When my kids were younger, they used to report back to me after each bowel movement. I am not going to share all the descriptive details we went into, but you get the idea: this topic has always been fairly important in our household. Dietitians love to talk poop!

But joking aside, constipation is one of the most common types of tummy trouble that worries parents all over the world. Some studies report up to 30% of kids suffer from constipation, although the diagnosis of constipation may vary from one country to another.

Apart from obviously unpleasant symptoms, a less known effect of constipation is lowering kids’ appetite and willingness to eat. Many of kids with feeding problems I see in my private practice are constipated. 

In this article, I will focus on constipation in children 1 to 18 years old. If you need help for a constipated baby, I encourage you to check this resource from PENnutrition.

Why do kids get constipated? 

There are two types of constipation: acute and chronic. Acute constipation lasts up to two weeks and, if not treated, it may turn into chronic or functional constipation.

It often happens because children start withholding stools to avoid painful experience. When a constipated child goes to the toilet, it hurts, so he clenches the muscles next time he feels the urge and, as a result, he gets constipated even more. The stool sitting in the colon gets drier and harder. The next time the child tries to push it out, it hurts even more. Over time, the colon stretches and loses some motility, so the urge to go to the bathroom occurs less frequently. At this time, some kids may start experiencing fecal incontinence, when some liquid contents of the colon pass around the hard impacted mass and escape involuntarily.

In a very small number of children, medical factors, such as organic causes of constipation, like Hirschsprung’s disease, may play a role in constipation. That is why it very important to see your doctor if you suspect that your child may be constipated.

Constipation may also be triggered by changes in lifestyle ( for example, rushed mornings, moving houses), changes in routine (starting school) and toilet training.

A few other reasons:

  • Dehydration
  • Changes in diet or fluid intake
  • Certain medications
  • Psychological issues

How to know your child is constipated?

Many clinicians around the world use ROME IV set of criteria to diagnose constipation.

Here is the list of chronic/functional constipation criteria according to ROME IV:

Children under 4: 

One month of at least 2 of the following:

1. 2 or fewer defecations per week

2. History of excessive stool retention

3. History of painful or hard bowel movements

4. History of large-diameter stools

5. Presence of a large fecal mass in the rectum (diagnosed by the doctor).

In toilet-trained children:

6. At least 1 episode/week of incontinence/soiling after the child have been off diapers

7. History of large-diameter stools that may obstruct the toilet.

Children older than 4 years:

Two or more of the following occurring at least once per week for a minimum of 1 month

1. 2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years

2. At least 1 episode of fecal incontinence per week

3. History of retentive posturing or excessive volitional stool retention

4. History of painful or hard bowel movements

5. Presence of a large fecal mass in the rectum

6. History of large diameter stools that can obstruct the toilet

Children who are constipated are more likely to be moody, have a lower appetite, abdominal pain, more gas, and less energy.

Constipation in children-symptoms and treatment options - child holding toilet paper

How to treat constipation?

If your child is constipated, your first reaction may be to improve the diet. But dietary changes are rarely successful as first-line treatment of chronic constipation, especially for picky eaters. Dietary changes are a great tool to ward off constipation or prevent it from turning into the chronic type,  but once your child has been constipated for more than 2 weeks, you need heavier guns to help them.

I always encourage parents to talk to a pediatrician regarding constipation and, based on the history and severity, they may prescribe a safe laxative to clear out the impaction. 

Once the impaction is out of the way, here are 5 key areas you and your doctor/dietitian may need to focus on to prevent it from coming back:

1. Fiber 

A balanced diet provided the appropriate amount of fiber will help keep your child regular. To see how I am adding fiber to my kids’ diet, click here.

Is your child getting enough fiber? The rule of thumb is: for children from 3 years old – Age +5grams to Age +10. For example, a 5-year-old needs 10 to 15 grams of fiber per day. 

NOTE:  The most fiber-rich foods are not fruit and vegetables. So no need to engage in a battle with your picky eater. Whole grains have the type of fiber that helps prevent constipation most effectively.

Foods highest in fiber:

Wheat, oat and corn bran (not recommended for under 2s) – 12-22 grams for 30 grams. Fiber champion: corn bran

Beans and lentils, cooked – 14-19 grams per cup. Fiber champions: navy beans and white beans

Berries – 5-8 grams per cup. Fiber champions: raspberries and blackberries

Whole grains – 2-8 grams per serving. Fiber champions: bulgur and whole wheat spaghetti

Vegetables (including potato with skin) – 3-4 grams per cup. Fiber champions: Brussels sprouts and acorn squash

Fruit – 3 to 8 grams per serving. Champions: pear and figs.

Greens, cooked – 4-5 grams per cup. Fiber champions: collard greens and mustard greens.

Make sure not to go above the upper limit and be especially careful with high fiber foods if your child is under 2 years of age. Too much fiber may interfere with the absorption of other nutrients in small kids. And always talk to your doctor before considering a fiber supplement.

2. Water 

Dehydration may cause constipation. So make sure your child is getting enough to drink, but do not stress about giving your child extra water – it has not been shown beneficial for constipation prevention. 

Water needs for different ages 

3. Probiotics

As always, take to your doctor or dietitian to help choose a safe option. At this point, we know very little about the role probiotics supplements can play in our health but some research indicated specific strains more helpful than others. 

4. Dairy 

Constipation can be a symptom of cow’s milk protein allergy, even if your child does not have any other signs of an allergic reaction.  Talk to your doctor about getting a referral to an allergist of experiment with dairy-free diet for a couple of weeks, under the supervision of a doctor or a dietitian.

5. Physical activity

Kids need to about a minimum of an hour of moderate to vigorous physical activity every day. Make sure your little one gets to move his body regularly throughout the day, without spending a long time sedentary. 

And I would like to leave you with a useful tool to look at with your older kids and have a chat about what a healthy bowel movement should look like. This is Bristol Stool Chart – a handy guide on the types of stool. Source: Continence Foundation of Australia. 

  • Type 1–2 indicate constipation
  • Type 3–4 are ideal stools
  • Type 5–7 may indicate diarrhea

Happy feeding (and pooping)!

Constipation in children - symptoms and treatment options

References:

Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S et al; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/24345831

Young R, Beerman L, Vanderhoof J. Increasing oral fluids in chronic constipation in children. Gastronterol Nurs. 1998;21(4):156-61. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/9849179

Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for water, potassium, sodium, chloride, and sulfate. Washington, D.C.: The National Academies Press; 2005. Available from: http://www.nap.edu/openbook.php?isbn=0309091691

Arnaud MJ. Mild dehydration: a risk factor of constipation? Eur J Clin Nutr. 2003 Dec;57 Suppl 2:S88-95. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/14681719

Mugie SM Benninga M A, Di Lorenzo C. Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol. 2011 Feb;25(1):3-18. Abstract available from: 

Koppen IJ, Kuizenga-Wessel S, Saps M, Di Lorenzo C, Benninga MA, van Etten-Jamaludin FS, et al. Functional defecation disorders and excessive body weight: a systematic review. Pediatrics. 2016 Sep;138(3). pii: e20161417. doi: 10.1542/peds.2016-1417. Epub 2016 Aug 16. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/27531145

DiLoreno C, Nurko S. Rome IV, Volume II. Functional Pediatric Gastrointestinal Disorders. Disorders of Gut-Brain Interaction. First Edition. Available from: https://romeonline.org/romeonline-books/rome-iv-pediatric/

Gastrointestinal System – Pediatric/Paediatric Constipation, Pen – The Global Resource for Nutrition Practice. https://www.pennutrition.com Retrieved on December 10, 2018

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