Constipation in children | Mate tūtae kore

Key points about constipation in children

  • Constipation (mate tūtae kore) is when your child has hard, infrequent poo and doesn't poo for 3 or more days.
  • It's a common problem in childhood.
  • Constipation often starts after 1 hard poo has caused pain, and so your child has tried to avoid pain the next time by 'holding on' to the poo, resulting in a vicious cycle.
  • Increasing fluid and fibre in their diet can help prevent it.
  • Laxatives are sometimes necessary to make the poo softer and easier to poo out. They may be needed for months or years.
  • Sitting on the toilet regularly is important.
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There's a wide range of normal pooing for breastfed babies. They may poo as often as after every feed, or as infrequently as once in 10 days. Breastfed babies' poo is mustard yellow, soft and can look like it has seeds in it.

Most bottlefed babies and older children will have a poo every day or every second day. Some have more than 1 poo a day. The poo should be like a soft sausage – like types 3 and 4 in the diagram below.

Bristol stool chart (poo)

Image credit: John C Bullas Creative Commons(external link)

Your child may be constipated if they have some of the following:

  • Large and hard poo.
  • Hard 'pebble-like' poo.
  • No poo for 3 or more days.
  • Pain or crying when having a poo.
  • Bright blood around the poo due to tears in the skin around the anus (anal fissures).
  • Tummy pain.
  • Urinary tract infections, wetting pants (urine incontinence), bedwetting – constipation can increase the risk of these.
  • Liquid poo that may leak out at times in between harder poo.
  • Soiling accidents (encopresis).

Constipation in children is common.

There are many possible reasons for your child's constipation. Often, it is several things:

  • not drinking enough water
  • weaning from breastmilk to formula
  • starting solids
  • not having enough fibre (vegetables, fruits, whole grains) – ready-made food and takeaways are low in fibre
  • not doing much physical activity
  • not eating and drinking as much as normal, for example when your child is unwell
  • a natural tendency to having slower gut movement.

Toileting habits are important. Your child can become constipated if they:

  • ignore the urge to do a poo
  • don't let all the poo come out when going to the toilet
  • don't sit on the toilet regularly.

Take a look at this video by the Pediatric Gastroenterology Clinic, Primary Children's Hospital, US, for more information. 

Video: Constipation in children: Understanding and treating this common problem

(Primary Children's Hospital, US, 2017)

Constipation often starts after 1 hard poo has caused pain. The natural response to a painful experience is to try and avoid or escape it in the future. So, the next time your child feels the urge to poo, they 'hold on' in an attempt to avoid passing another painful poo. This results in the poo becoming firmer, larger and even more painful to poo out and your child becomes even more reluctant to poo in the future.

This leads to a vicious cycle of pain, hard poo, trying to avoid pain by 'holding on' to poo.

Pain and constipation cycle in children infographic

Image credit: Healthify He Puna Waiora

The key to stopping this cycle is making the poo soft again.

If constipation continues for a long time and all the poo doesn't come out, the bowel can become overloaded and stretched. The overloaded and stretched bowel means the feeling of needing to do a poo is lost and can cause soiling accidents. Read more about soiling.

Constipation is hardly ever due to an abnormal bowel. Most bowel problems show up in early life and are diagnosed within the first few months. Occasionally, constipation in children can be due to coeliac disease.

If your child passed meconium (the green/black poo newborn babies pass) within 24 hours of birth, it's unlikely your child has a bowel problem causing constipation.

Your healthcare provider may suggest your child sees a specialist nurse or doctor if:

  • your child's constipation is proving difficult to treat after standard treatments, or
  • they think there may be another condition causing your child's constipation.

The following links provide further information on constipation in children:

Continence information – children(external link) Continence NZ
Constipation(external link) ERIC Education and Resources for Improving Childhood Continence), UK

Brochure for printing

Soiled pants – a guide for parents and children(external link) KidsHealth NZ

References

  1. Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children – evidence-based recommendations from ESPGHAN and NASPGHAN(external link). JPGN 2014;58(2):258-274
  2. Clinical practice guideline – constipation (external link)Royal Children's Hospital, Melbourne, Australia, 2020
  3. Constipation in children and young people (external link)National Institute for Health and Clinical Excellence, UK, 2010 (updated 2017)

Clinical pathways and guidelines

Constipation(external link) Starship Clinical Guidelines, NZ, 2012
Constipation(external link) BPAC, NZ, 2007

Continuing professional development

Podcast

Constipation in children(external link) Goodfellow Podcast, NZ, 2020

In this podcast, Dr Rebecca Hayman reviews the optimal management of childhood constipation. She discusses pathophysiology, the important clues that can be gained from a comprehensive history and thorough examination, and finally the management including dis-impaction, and why long term maintenance treatment is so important.

e-Learning Module

Idiopathic constipation and nocturnal enuresis in childhood – a guide to management: putting NICE guidelines into practice(external link) BMJ Learning

Resources

Bristol Stool Chart(external link) 

Cochrane review 

Laxatives for the management of childhood constipation (Plain language summary) 

"Constipation within childhood is an extremely common problem. Despite the widespread use of laxatives by health professionals to manage constipation in children, there has been a long-standing lack of evidence to support this practice.

  • This review included eighteen studies with a total of 1643 patients that compared nine different agents to either placebo (inactive medications) or each other.
  • The results of this review suggest that polyethylene glycol preparations may increase the frequency of bowel motions in constipated children. Polyethylene glycol was generally safe, with lower rates of minor side effects compared to other agents. Common side effects included flatulence, abdominal pain, nausea, diarrhoea and headache.
  • There was also some evidence that liquid paraffin (mineral oil) increased the frequency of bowel motions in constipated children and was also safe. Common side effects with liquid paraffin included abdominal pain, distention and watery stools.
  • There was no evidence to suggest that lactulose is superior to the other agents studied, although there were no trials comparing it to placebo.
  • The results of the review should be interpreted with caution due to methodological quality and statistical issues in the included studies. In addition, these studies were relatively short in duration and so it is difficult to assess the long-term effectiveness of these agents for the treatment of childhood constipation. Long-term effectiveness is important, given the often chronic nature of this problem in children." (Gordon M et al, Cochrane Review 2012)

Gordon M, Naidoo K, Akobeng AK, Thomas AG. Osmotic and stimulant laxatives for the management of childhood constipation(external link) Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD009118. DOI: 10.1002/14651858.CD009118.pub2.

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Credits: Content shared between HealthInfo Canterbury, KidsHealth and Healthify He Puna Waiora as part of a National Health Content Hub Collaborative.

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