Constipation – Pediatric

WHAT IS CONSTIPATION?

Constipation means that stools are difficult or painful to pass and less frequent than usual.

A child with constipation feels a strong urge to have a stool and has discomfort in the anal area, but is unable to pass a stool after straining and pushing for more than 10 minutes.

After four weeks or so of life, some breast-fed babies pass normal, large, soft stools at infrequent intervals (up to seven days without a stool is not abnormal) without pain. For older children, going three or more days without a stool can be considered constipation, even though this may cause no pain and even be normal in some children.

Common Misconceptions About Constipation

Some people normally have hard stools daily without any pain. Children who eat a lot of food pass extremely large stools. Babies less than six months of age commonly grunt, push, strain, draw up the legs, and become flushed in the face during passage of stools. These behaviors are normal because it is difficult to produce a stool while lying down. Crying is not usual and would be a sign of distress.

WHAT IS THE CAUSE?

Constipation is often due to a diet that does not include enough fiber. A balanced diet is essential for a healthy digestive system. Constipation may also be caused by repeatedly waiting too long to go to the bathroom, not drinking enough liquids, or not getting enough exercise. The memory of painful passage of stools can make young children hold back when passing stool. If constipation begins during toilet training, usually the child is feeling stressed about using the toilet. It may be best to delay toilet training for some time.

HOW LONG WILL CONSTIPATION LAST?

Changes in the diet usually relieve constipation. After your child is feeling better, be sure to keep them on a healthy, non-constipating diet so that it doesn’t happen again.

Sometimes the trauma to the anal canal during constipation causes a small tear called an anal fissure. If your child has an anal fissure, you may find small amounts of bright red blood on the toilet tissue or the stool surface. If this occurs you should see a health-care provider.

TREATMENT ADVICE TO CARE FOR YOUR CHILD

  • Diet treatment for infants less than one year old
    Give one ounce (30 mL) of apple or pear juice per month of age daily to babies over 2 months old, to a maximum of four ounces (120 mL) per day. If your baby is over six months old, add strained baby foods with a high-fiber content such as cereals, apricots, prunes, peaches, pears, plums, beans, peas, or spinach twice a day. Strained bananas and apples are also helpful.
  • Diet treatment for older children over one year old
    • Make sure that your child eats fruits or vegetables at least three times a day. Some examples are prunes, figs, dates, raisins, bananas, apples, peaches, pears, apricots, beans, peas, cauliflower, broccoli, and cabbage. Warning: Avoid any foods your child can’t chew easily and might choke on.
    • Increase bran. Bran is a natural stool softener because it has a high fiber content. Make sure that your child’s daily diet includes a source of bran, such as one of the whole grain cereals, unmilled bran, bran muffins, graham crackers, oatmeal, high-fiber cookies, brown rice, or whole wheat bread. Popcorn is one of the best high-fiber foods for children over four years old.
    • Ensure your child eats a balanced diet not overly focused on one food.
    • Eat and drink the recommended intake of dairy, without letting it dominate the diet to the exclusion of other foods. After 12 months of age, a child does not require more than three servings of dairy per day.
    • Increase the amount of pure fruit juice your child drinks. (Orange juice will not help constipation as well as other juices).
  • Sitting on the toilet (children who are toilet trained)
    Encourage your child to establish a regular bowel pattern by sitting on the toilet for five minutes after meals, especially after breakfast. Some children and adults repeatedly get blocked up if they don’t have regular sit times. Feet should be on the floor or a foot stool.
    If your child is resisting toilet training by holding back, stop the toilet training for a while and put them back in diapers or pull-ups. Holding back stools is harmful. Use rewards to help your child give up this bad habit.
  • Flexed position
    Help your baby by holding the knees against the chest to simulate squatting, the natural position for pushing out a stool. It’s difficult to have a stool while lying down. Gently pumping the legs and rubbing the lower abdomen may also help.
  • Stool softeners
    If a change in diet doesn’t relieve the constipation and your child is over one year old, talk to your health-care provider about other interventions. Giving a stool softener with dinner every night for one week may be effective. Stool softeners are not habit forming. They work 8 to 12 hours after they are taken. Examples of stool softeners that you can buy without a prescription are MiraLAX, Metamucil, Citrucel, milk of magnesia, and mineral oil.
  • Common mistakes in treating constipation
    Don’t use any suppositories or enemas without your health-care provider’s advice. These can irritate the anus, resulting in pain and stool holding. Do not give your child laxatives such as products that contain senna without consulting your health-care provider because they can cause cramps.
  • Relieving rectal pain
    If your child is very constipated and has rectal pain needing immediate relief, one of the following will usually provide quick relief:

    • Sitting in a warm bath to relax the muscle around the anus (anal sphincter)
    • Placing a warm wet cotton ball on the anus and moving it to stimulate the rectal muscle

If your child is still blocked up after trying this advice, talk to your health-care provider now about being seen or using a suppository or an enema.

In summary, encourage lots of water, try apple or pear juice, and focus on a diet with as much fiber as possible. Right now, warm baths to relax and for babies warm wet cotton ball on the rectum to stimulate rectal muscles may help. For young children gentle tummy rubs and gently pumping the legs may ease discomfort and support passing a stool. Stool softener may help on a one time basis – ask your child’s health care-provider or a pharmacist for advice for your child’s age and follow product instructions. Even if this episode resolves, discuss the issue with your health-care provider. Don’t insert anything into rectum (thermometer, suppository or enema) without your health-care provider’s advice to do, even if people recommend this or you see it advised on the Internet.

WHEN SHOULD I SEE A HEALTH-CARE PROVIDER?

SEE A HEALTH-CARE PROVIDER IMMEDIATELY if:

  • Your child develops severe abdominal or rectal pain.

SEE A HEALTH-CARE PROVIDER TODAY if:

  • Your child is uncomfortable with abdominal or rectal pain.

See a Health-Care Provider during office hours if:

  • Your child does not have a stool after three days on the non-constipating diet.
  • You are using suppositories or enemas (should not use without your provider’s direction to do so).
  • You have other concerns or questions.

If you haven’t spoken to us yet, call Health Links – Info Santé to discuss your child’s symptoms with a nurse. Call back any time if your condition changes and you need assessment, or you have any questions or concerns.