Constipation is defined as a decreased frequency or painful passage of bowel movements. Children 1–4 years old typically have a bowel movement one to four times a day. Most children go at least every other day, although some of these children may be constipated. When children are constipated for a long time, the colon (or large intestine) stretches, and fecal retention can occur. Over time, children may begin to soil their underwear. This fecal soiling is involuntary — the child has no control over it.

On this week’s On Call for All Kids, Michael Wilsey, M.D., who specializes in pediatric gastroenterology, hepatology and nutrition in the Department of Pediatric Medicine at Johns Hopkins All Children's Hospital, gives parents some other helpful information about constipation.

How common is constipation?

Constipation is very common, especially in preschool and school-age children. Up to 3% of all visits to the pediatrician, and up to 25% of visits to a pediatric gastroenterologist are related to constipation issues. 

Why does constipation happen?

Constipation is often defined as either organic or functional. Organic constipation has an identifiable cause, such as an intestinal or spinal cord issue. Functional constipation describes those children in whom constipation does not have an organic etiology. Fortunately, most childhood constipation is functional. Functional constipation commonly results from stool withholding behavior in a child who wants to avoid painful defecation. 

In infants, straining and difficulties expelling an often-soft bowel movement are due to an immature nervous system and/or uncoordinated defecation (“infant dyschezia”). Some healthy breast-fed infants also can go several days without having a bowel movement. 

In children, constipation often results from changes in the diet or routine, during toilet training, or after an illness. Anything that gets children out of their normal routine can affect their stooling routine. Occasionally, children may stool withhold when they are reluctant to use unfamiliar toilet facilities. This occurs more commonly in school-age children. 

Once the child has been constipated, retained stool can build up and slowly stretch the colon. An over-stretched colon does not work properly and retains more stool. Defecation becomes very painful, and many children will attempt to withhold stool. Stool withholding behaviors include stiffening, squeezing buttock muscles, crying, or crossing the legs when the urge to have a bowel movement is felt. These withholding behaviors are often misinterpreted as attempts to push the stool out. Stool withholding makes constipation worse and treatment more challenging.

When should you child see a health care provider for constipation?

Consider seeing a health care provider if your child: 

• Develops hard, painful stools that are difficult to pass.
• Your child consistently skips days without having a normal bowel movement.
• Your child has large stools that clog the toilet.
• You child develops soiling accidents or rectal bleeding

Other symptoms that may accompany constipation include abdominal pain, bloating, poor appetite and irritability. In most cases, there is no need for testing before treatment for constipation. However, depending on severity, your doctor may order X-rays or other tests to clarify your child’s situation.

How is constipation treated?

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

Some children may only require changes in diet, such as an increase in fiber (often fresh fruits and vegetables) or the amount of water they drink. Other children may require medications, such as stool softeners or laxatives. Stool softeners are not habit-forming and may be taken for a long time without side effects. If your child has soiling accidents, it may take up to 9-12 months for the stretched-out colon to return to a normal size.

Some children with fecal retention may require an initial “cleanout” to help empty the colon of a large amount of stool. This typically entails using oral laxatives or even suppositories or enemas for a short period of time. 

It is important for your child to start a bowel retraining routine. Have your child sit on the toilet for 5–10 minutes after every meal to help build a daily habit. Using a footstool can be helpful to promote complete evacuation with defecation. Praise your child for trying. If the child is not yet toilet trained, it is best to wait until constipation is under control.

On Call for All Kids is a weekly series featuring Johns Hopkins All Children's Hospital experts. 

Michael Wilsey, M.D., is on the medical staff of Johns Hopkins All Children’s Hospital, Inc. (“JHACH”), but is an independent practitioner who is not an employee or agent of JHACH.