a significant transition in a child's life. Some children are not developmentally ready when training begins and may resist using the toilet. Others may experience fear or anxiety about sitting on a large toilet seat. Pressure or stress during training can lead to withholding behavior.

The transition from diapers also changes the physical mechanics of defecation. When wearing a diaper, many children squat or stand while having a bowel movement. Sitting on a toilet requires different muscle coordination and may feel unfamiliar or uncomfortable. Using a footstool to allow proper positioning can help during this transition.

Life Changes and Stress

Children are sensitive to changes in their environment and routine. Starting daycare or school, moving to a new home, family changes such as divorce or a new sibling, travel, and other life transitions can trigger constipation. Stress and anxiety affect the digestive system and can slow intestinal motility. Children may also have less access to their preferred bathroom during transitions, leading to withholding.

Medical Causes

While uncommon, certain medical conditions can cause constipation in children. These include hypothyroidism (underactive thyroid), celiac disease (gluten intolerance), cow's milk protein allergy, anatomical abnormalities, Hirschsprung's disease (a rare condition where nerve cells are missing from the colon), and neurological conditions affecting the spine or nerves. Certain medications, including some used for allergies, pain, and behavioral conditions, can also cause constipation as a side effect.

What Can I Do to Help My Child with Constipation?

To help your child with constipation, increase fiber-rich foods gradually (fruits, vegetables, whole grains), ensure adequate water intake, establish regular toilet time after meals, use a footstool for proper positioning, encourage physical activity, and reduce constipating foods. Create a calm, pressure-free bathroom environment.

Parents play a crucial role in managing and preventing constipation in children. Most cases of functional constipation can be significantly improved through dietary changes, increased fluids, behavioral strategies, and creating healthy toilet habits. These approaches work best when implemented consistently and with patience, as it may take weeks to see improvement in chronic cases.

The goal of home management is to ensure soft, painless bowel movements that help break the cycle of constipation and withholding. When having a bowel movement is no longer associated with discomfort, children naturally stop avoiding it. This requires a multifaceted approach addressing diet, hydration, activity, and toilet habits simultaneously.

Increase Fiber Intake

Dietary fiber is essential for healthy bowel function. Fiber adds bulk to stool and helps it retain water, making it softer and easier to pass. However, it is important to increase fiber gradually to prevent gas, bloating, and discomfort. Sudden large increases in fiber can actually worsen symptoms temporarily.

Excellent sources of fiber for children include fruits such as prunes, pears, apricots, kiwis, figs, and berries. Vegetables like broccoli, peas, carrots, and sweet potatoes are also good choices. Whole grain breads, cereals, oatmeal, and brown rice provide fiber as well. Legumes including beans, lentils, and chickpeas are excellent fiber sources that can be incorporated into many child-friendly dishes.

Prunes and prune juice are particularly effective for constipation because they contain both fiber and sorbitol, a natural sugar that draws water into the intestines. Pear juice has similar properties and may be more palatable for some children.

Ensure Adequate Fluid Intake

Water is essential for fiber to work effectively. Without adequate fluids, increasing fiber intake can actually worsen constipation. Make water readily available throughout the day and encourage your child to drink regularly. Good hydration is indicated by light-colored urine and regular urination.

Water should be the primary beverage, but other fluids count toward hydration as well. Limit sugary drinks which provide empty calories without nutritional benefit. Milk should be given in moderate amounts, as excessive dairy intake may contribute to constipation in some children.

Reduce Constipating Foods

While not eliminating these foods entirely, reducing the amount of constipating foods in your child's diet can help. Foods that tend to contribute to harder stools include those made with white flour (white bread, pasta, crackers, pastries), white rice, bananas (especially unripe ones), and excessive dairy products. Focus on moderation rather than complete elimination, as these foods can still be part of a balanced diet.

Establish Regular Toilet Time

Encouraging your child to sit on the toilet at regular times helps establish healthy bowel habits. The best time is typically after meals, when the gastrocolic reflex (a natural response that stimulates bowel activity after eating) makes bowel movements more likely. After breakfast is often ideal, as there is usually time before the day's activities begin.

Have your child sit on the toilet for 5-10 minutes after meals in a relaxed, pressure-free environment. Make it clear that having a bowel movement is not required, just encouraged. Avoid expressions of disappointment if nothing happens. Some families find it helpful to provide books, games, or other entertainment during toilet time to make it a positive experience.

Use Proper Toilet Positioning

Proper positioning makes bowel movements significantly easier. When sitting on the toilet, children's feet should be supported on a stool so their knees are slightly higher than their hips. This position straightens the rectum and allows for more effective evacuation. Without foot support, children's legs dangle, which creates a less optimal angle for defecation.

For younger children or those still in toilet training, a smaller toilet seat insert can help them feel more secure. Some children prefer a potty chair placed on the floor, which naturally provides a squatting-like position.

Encourage Physical Activity

Regular physical activity stimulates intestinal motility and helps maintain healthy bowel function. Children aged 6 and older should aim for at least 60 minutes of physical activity daily. For younger children, active play throughout the day is beneficial. Any form of movement helps, from running and jumping to swimming and dancing.

Massage for Infants

For infants who appear to be straining without results, gentle abdominal massage may help. Using light circular motions on the baby's abdomen, moving clockwise (following the path of the colon), can stimulate intestinal movement. Stop if the baby appears uncomfortable or distressed.

How Is Constipation in Children Treated?

Treatment for child constipation typically involves stool softeners such as polyethylene glycol (PEG), combined with dietary changes, increased fluids, and behavioral strategies. Severe cases may require initial disimpaction to clear accumulated stool. Treatment often needs to continue for months to allow the bowel to return to normal function.

When home management strategies are not sufficient, medical treatment may be necessary. The goal of treatment is to produce regular, soft, painless bowel movements that help the child overcome any fear or avoidance of defecation. Treatment is typically managed in stages: first addressing any fecal impaction, then establishing regular bowel movements, and finally maintaining these improvements long-term.

Medical treatment for constipation is generally safe and well-tolerated by children. Parents should understand that treatment may need to continue for months or even longer to allow the stretched bowel to return to normal size and function. Stopping treatment too early, even when symptoms have improved, is a common cause of relapse.

First-Line Medication: Polyethylene Glycol (PEG)

Polyethylene glycol, also known as PEG 3350 or macrogol, is the most commonly recommended medication for childhood constipation. It works by drawing water into the stool, making it softer and easier to pass. PEG is tasteless and odorless and can be mixed with water or juice. It is not absorbed by the body and has an excellent safety profile, even with long-term use.

PEG is available over-the-counter in many countries but should ideally be used under healthcare provider guidance, especially for young children or for long-term treatment. The dose is adjusted based on the child's response, with the goal of producing 1-2 soft bowel movements daily.

Other Medication Options

Other stool softeners such as lactulose (a synthetic sugar that draws water into the bowel) may also be used. Lubricant laxatives like mineral oil can help stool pass more easily. Stimulant laxatives, which cause the bowel muscles to contract, are sometimes used short-term but should only be used under medical supervision in children.

Treatment Duration

One of the most important aspects of treatment that parents need to understand is duration. Treatment typically needs to continue for at least one month after symptoms have resolved to allow the bowel to fully recover. For many children, this means several months of maintenance treatment. Some children with chronic constipation may need medication for a year or longer.

Stopping treatment too soon is the most common cause of relapse. Even when stools are regular and soft, the child may still remember the pain of constipation and continue withholding behavior. Adequate time on treatment allows these memories to fade and new, healthy toilet habits to become established.

Disimpaction

If a child has a large amount of hard stool impacted in the rectum, initial disimpaction may be necessary before maintenance treatment can be effective. This typically involves higher doses of PEG for several days or, in more severe cases, enemas administered by a healthcare provider. Disimpaction should always be supervised by a doctor who can monitor progress and adjust treatment as needed.

Follow-Up Care

Children undergoing treatment for chronic constipation benefit from regular follow-up with their healthcare provider. This allows for dose adjustments, monitoring of progress, and support for families navigating the treatment process. Some children may also benefit from counseling or psychological support, particularly if there is significant anxiety around toileting or if fecal soiling has caused emotional distress.

Frequently Asked Questions