Constipation (mate tūtae kore) is when your child has hard and/or infrequent bowel motions (poos, stool). Constipation often starts after one hard poo has caused pain, and so your child tries to avoid pain the next time by holding on and not going to the toilet.
Key points
Constipation in children is very common affecting up to 30% of children.
It is most common in 2 to 4-year-olds who are potty training.
In most children constipation lasts a short time and is not serious.
If your child has constipation that doesn’t go away, see your doctor.
If left untreated, constipation may cause your child to ignore the urge to poo due to pain and/or distress associated with this.
If your child has been given laxatives or stool softeners and is still not getting better, see your doctor.
Common symptoms of constipation in children
A child with constipation may:
move in a way that suggests they are holding in their poo, such as standing on tiptoes and then rocking back on the heels of the feet, clenching their bottom, and other unusual, dance-like behaviours
cry, strain or show other signs of pain when going to the toilet
have hard, dry or small poo (like pebbles)
complain of stomach pain or cramps
experience urinary tract infections and bedwetting
have poo in their pants or 'skid marks'.
What causes constipation in children?
Constipation is caused when poo moves too slowly through the gut, where water is absorbed from the poo, making it hard and dry. Hard, dry poo is more difficult for the muscles in the bottom to push out of the body.
Cause
Description
Ignoring the urge
Children most commonly develop constipation as a result of holding in poo
The may do this because they are feeling stressed about potty training, are embarrassed to use a public bathroom, do not want to interrupt playtime, or are fearful of having a painful or an unpleasant poo
Diet
Constipation in children is often caused by a poor diet that is high in fat and refined sugar (sweets, cakes, biscuits) and has too little fibre
Fibre helps the poo stay soft so it moves smoothly through the gut
Fruit (fresh and dried), vegetables, whole grain cereals and bread, nuts and lentils are good sources of fibre
Dehydration
Dehydration can make constipation worse
It is often as a result of drinking too little fluid, or losing too much fluid such as by vomiting or excessive sweating
Changes in routine
Changes in the usual time of meals, as well as changes in their daily toileting routine (for example when on holiday) can cause your child to become constipated
Medicines
A number of medicines can cause constipation as a side effect, for example antacids, iron supplements, some anti-cough medicines and some pain medicines
Constipation in babies
It can be difficult to know if a baby has constipation because there is such variation in the firmness and frequency of poo in babies.
Breastfed babies may have a poo following each feed but some breastfed babies only poo every 7 to 10 days.
Babies fed formula tend to poo at least every 2 to 3 days.
It is common for babies to strain a lot when they poo. As long as their poos are soft, they aren’t constipated.
How to prevent constipation in babies
Constipation is often caused by changes such as weaning from breastmilk or other types of milk. To ease constipation in babies:
try increasing the amount of water your baby drinks, by offering small amounts of water between feeds
for bottle-fed infants, consider trying out different infant formulas to find one that makes poo softer and easier to pass.
Limit foods that have little or no fibre, such as ice cream, cheese, meat and processed foods.
Increase the amount of water your child drinks by giving them water at each meal time and extra water when it is hot.
Encourage a regular toileting routine such as sitting on the toilet for 5 minutes, once or twice a day.
Encourage daily exercise and physical activity. This helps stimulate normal bowel function.
For children over 12 months of age, try giving them one glass of undiluted apple juice or kiwifruit juice.
If these methods don't work, medications such as laxatives may be needed. Laxatives usually work by softening the poo. Some help the bowel push out the poo by stimulating the nerves in the bowel.
Your doctor or pharmacist will advise you on a suitable laxative for your child. Children should take medication until their bowel habits are normal for an extended period of time and they have overcome their holding behaviour. If treatment is stopped too soon, a child will likely become constipated again.
You should take your child to the doctor if any of the following apply:
your child has been constipated for a long time and the methods described above have not worked
your child has tummy pain
your child is pooing in their pants (soiling).
If left untreated, constipation in children can lead to faecal impaction, where hard poo blocks the gut and normal bowel action cannot push the poo out. Over time, this can cause faecal incontinence, where children over the age of 4 years regularly poo their pants because the bowel has stretched and is unable to register that there is a poo.
If your child has ongoing problems with toileting your doctor may refer them to a paediatrician or continence nurse.
Credits: Health Navigator Editorial Team. Reviewed By: Nir Fireman, Auckland DHB (5 May 2017)
Fibre makes poo softer and easier to pass
It is important to get your child into the habit of eating a healthy, balanced diet that includes food with fibre and plenty to drink (mainly water). This will help to prevent constipation.
Giving your child (aged over 15 months) more fibre in their diet can help prevent constipation and also treat short term or very mild constipation. Fibre is also important long term for regular bowel functioning. If your child has had constipation a long time, just increasing fibre without other treatment is unlikely to resolve the problem.
(Canadian Digestive Health Foundation, 2016)
How to increase fibre in your child's diet
give at least 3 servings of vegetables each day; this includes potato, pumpkin, kumara
fruits with the peel left on, such as plums, prunes, raisins, apricots, and peaches have a lot of fibre as does kiwifruit
give cereals high in fibre, such as bran cereals, Weet-Bix, whole grain cereals, porridge; avoid refined cereals, such as cornflakes, rice bubbles or those with added sugar
for children older than 12 months, give wholemeal breads (instead of white bread)
try adding bran to muffins and other baking, or add it to your child's regular cereal
try adding 1 to 2 tablespoons of ground flax seed/linseed meal to cereals, soup or mixed into a smoothie
give legumes (beans and peas), such a baked beans, hummus, lentils.
It is also important to give your child plenty of water with the increase in fibre.
How can I encourage good toileting habits in my child?
Encouraging good toileting habits in your child can help prevent constipation. Here are some handy hints:
Teach your child to develop a regular toilet routine by sitting on the toilet for 5 minutes once or twice a day preferably within 30 minutes of a meal. After breakfast is best.
Try to allow plenty of time so they don't feel rushed.
Even if your child does not do a poo, still encourage this habit.
Make sure your child is comfortable on the toilet by:
using a footrest stool for them to rest their feet on so their knees are higher than their hips – this is a comfortable seating position
using a toilet seat inner so that the child's bottom can fit comfortably on an adult-sized toilet – if your child is not relaxed because they are worried about falling in to the toilet they tend to tighten their pelvic floor muscle and this makes it difficult to have a relax and do a poo.
When they are sitting on the toilet, encourage your child to lean forward and rest their elbows on their knees.
Make the toilet child friendly and fun with books, toys or a blackboard nearby – for them it can be a lonely place and children get bored.
Incentive or 'star' charts are useful to reward your child for sitting on the toilet and doing a poo, and can help keep track of progress.
Praise your child for doing a poo in the potty or toilet but do not punish accidents.
What should I do if my child isn't developing good toilet habits?
It is easy to become frustrated when your child poos in their pants or refuses to go to the toilet. Talk to your doctor if toileting continues to be a problem for your child. They may refer you to a continence nurse or paediatrician for specialist advice and support.
Information for healthcare providers on constipation in children
The content on this page will be of most use to clinicians, such as nurses, doctors, pharmacists, specialists and other healthcare providers.
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.
Access to the following regional pathways is localised for each region and access is limited to health providers. If you do not know the login details, contact your DHB or PHO for more information:
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)
