Constipation is easily the most misunderstood pediatric medical condition. It is so common that it’s practically universal, and can be so subtle at times that parents are rarely aware their children are experiencing it. Because it can have significant health consequences if left untreated, it's important to identify when it is present and address it thoroughly.
First off, what is constipation? Constipation happens in two different ways: acute or chronic. Acute constipation is when a child who has always pooped normally suddenly develops a single hard, large, or painful poop after a binge of carbs, dehydration, or surgery. In such a case, flushing it through quickly and returning to a normal diet may be all it takes to resolve the issue. This, however, is less common than you'd think. While most people think they are dealing with acute constipation, in reality it's often a "silent" case of chronic constipation to which they have only suddenly become aware. I'll help you figure out the difference so we can treat it appropriately. First, let's explore what goes on inside the colon with constipation, which will help you determine if your child may be dealing with an acute or chronic issue, and then we'll move on to the best way to treat it.
Try not to think of constipation as hard stools, or even infrequent bowel movements, or really anything having to do with the poop that comes out of the body, though these problems may be present. Constipation is best thought of as the storage or buildup of excess stool within the colon. This is something you cannot see, which is why it’s hard to be aware of how deep the problem goes, or how long it's been going on. With retained stool in the colon, its function becomes impaired, and many different stooling patterns can result, including anything from loose, frequent squirts to hard pellets to anything in between, even normal-appearing daily stools.
How can this be? If a child retains just a little bit of extra feces in their colon here and there, but keeps pooping, you'd never know it. They may continue to poop around it, or gradually get behind by a day or two, pooping out yesterday's poop today. Everything continues to move through as far as you can tell, and looks pretty normal, but the amount stored within the colon increases little by little. Cue ominous-sounding music: dun dun dun dun…
Now, the colon has stretch receptors that send signals to the child's brain to let them know it's time to poop. When a child stores extra feces within the colon, it remains in a more stretched state, and that signal is constantly firing yet being ignored. Basically, the child is training themselves not to pay attention to that signal, until one day they just can't hear it anymore. At this point, it's really hard for them to tell when they need to poop and when they don't because the signal is broken.
Furthermore, the colon has muscles within it that help it expand and contract. Think of constipation just like a muscle that isn't exercising properly: it's no healthier to leave your arm strapped to your side for 2 years than it is to leave your colon expanded with feces for the same duration, regardless of whether the poop itself is hard, soft, daily or weekly.
Finally, the poop moving through the colon gets so disrupted that it may slow down to such an extent that it hardens and grows to a large, painful movement, which is the first time you become aware of it, mimicking acute constipation. Now you can see the dilemma in telling the two apart. But most importantly, let's start thinking about constipation as a problem of poop storage, not simply a problem of poop appearance.
What’s the harm in being a little backed-up? What seems like “a little constipation” is often the tip of an iceberg that is a more significant problem than most parents realize. Did you know that it may increase a child’s risk of diabetes, colon cancer, hemorrhoids, behavior problems, incontinence, diverticulitis, urinary problems, and others? When you think about it, poop is waste, and it’s not a great idea to retain that waste longer than necessary. Furthermore, when the colon is stretched for too long, as previously noted it can lead to chronic incontinence. To top it all off, the excess mass puts pressure on the bladder, causing difficulties with urination. In fact, it’s one of the most common causes of urinary problems in children. And this is all in addition to the fact that constipation could be a sign that the child’s diet might be unhealthy, which can be harmful in other ways. In some children, it may be that pooping has become an unpleasant experience for them, something we wouldn’t want either.
Fortunately, constipation is very treatable, and as it turns out, addressing this common problem is one of the highest yield things you can do to improve your child’s quality of life and health.
To start with, let's figure out the extent of your child's constipation so we can make sure to treat it appropriately.
Is it acute or chronic?
Acute constipation: This is when a child with a healthy diet and history of very regular and normal pooping suddenly develops a single large, hard, or painful bowel movement after an obvious trigger (binge of carbs, dehydration, travel or surgery). The trigger is important, without it things may have been brewing for a while.
Chronic constipation: Because it can be hard to detect, look closely for the following signs that might clue you in. Note that they can be subtle at times, and only a few may actually be present:
- Distended abdomen
- Change in bowel habits (i.e. used to be in the morning, now it’s in the evening, etc.)
- Pooping during dinner time (the colon is already so full, there's no where else for the food to go)
- Varying bowel habits (sometimes poops in morning, sometimes evening, sometimes both, sometimes not at all, etc.)
- Urgency (doesn’t have to poop, then suddenly has to go really badly, maybe can’t hold it)
- Occasional hard pellets
- The poop alternates a lot in consistency (harder/dryer to looser/wetter, etc.)
- Poop “accidents”, like squirts of poop in their underwear.
- Urinary problems (accidents, bed wetting, UTI, pain with urination, etc)
- Your child has to strain to poop, and/or develops anal fissures or hemorrhoids
- Large diameter stools - they should be kid sized, not grownup sized.
- Stools that tend to be on the firmer/drier side (you shouldn’t be able to pick up a poop with two fingers. You should theoretically need your whole hand).
- Your child doesn’t poop at least every day (exception: healthybreastfed infants; see box below)
- Constipation may cause abdominal pain and/or blood in the stool, but because these symptoms could be signs of something more serious you should make sure to come see me as soon as possible if this ever happens.
Special case: the constipated infant. We need to pay a bit closer attention to infants because their presentation, causes and complications can be unique. For example, it can be normal for exclusively breastfed babies to go long periods (7-10 days) without pooping, provided the poop comes out soft and they are eating and growing well. In such a case you do not need to change anything or contact me, though adding more movement (i.e. bicycling their legs) several times per day can help a ton. But if any baby has rock-hard stools, pellets, or blood in the stool I would like to see you in clinic, do not proceed with treatment on your own.
What causes constipation?
It’s usually a combination of diet and withholding patterns. I’ll approach it briefly here, and we’ll go into more detail on addressing these causes once we start talking about treatment.
- Diet factors: Of all the foods, the most constipating are the starchy foods that are white in color. Think refined grains (rice, wheat, etc), dairy products, bananas, potatoes, etc. Basically, in the same way that rice or pasta would stick to your plate, these foods get stuck inside our intestines. Compare that to a piece of broccoli, which would simply bounce off the wall (if you were inclined to throw it at one). Higher fiber vegetables and fruits are less “sticky” and pass through more easily. Formula-fed infants are often constipated due to the formula.
- Behavior factors: There are too many exciting things to see and do in the world, who would want to stop and poop? Also, some children are uncomfortable with the act of pooping, bathrooms, potty training, etc. Withholding stool makes it move through more slowly, which causes the stool to get harder as the body absorbs more water from it, which causes more pooping discomfort, which makes them withhold even more, and you can see how that rapidly becomes a vicious cycle. So vicious, in fact, that it can cause a young child even with a healthy diet to develop severe constipation.
- Sedentary lifestyle and inadequate water intake may compound the above issues.
- Less common causes of constipation might include medications (such as codeine), recent operation, or rare medical conditions. If your child’s constipation doesn’t respond normally to therapy or has severe complications (such as rectal prolapse), you should let me know.
Chicken or the egg? Often, constipation is a combination of several factors, where physical discomfort leads to emotional discomfort, and vice versa, so it's hard to tell which came first.
Treatment of constipation
Acute constipation: If your child does not meet the description of chronic constipation above and you think you may be dealing with acute constipation, feel free to try "flushing things out" by giving some extra fiber, water, prune juice, etc., and temporarily eliminating refined grains (white flour, white rice, etc.) and dairy products from the diet. If all returns to normal, problem solved—but be on the lookout in the future, and try to keep refined grains and dairy products to a minimum. You may also do an abbreviated course (i.e. two weeks) of the chronic constipation treatment as described below, and certainly follow the tips to prevent recurrence. But if this treatment is unsuccessful, or if you try this but the problem returns, you'll want to follow the full treatment course for chronic constipation as discussed in the next section.
Chronic constipation: Treatment is a multi-faceted approach. It focuses on achieving immediate disimpaction of stool, improving the diet, increasing exercise, addressing the behavioral aspect of stooling, and allowing lots of time for the colon to return to its normal function. While it's temping to simply take some prune juice or increase fiber, this doesn't address the underlying disfunction of the colon, which has likely been going on for longer than you think, and will continue for long into the future unless healed. Know that success will not happen overnight, it takes months to years to address a problem that has been brewing for months to years. But don't worry, treatment is highly successful if followed correctly.
Because treatment of chronic constipation is complicated and prolonged, it’s a good idea to come in for a quick visit first to make sure we have the right diagnosis, and that the treatment plan is safe and appropriate for your child. After your visit, you may proceed with treatment (link below), plus any modifications I may have mentioned during your visit.
For urgent needs, same-day appointments are available Monday through Friday. Please call as early in the day as possible, the more notice we have the easier it is to fit everyone in.
Need help outside of office hours?
Firstly, if your child has an emergency, please call 911 or go directly to the ER - they will contact us if needed once your child has been evaluated.
Urgent Care centers can also be helpful when something needs to be seen outside of office hours but it's not an emergency.
For our list of preferred Urgent Cares and ERs, see our resources page.
And if you have something that might need urgent attention but you're not sure/don't know what to do, we can help: