Constipation in Children: My child takes long time to Poo, What to do?

It is quite a common problem in children of all ages, particularly common during potty training period. Around 3 to 5% visits to Paediatrician and at least 25% of visits to a pediatric gastroenterologist are due to problems with constipation. 

What is it? 

Bowel patterns vary in children, as it is the case in adults. Hence, it is sometimes difficult to tell if your child is truly constipated. One child may go two or three days without a stool (bowel movement) and still not be constipated, while another might have relatively frequent bowel movements but have difficulty passing the stool. Sometimes constipation in a child may go unnoticed if he passes only a small stool each day, while a buildup of stool develops in his large bowel. In general, it is best to watch for the following signals if you suspect constipation: 

• In a  baby less than 3 months of age, firm stools less than once a day, though this can be normal in some exclusively breastfed infants 

• In an older child, stools that are hard and compact, with three or four days between bowel movements 

• At any age, stools that are large, hard and dry and associated with painful bowel movements 

• Episodes of abdominal pain relieved after having a large bowel movement 

• Blood in or on the outside of the stools due to fissure (tear in the anus from passing hard stool). 

• Passing some stools in underwear (soiling) between bowel movements in a child who have been previously toilet trained. 

• Other symptoms that can accompany constipation are poor appetite, crankiness, stool withholding behaviour and sometimes urinary problems. 

Why does it happen? 

Constipation can be due to organic or functional causes. Organic means there is an identifiable cause such as large bowel (Colon) disease, neurological problem, under-active thyroid, food allergy and other uncommon medical problems. Fortunately, most constipation is functional, meaning there is no identifiable disease. In functional causes, constipation is still a problem, but there is usually no underlying significant medical cause behind to worry about it. Functional constipation is usually due to improper unhealthy diet habits like taking less fibre, less water intake, too much milk and sedentary life style. 

It has been noticed that constipation usually develops when there has been a change in diet, routine, toilet training or illness. In school going children, the reason could be unfamiliar toilet facilities at school (unclean or not private enough) as they tend to with hold stools even when they have urgency to pass stools. Most importantly in this modern era children have been rushed from the moment they wake up to get ready to school and they do not spend adequate time in the toilet. 

When there is a likely possibility of an underlying medical disease/disorder for constipation? 

Red flags to see doctor soon

• Baby not passed the first stool (black sticky stool called meconium) within 24 to 48 hours after birth 

• Abnormal bowel habits since birth 

• Poor weight gain or weight loss 

• Change of bowel habits with introduction of cow’s milk 

• Neurological problem 

• Sensitivity to cold, fatigue, dry skin and pallor 

What happens in constipated children? 

The normal function of large intestine (colon) is to absorb water from the faeculent material. Hence if the child has been constipated for more than a few days, more and more water would be absorbed from the retained stool and it becomes harder. The large hard stool over-stretch the colon and it cannot work efficiently. Also then passing hard stools becomes very painful and these children will try to withhold stool consciously and keep postponing the act of defaecation making the problem worse. Parents mistake this act of withholding, as if the child is attempting hard to pass stool whereas it is entirely opposite. Typical with holding behaviours include standing rigidly upright, crossing the legs, tightening up legs/buttocks or squat quietly when there is an urge to pass stools. I have seen children trying to do similar withholding behaviours while lying on the floor and parents mistaking it for fits. 

What is the treatment? 

Treatment of constipation varies according to the child’s age, personality and the cause of the problem. 

If they are identified early and prompt medical advice sought these children would need only dietary changes and appropriate toilet training activity. Dietary changes include increasing fibre content in their food and drinking adequate amount of water. It would be useful to start a bowel training routine where the child sits on the toilet for 5 – 10 minutes after every meal. It is important to do this consistently in order to encourage good behaviour habits. Praise your child for trying. If the child is not toilet trained yet, it is best to wait until constipation is under control.  

Many of the constipated children do need stool softeners (laxatives) and in few selected children medicines to stimulate bowel activity. Stool softeners are not habit forming and if needed has to be used even for long as 6 months to 1 year. Few children may need initially a clean out of the large hard stool with gradually increasing amount of laxatives by mouth over few days or occasionally enema.  

Although some laxatives are available from the pharmacists never give your child a laxative or other types of stool-loosening or softening medications without first consulting with your doctor. 

What you could do? 

• Encourage your child to drink plenty of water and eat more high fibre foods. 

• Help your child set up a regular toilet routine. 

• Encourage your child to be physically active. Exercise along with a balanced diet provides the foundation for a healthy, active life. 

• Do not take laxatives from local pharmacist (over the counter) without doctor’s advice. 

• See the child specialist soon particularly with above red flags in the box. 

5 foods to take 

• All vegetables – green leafy vegetables, broccoli, carrot, cauliflower, okra,  

• Most fruits with skin – plums, pears, apples 

• Whole grain flour – atta made with whole wheat, bajra, corn 

• Beans & Dals – baked beans, kidney beans, black eyed peas, toor dal  

• Dried fruits – dates, raisins, prunes 

5 foods to avoid 

• Dairy products – cheese, chocolates, ice cream, sweets, cakes, paneer 

• Maida flour products – pizzas, burgers, breads, instant noodles 

• Red meat 

• Oily & salty foods – chips, french fries, crisps 

• Caffeinated drinks - coffee, tea and cola. 

Featuring insights from Dr M S Viswanathan, Senior Consultant - Paediatric Gastroenterologist, Transplant Hepatologist &  Therapeutic endoscopist, Apollo Children's Hospitals, Chennai. 

📞 For appointments, call 044 4040 1066