Constipation: Answering the ‘Hard’ Questions

Childhood constipation is frustrating, but the more you know, the more they'll go!
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Of all the adjectives used to describe constipation, “frustrating” is by far the most commonly used by parents in my practice. If you are reading this article, know that you are not alone. Constipation is a very common complaint of otherwise healthy children. Understanding the answers to the following commonly asked questions will give you a solid foundation in the subject, so let’s get moving.

Q: What is a normal bowel pattern?

A: This will vary based upon age. “Normal” stools are not rock hard, and not watery, but anywhere in between. Breastfed infants can stool anywhere from once a week to as much as with every diaper change. For formula fed and older infants, stooling between three times a day and three times a week can generally be considered normal.


Q: What is constipation?

A: There are technical definitions of constipation, however the answer really is “you know it when you see it.” In practical terms, constipation is difficulty passing stool.  Even if your child stools daily, if the stool is hard, dry, and associated with straining and pain, that is constipation. If your child stools only three times a week but they are soft and painless, that is normal. 


Q: What causes constipation?

A: In a nutshell, the muscles of the colon (large intestine) contract and move stool from the beginning (ascending colon) through to the rectum. This is mostly controlled by nervous system input to the colon, which is out of our control. Staying well hydrated and eating a balanced diet can help with colon movement. Some kids, however, have naturally slower colon movement than others, which may lead to constipation.

The most common cause of constipation is “stool withholding,” when instead of relaxing our bottom while attempting to stool, we contract our pelvic muscles and external anal sphincter to prevent stool from coming out. Repeating this over time will cause the rectum to distend, which only worsens the problem. Fear of defecation due to a history of painful bowel movements or due to inconvenient timing (not wanting to stop playing) are common causes of this behavior. 


Q: What are “red flags” that constipation is from a serious underlying medical condition?

A: Well over 95 percent of constipation is called “functional” constipation, meaning there is no medical or surgical cause. However, red flags that should prompt medical attention would be lack of meconium bowel movement at birth, failure to thrive, abdominal distension and blood mixed in stool, among others.


Q: How can I help my constipated child?

A: Provide a healthy, balanced diet, a supportive and positive environment during toilet training, and look for the stool withholding behavior discussed above. If your child is still exhibiting signs of constipation despite the above, or if they develop fecal incontinence (accidents) after already being toilet trained, please bring this up with your child’s doctor.


Q: What are the most commonly prescribed medical treatments for constipation?

A: There are medications called “osmotic laxatives,” which hold water in the colon to soften stool and make it easier to pass (Lactulose for younger infants, Miralax for older infants and children). There are “stimulant laxatives” which help the colon to contract, usually used on an intermittent basis when osmotic laxatives are not working (Senna or Bisacodyl). There are suppositories and enemas given at certain times, but in general we try to avoid using these.


Q: Will my child become dependent upon laxatives?

A: The medicines themselves are not habit forming and have no chemical dependency. Your colon does not “forget how to work.”


Q: Will this ever get better?

A: The vast majority of children will improve and go on to have a normal bowel pattern. A small percentage of children do develop chronic or severe constipation, which is where a pediatric gastroenterologist can be of help.


Dr. Dranove is board certified in general pediatrics and pediatric gastroenterology, hepatology and nutrition. He is a fellow of the American Academy of Pediatrics and the director of neurogastroenterology and motility disorders in the division of pediatric gastroenterology at Atrium Health Levine Children’s Hospital

For more information on keeping your child safe and well, visit pedsurgical.com