Constipation means that the bowel is healthy but not working properly. Constipation is defined as having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry and difficult to eliminate. Some people who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel.

Causes

Some children experience constipation either from a change in diet or because of stool avoidance behavior. In most cases, the cause is unknown.

Dietary Changes

Constipation following dietary changes usually occurs during the first year or two of life commonly after the introduction of rice cereal or solid foods, or during the change from breast milk or formula to cow's milk.

Stool Avoidance Behavior

Stool avoidance behavior occurs because of either painful bowel movements or fear of having a bowel movement. Initially the child is able to hold the stool in, but over time the stool becomes too large and must be passed. Occasionally the stool is so large that it causes small tears in the anus that result in blood on the toilet paper or in the toilet water. The passage of the large stool is painful and can perpetuate the cycle of pain leading to stool withholding. Over time, the rectum becomes stretched and the child cannot feel the urge to have a bowel movement. After a while, some children with constipation begin to experience fecal soiling of their underpants. This is called encopresis.

Encopresis

Encopresis occurs when the child resists having bowel movements, causing impacted stool to collect in the colon and rectum. When the child's colon is full of impacted stool, liquid stool can leak around the impacted stool then out of the anus, staining the child's underwear.

In most cases, encopresis is not a disease, but rather a symptom of chronic constipation. Less frequently, it may be the result of developmental or emotional issues. Encopresis occurs more commonly in boys after age 4, when your child has already learned to use a toilet. Emotional stress, such as premature toilet training or an important change in the child's life – for instance, the divorce of a parent or the birth of a sibling — also may trigger encopresis.

Symptoms

• Leakage of stool or liquid stool on your child's underwear when he or she isn't sick. If the amount of leakage is large, you may misinterpret it as diarrhea.
• Constipation and dry, hard stool
• Passage of large stool that clogs or almost clogs the toilet
• Avoidance of bowel movements
• Lack of appetite
• Abdominal pain

Exams and Tests

Your child's pediatric GI specialist will ask about his or her symptoms. The doctor may conduct a physical examination, including a rectal examination to check for impacted stool. During this exam, the doctor inserts a lubricated, gloved finger into your child's rectum. Your child's pediatric gastroenterologist also may recommend an abdominal X-ray to confirm the presence of impacted stool.

Barium Enema

A pediatric radiologist will insert a small catheter into your child's rectum and pass dye through the catheter to look for structural abnormalities of the large intestine (colon). No sedation is needed.

Anorectal Manometry

This test uses small balloons to test the function of the anal muscles. A pediatric GI specialist conducts the test in the endoscopy suite under general anesthesia. More extensive studies can be conducted in cooperative children while they are awake in the motility lab.

Treatment

There are four equally important parts of treating children with constipation.

1. Clean out – If your child has a fecal impaction, this stool must be removed before therapy can be successful. An enema or a high dose of oral medication may be used.
2. Maintenance medication – Once the rectum is cleared of stool, long-term therapy can be initiated. Stool softeners such as Miralax, lactulose, Milk of Magnesia or mineral oil are most often used. Occasionally, stimulant laxatives are used in addition to stool softeners. Maintenance medications usually are continued for several months.
3. Dietary modifications – Increasing the fiber in the diet and drinking plenty of fluids may help. Your doctor will give your child a goal for daily fiber intake. In some cases, it may be necessary to use a fiber supplement.
4. Behavioral modifications – This part of the treatment is key. In order for the above treatment to work, regular bowel habit must be established and maintained. In order to promote a regular bowel habit, children who are toilet trained (or in the process) should sit on the toilet for 5-10 minutes following their morning and evening meals. Meals are often followed by contractions in the colon which are meant to rid the colon of stool (the gastrocolic reflex). Sitting on the toilet takes advantage of this natural reflex.

Points to Remember

• Constipation is defined as fewer than three bowel movements per week.
• Stool avoidance behavior is commonly the cause of constipation. Infants during the first year of life may experience constipation due to dietary changes.
• Treatment for constipation is dietary and behavior modifications along with the use of stool softeners.

For More Information

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition - NASPGHAN.org

Children's Digestive Health & Nutrition Foundation - cdhnf.org

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