Constipation in children is quite common and is characterized by infrequent bowel movements or difficulty passing stools, often causing discomfort. Typically, children between 1 and 4 years old have bowel movements 1 to 4 times daily. However, constipation can occur even if bowel movements occur every other day in more than 90% of children. Prolonged constipation may lead to involuntary fecal soiling, especially during toilet training stages.
Constipation is a common issue among children, particularly during toilet training and school years. It contributes significantly to pediatrician visits, with about 3% of all visits related to constipation. Moreover, a quarter of visits to pediatric gastroenterologists are due to constipation-related concerns. Each year, millions of prescriptions are issued for laxatives and stool softeners.
Understanding & Managing Pediatric Constipation
Causes of Constipation
Constipation can be organic, with a clear cause such as colon disease or neurological issues. However, most cases are functional, meaning no identifiable cause is found. Functional constipation can result from changes in diet or routine, toilet training, or after an illness. Children may also withhold stool due to discomfort with unfamiliar toilet facilities or environments.
Healthcare providers diagnose constipation based on symptoms such as:
- Hard or small stools that are difficult or painful to pass
- Irregular bowel movements
- Large stools that clog the toilet
- Stomach pain
- Poor appetite
- Irritability, or bleeding from the anus
In most cases, constipation can be diagnosed without extensive testing. Treatment varies based on the child's age, the severity of symptoms, and underlying causes. It may include dietary adjustments, increased fluid intake, medications like stool softeners or laxatives, and sometimes a "cleanout" procedure to remove accumulated stool. Establishing a consistent bowel routine, such as sitting on the toilet after meals, can also be beneficial. Parents are encouraged to praise their child's efforts and ensure toilet training is approached once constipation is managed effectively.
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Prolonged constipation can lead to fecal soiling, where children involuntarily pass stool in their clothing without realizing it. Encopresis is a related condition involving involuntary or voluntary fecal incontinence not caused by any disease, often linked to chronic stool withholding.
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Treatment involves a three-step process, which can take several months to a year for improvement:
Step 1: Initial Cleanout
To remove impacted stool from the colon, stool must be softened and broken down using oral agents like mineral oil, magnesium citrate, Milk of Magnesia, MiraLAX™, and lactulose. These agents are safe for long-term use as they are not absorbed into the bloodstream. MiraLAX™ is commonly used for its tasteless, colorless properties and can be mixed into any drink. Enemas or suppositories may also be used to start the process by softening stool near the rectum.
Step 2: Maintenance Therapy
Maintenance therapy prevents stool buildup and helps the colon return to normal function. The goal is to encourage regular bowel movements with softer stools. This involves:
- Adjusting medication to achieve 1-2 soft bowel movements daily.
- Encouraging toilet-trained children to sit on the toilet for 5 minutes after meals.
- Increasing dietary fiber through whole grains, fruits, vegetables, and fiber supplements.
- Ensuring adequate fluid intake, especially water.
- Promoting physical activity to aid bowel movement.
Encouraging older children to take responsibility for their medication, toilet habits, and cleaning up after accidents.
Step 3: Counseling
Counseling helps address the emotional and behavioral impact of constipation and soiling. A counselor can assist in reducing family tensions and developing a reward system for proper toilet habits. Psychological support may be necessary for children facing peer conflicts, academic challenges, and low self-esteem.
Achieving Success
Constipation and fecal soiling are manageable conditions. With consistent treatment and behavioral adjustments, children can regain control of their bowel movements. While relapses may occur, repeating the initial cleanout and maintenance therapy can restore normal function. Some children may continue to need a high-fiber diet and stool softeners into adulthood to manage symptoms. If a child does not respond to treatment, further testing may be required to rule out other underlying conditions.