Constipation in Children: Symptoms, Causes & Treatment

What Is Constipation in Children?

Constipation in children is a condition where bowel movements occur infrequently (fewer than 3 times per week) and stools are hard, dry, and difficult or painful to pass. It is one of the most common childhood health problems, accounting for 3-5% of all pediatric visits and up to 25% of pediatric gastroenterology consultations.

Constipation is an extremely common condition affecting children of all ages, from infants to teenagers. While it can be distressing for both children and parents, the vast majority of cases are what doctors call "functional constipation" - meaning there is no underlying disease causing the problem. Instead, it develops due to a combination of dietary factors, toilet habits, and sometimes psychological factors like stress or anxiety.

Understanding what constitutes normal bowel habits in children is important. Normal bowel movement frequency varies considerably by age. Breastfed infants may have several bowel movements per day or go several days between movements without being constipated, as long as the stool remains soft. Children eating solid foods typically have one to two bowel movements per day, though anywhere from three times daily to every other day can be normal for individual children.

The condition becomes problematic when children have fewer than three bowel movements per week, combined with hard stools that are difficult or painful to pass. This can create a vicious cycle: painful bowel movements lead children to avoid going to the toilet, which causes stool to accumulate and become even harder, making the next bowel movement more painful still. Breaking this cycle is the key to successful treatment.

Normal Bowel Patterns by Age

Understanding what is normal for your child's age helps identify when constipation may be developing. Newborns, especially those who are breastfed, typically have frequent, soft stools - often after every feed. As babies grow and particularly when they transition to formula or solid foods, bowel movements typically become less frequent and stools become more formed.

By the time children are eating a regular diet, most will have one to two bowel movements per day, though some healthy children may go every other day. The key indicators of healthy bowel function are that stools are soft and easily passed without straining or pain, rather than strict frequency alone.

What Are the Symptoms of Constipation in Children?

Common symptoms of constipation in children include infrequent bowel movements (fewer than 3 per week), hard and dry stools, painful defecation, abdominal pain, blood on toilet paper due to anal fissures, stool withholding behavior, and sometimes fecal soiling in underwear despite being toilet trained.

Recognizing constipation in children is not always straightforward, especially in younger children who cannot articulate their symptoms. Parents should be aware of both the obvious signs and more subtle behavioral changes that may indicate their child is struggling with constipation.

The most obvious symptoms include infrequent bowel movements and hard, pellet-like or very large stools that are difficult to pass. Children may complain of stomach aches, particularly around mealtimes, and may lose their appetite. They may spend long periods on the toilet straining, or alternatively may avoid the toilet altogether despite showing signs that they need to go.

Behavioral signs of constipation are often misinterpreted. Children who are constipated frequently exhibit stool withholding behavior - they cross their legs, clench their buttocks, become restless, or hide in corners. Parents sometimes mistake this for the child trying to have a bowel movement, when in fact they are actively trying not to because they associate defecation with pain.

Fecal Soiling (Encopresis)

One of the most confusing symptoms for parents is fecal soiling - when liquid or soft stool leaks into the child's underwear despite being toilet trained. This paradoxically occurs because of constipation, not despite it. When a large mass of hard stool accumulates in the rectum, liquid stool from higher in the intestine can leak around it. Parents often initially think their child has diarrhea when the opposite is actually true.

Fecal soiling is not intentional and should never be punished. It occurs because the child has lost the normal sensation of needing to have a bowel movement due to the chronic stretching of the rectum. With proper treatment of the underlying constipation, this symptom resolves, though it may take time for normal sensation to return.

Urinary Symptoms

Hard stool accumulating in the rectum can press on the bladder, causing urinary symptoms. Children may need to urinate more frequently, may have accidents during the day or night, or may develop recurrent urinary tract infections. These symptoms typically resolve once the constipation is treated, but it's important to mention them to your healthcare provider.

When Should You See a Doctor for Child Constipation?

See a doctor if constipation lasts more than one week, if there is blood in the stool, if the child has severe abdominal pain or vomiting, if there is unexplained weight loss, or if constipation keeps recurring. Seek emergency care immediately for severe abdominal pain with vomiting and a distended abdomen.

Most children with short-term constipation do not need to see a doctor - simple dietary changes and increased fluid intake will resolve the problem within a few days. However, there are situations where medical evaluation is important to rule out underlying conditions and to prevent complications.

You should schedule an appointment with your healthcare provider if your child has been constipated for more than a week despite home treatment, if they have recurring episodes of constipation, if there is blood in the stool, if they are losing weight or failing to gain weight as expected, or if they have fecal soiling. For babies under six months who seem constipated, it's always wise to consult a healthcare provider before trying home remedies.

What to Expect at the Doctor's Visit

During the medical consultation, the doctor will ask detailed questions about your child's bowel habits, diet, fluid intake, and any behavioral changes. They will perform a physical examination, including feeling the abdomen for hard stool masses and possibly a gentle digital rectal examination to assess stool consistency and rule out anatomical problems.

In most cases, no further testing is needed - the diagnosis can be made from the history and examination alone. Occasionally, an abdominal X-ray may be performed to assess the amount of stool in the bowel, particularly if fecal impaction is suspected. Blood tests may be ordered if the doctor suspects an underlying condition such as thyroid problems or celiac disease.

What Causes Constipation in Children?

Most childhood constipation is "functional" - caused by dietary factors (low fiber, inadequate fluids), stool withholding behavior, toilet training issues, changes in routine, or psychological factors. Rarely, it can be caused by underlying conditions such as Hirschsprung's disease, hypothyroidism, celiac disease, or neurological disorders.

Understanding the causes of constipation helps in both prevention and treatment. In the vast majority of cases, constipation in children is functional, meaning it develops due to lifestyle and behavioral factors rather than an underlying medical condition. The most common scenario is that a child experiences a painful bowel movement for some reason, which leads them to start avoiding defecation, creating a self-perpetuating cycle.

The initial trigger for this painful episode might be as simple as a bout of illness where the child drank less and became slightly dehydrated, causing harder stools. It might coincide with a dietary change, such as transitioning from breast milk to formula or starting solid foods. Toilet training is another common trigger - children may become anxious about using the potty or toilet and start withholding.

Psychological and environmental factors play a significant role. Children may avoid using unfamiliar toilets at school or when traveling. They may be so absorbed in play that they ignore the urge to defecate until it passes. Stress from family changes, starting a new school, or other life events can also contribute to constipation.

Dietary Factors

Diet plays a crucial role in maintaining healthy bowel function. Children who consume insufficient fiber - found in fruits, vegetables, whole grains, and legumes - are more likely to develop constipation. Similarly, inadequate fluid intake, particularly water, contributes to harder stools that are more difficult to pass.

Excessive consumption of certain foods can worsen constipation. These include white bread and pasta, white rice, excessive dairy products, bananas, and processed foods low in fiber. While these foods don't need to be eliminated entirely, they should be balanced with plenty of fiber-rich foods and adequate hydration.

Stool Withholding Behavior

Children often learn that they can control the urge to defecate by tensing their muscles and holding back. While this might seem like a solution to avoiding a painful bowel movement, it actually makes the problem worse. When stool remains in the rectum for too long, the intestinal wall absorbs more water from it, making it even harder and larger. Eventually, the rectum becomes stretched and less sensitive, reducing the child's awareness of the need to defecate.

Parents can often recognize withholding behavior: the child may stand on tiptoes, cross their legs, rock back and forth, or retreat to a corner. These behaviors are often mistaken for attempts to defecate when the child is actually trying to prevent a bowel movement.

Medical Causes (Rare)

While uncommon, certain medical conditions can cause constipation in children. These include Hirschsprung's disease (a congenital condition where nerve cells are missing from part of the colon), hypothyroidism (underactive thyroid), celiac disease, cow's milk protein allergy, spinal cord abnormalities, and certain medications. If your child's constipation doesn't respond to standard treatments or they have other concerning symptoms, your doctor may investigate these possibilities.

How Can You Treat Constipation at Home?

Home treatment for childhood constipation includes increasing dietary fiber gradually (fruits, vegetables, whole grains), ensuring adequate water intake, establishing regular toilet times after meals, using a footstool for proper positioning, increasing physical activity, and creating a calm, unhurried bathroom environment.

The cornerstone of treating constipation in children involves dietary modifications, establishing healthy toilet habits, and ensuring adequate physical activity. These lifestyle changes are effective for most children with mild to moderate constipation and are essential even when medications are needed.

It's important to implement these changes gradually and consistently. Sudden dramatic changes in diet can cause bloating and discomfort, potentially making the child more reluctant to eat healthy foods. Similarly, toilet training and habit changes should be approached without pressure, as stress and anxiety can worsen constipation.

Dietary Changes

Increasing fiber intake is one of the most important dietary interventions for constipation. The general recommendation for daily fiber intake in children is their age plus 5 to 10 grams. So a 5-year-old should aim for 10-15 grams of fiber daily. Good sources of fiber include whole fruits (especially prunes, pears, kiwis, apricots, and berries), vegetables, legumes (beans and lentils), and whole grain breads and cereals.

Certain foods are particularly helpful for constipation. Prunes and prune juice have a natural laxative effect. Kiwifruit has been shown in studies to improve bowel function. Pears, apricots, and other high-fiber fruits are also beneficial. Conversely, reducing intake of constipating foods like white bread, white rice, and excessive dairy may help.

Hydration

Adequate fluid intake is essential, especially when increasing fiber. Without sufficient fluids, high-fiber foods can actually worsen constipation. Water is the best choice - encourage your child to drink water throughout the day. A simple indicator of adequate hydration is that your child urinates regularly with pale yellow urine.

While fruit juices like apple, pear, or prune juice can help with constipation due to their sorbitol content, they should be given in moderation due to their sugar content. Avoid sugary drinks like sodas, which do not help with hydration as effectively as water.

Establishing Regular Toilet Habits

The gastrocolic reflex - the natural urge to have a bowel movement after eating - is strongest in the morning and after meals. Take advantage of this by encouraging your child to sit on the toilet for 5-10 minutes after breakfast and other meals. Make this a relaxed, unhurried time without pressure to produce results.

Never punish or shame a child for accidents or for failing to have a bowel movement. Keep the atmosphere positive and use praise when the child sits on the toilet, regardless of the outcome. Some families find reward charts helpful, particularly for younger children.

Proper Toilet Position

The position a child adopts on the toilet significantly affects their ability to have a comfortable bowel movement. When children sit on a standard toilet with their feet dangling, it's difficult to achieve the relaxed pelvic floor needed for easy defecation. Provide a footstool so your child can rest their feet flat with knees slightly above hip level. This position mimics squatting and makes bowel movements easier.

For children still in nappies (diapers), encourage them to squat rather than stand when having a bowel movement. Standing makes it harder to fully evacuate the bowel and can contribute to constipation.

Physical Activity

Regular physical activity helps stimulate intestinal function and promotes regular bowel movements. Children should get at least 60 minutes of physical activity daily. This doesn't have to be structured exercise - active play, walking, cycling, and swimming all count. Even for younger children, floor play and tummy time help with digestive function.

Over-the-Counter Remedies

If dietary and lifestyle changes alone aren't sufficient, over-the-counter stool softeners may help. Osmotic laxatives such as lactulose are safe for children and work by drawing water into the stool to soften it. Always follow age-appropriate dosing instructions and consult a pharmacist or healthcare provider if you're unsure what product is suitable for your child's age.

How Is Chronic Constipation Treated Medically?

Medical treatment typically involves osmotic laxatives like polyethylene glycol (PEG) or lactulose to soften stools, used daily for several months. Severe cases may require disimpaction first. Treatment continues until the child has been symptom-free for at least one month, then is gradually tapered. Some children need treatment for a year or longer.

When home remedies are insufficient, prescription treatment becomes necessary. The goal of medical treatment is to soften the stool, establish regular bowel movements, and allow the stretched rectum to return to normal size and function. This process takes time - parents should be prepared for treatment lasting several months to over a year.

The first-line medication for childhood constipation is polyethylene glycol (PEG), an osmotic laxative that draws water into the bowel to soften stool. PEG is very safe for long-term use and does not cause dependency. It comes as a powder that is mixed with water or juice. Lactulose is an alternative osmotic laxative, also safe for long-term use.

Treatment Phases

Treatment typically proceeds in phases. If significant fecal impaction (a large mass of hard stool in the rectum) is present, this must be cleared first through "disimpaction." This usually involves higher doses of osmotic laxatives for several days. In severe cases, enemas may be needed, but this is always done under medical supervision.

After disimpaction, maintenance therapy begins. The child takes daily laxatives at a dose adjusted to produce one or two soft bowel movements per day. This phase continues for months - long enough for the rectum to return to normal size and for the child to "unlearn" stool withholding behavior.

When the child has been completely free of symptoms for at least one month (ideally longer), the medication dose is gradually reduced over several weeks. If symptoms return during tapering, the dose is increased again and treatment continues for longer before the next attempt at tapering.

Why Long-Term Treatment Is Important

One of the most common reasons for treatment failure is stopping medication too soon. Even when stool has become soft and bowel movements are regular, the child may still remember the pain of previous episodes and may still have an enlarged rectum that hasn't fully recovered. Stopping treatment prematurely often leads to rapid recurrence.

It's important to understand that osmotic laxatives like PEG and lactulose are safe for long-term use - they don't make the bowel "lazy" or cause dependency. Continue treatment as long as your healthcare provider recommends.

Behavioral Support

For some children, particularly those with significant stool withholding behavior or anxiety related to defecation, behavioral therapy or counseling may be helpful. This is especially true when constipation has been long-standing and the child has developed fears around using the toilet. Working with a psychologist or behavioral specialist can help address these issues.

What Complications Can Occur from Untreated Constipation?

Untreated constipation can lead to fecal impaction (hard stool mass that cannot be passed), encopresis (fecal soiling), anal fissures (painful cracks in the anus), hemorrhoids, recurrent urinary tract infections, and behavioral/psychological issues including school avoidance and social withdrawal.

While constipation itself is not dangerous in most cases, chronic untreated constipation can lead to several complications that affect a child's physical and emotional wellbeing. Understanding these potential complications emphasizes the importance of treating constipation effectively.

Fecal impaction occurs when a large mass of hard stool accumulates in the rectum and cannot be passed normally. This is uncomfortable and can cause severe abdominal pain. It usually requires medical intervention to clear. Encopresis - involuntary soiling - often accompanies chronic constipation and can cause significant embarrassment and social problems for school-age children.

Anal fissures are small tears in the skin around the anus caused by passing hard stool. They are painful, especially during bowel movements, and may bleed. The pain from anal fissures often worsens stool withholding behavior. While they usually heal with proper constipation treatment, they can become chronic if constipation continues.

The psychological impact of chronic constipation should not be underestimated. Children may become anxious about using the toilet, may avoid school to avoid using unfamiliar bathrooms, and may become socially withdrawn due to fear of accidents. Prompt, effective treatment helps prevent these complications.

How Can You Prevent Constipation in Children?

Prevention involves maintaining a high-fiber diet with plenty of fruits, vegetables, and whole grains; ensuring adequate water intake; establishing regular toilet times; encouraging physical activity; responding promptly to the urge to defecate; and managing toilet training without pressure.

Prevention is always better than treatment, and many of the same strategies used to treat constipation are effective in preventing it. Establishing healthy habits early in childhood sets the foundation for good digestive health throughout life.

A balanced diet rich in fiber from an early age is essential. Introduce a variety of fruits, vegetables, and whole grains as your child begins eating solids, and continue to emphasize these foods as they grow. Make water the default drink, limiting sugary beverages. Lead by example - children are more likely to eat healthy foods if they see their parents doing the same.

Establish regular toilet times from an early age, even before formal toilet training begins. Sitting on the potty or toilet after meals, when the gastrocolic reflex is active, helps establish regular bowel habits. Approach toilet training gradually and without pressure - forcing or rushing toilet training is associated with increased rates of constipation and stool withholding.

Encourage physical activity every day. Active children generally have better bowel function than sedentary ones. Limit screen time and promote active play, sports, and outdoor activities.

Pay attention to transitions and stressful times, as these are when constipation often develops. Starting childcare, school, or moving house can all trigger constipation. During these times, be especially attentive to your child's toilet habits and diet, and address any problems promptly before they become established.