What is Constipation?
Constipation in children is defined as a condition where they pass two or fewer painful, hard stools per week. It is a common issue, affecting approximately 3% of children visiting pediatric outpatient clinics. While 95% of constipation cases in children are functional, meaning there’s no underlying medical condition, the remaining 5% may be attributed to surgery or other diseases.
Identifying Constipation Symptoms
A diagnosis of constipation is considered if a child under 4 years old exhibits at least two of the following symptoms for a month, or for two months in children older than 4:
- Two or fewer bowel movements per week
- Painful or hard stools
- History of fecal retention
- Passage of large stool
- Soiling of underwear at least once a week
- Consistent fullness in the rectum
Normal Bowel Function in Children
Infants typically pass their first black stool (meconium) within 24 to 48 hours after birth. Subsequently, breastfed babies may have around four golden yellow stools daily, although formula-fed infants might have fewer.
- By age 2, children usually have about two bowel movements a day.
- By age 4, bowel movement patterns start to resemble adults, ranging from one to two times a day to once every two to three days.
Causes of Constipation
The majority of constipation cases in children are functional, with no anatomical problems involved. This is often due to dietary changes or stressors that children face:
- Transitioning from breast milk to formula
- Introduction of solid foods
- Toilet training (especially pressure-filled training)
- Starting kindergarten or school
- Busy daily schedules (school and extra lessons)
- Stressful home environments
- Illness or dehydration
The Vicious Cycle of Constipation
A child who experiences constipation once may associate bowel movements with pain due to straining. This fear can lead to stool withholding, where the child avoids bowel movements to avert pain. This results in harder stools as the liquid is absorbed, leading to more pain and perpetuating the cycle. Over time, complications like anal fissures, rectal prolapse, or hemorrhoids may develop. Persistent fecal retention can cause the rectum to expand, allowing softer stools to leak and soil the child’s underwear.
Diagnosing Constipation
A thorough history and physical examination are usually sufficient for diagnosing constipation. The family should be questioned in detail, and even minor details should not be overlooked. The abdomen and anal area are examined, with further tests conducted if necessary during follow-up.
Types of Constipation
- Idiopathic constipation (unknown cause, begins in infancy)
- Breast milk constipation (‘false constipation’)
- Formula constipation (occurs when infants switch from breast milk to formula)
- Rice cereal constipation (from rice flour introduction at 4-5 months)
- Infant dyschezia (straining before stooling in infants up to 6 months)
- Whole milk constipation (high protein-to-carbohydrate ratio)
- Psychosocial constipation (newly toilet-trained children)
- Functional constipation (95% of cases, ‘vicious cycle’)
- Constipation from anatomical causes (surgical and non-surgical diseases)
Is Infrequent Stool a Sign of Constipation in Babies?
Exclusively breastfed babies might not defecate daily, and this can last up to a week. They generally remain content, with soft stools upon defecation, and do not exhibit distress, vomiting, or swollen abdomens. This condition, known as ‘false constipation,’ is normal and typically resolves with the introduction of solid foods.
Additionally, infants under 6 months may strain before defecating, pulling their legs up, which is not constipation. This phenomenon, termed ‘infant dyschezia,’ is due to the underdevelopment of their defecation mechanism, which usually resolves on its own in a few weeks. Avoiding interventions like rectal stimulation is advised.
Treating Constipation in Children
Treating constipation is a complex process requiring collaboration between the child, family, and healthcare provider. It often occurs without underlying diseases, and treatment should address all contributing factors:
- Emptying impacted stools (using oral medications or enemas)
- Prescribing medications for regular, soft stools (based on the child’s age and constipation severity)
- Establishing proper toilet habits (sitting after meals, using a footstool, relaxed posture, not rushing or delaying)
- Treating associated conditions like anal fissures
- Adjusting the child’s diet
- Increasing fluid intake
- Incorporating fiber-rich foods
- Educating the family
- Providing psychological support if needed (emphasizing family support and non-blaming attitudes)
- Exploring other underlying diseases in suspicious cases
Constipation treatment requires patience and persistence. Medications may take time to be effective and might need long-term usage, with occasional dose adjustments. It can take time for children to overcome fear of painful defecation. Families may prematurely stop treatment, thinking it unnecessary. Treatment should continue for at least 2-3 months, ensuring regular, soft stools for at least a month before considering cessation.
Will Constipation Recur?
If treatment is stopped too soon or not followed as advised, constipation can persist or recur. Around 25% of those with childhood constipation may experience it into adulthood.
Underlying Conditions That May Cause Constipation
Approximately 5% of constipation cases have anatomical causes. Conditions like Hirschsprung’s disease, anal atresia, and anal stenosis, which may require surgical intervention, are common. Other conditions include hypothyroidism, hypokalemia, hypercalcemia, and celiac disease. Appropriate testing can confirm these diagnoses when suspected.
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