Constipation in your kids

No one likes to talk about constipation, least of all school-age children, preteens and teenagers. While a degree of banter on the subject may be common at school, the realities of living with it amount to a very private embarrassment. Pediatric constipation affects 10% to 30% of kids under 18 and can occur for many reasons, including potty training resistance, life changes, poor diet, a lack of exercise and, less often, undetected medical conditions. So what exactly is constipation? What can a parent do? And when should you seek expert care and treatment?

What is constipation?

Bowel habits vary from child to child, just as they do in adults. Babies generally poop several times a day. Preschoolers and school-age children have a bowel movement once or twice a day, or every other day, on average.

 Almost everyone becomes constipated at some point in life, and your child is no exception. Constipation can be recognized with the following:

• Infrequent bowel movements, typically less than three a week for children and teens, and one a week for infants with developing digestive systems
• Persistent difficulty passing stools and straining on the toilet
• Hard or lumpy stools that cause pain when passed and may plug the toilet
• A feeling that the poop didn’t completely come out after a bowel movement
• Having tummy pain or abdominal discomfort
• An itchy bottom, seeing your child scratching their rear end, or seeing streaky poop marks in underwear
• Overflow diarrhea, which is where new stool forms around existing hardened stool and leaks out as sudden diarrhea
• Having day or nighttime pee or poop accidents

Occasional versus chronic constipation

Before you reach for the parental panic button, realize that while constipation can be uncomfortable, it usually isn’t serious. Mayo Clinic experts connect occasional constipation with changes such as travel with time zone adjustments, an alteration to regular diet (such as staying with grandparents and eating differently), a new medication side effect, or an upcoming stressful event, such as a school test. It will be a phase, and your child’s constipation can be treated at home. Ask your child to:

• Drink plenty of water
• Eat more fruits (prunes, apples) and vegetables, especially leafy greens (cabbage, kale, spinach)
• Get plenty of exercise like playing outside, participating in a sport or doing other activities that involve physical movement
• Go to the bathroom after breakfast, even if no bowel movement occurs, to promote reflex and behavioral routine
• Head to the bathroom when the urge to poop occurs

With younger children, place a footstool in front of the toilet so their feet are not dangling. This allows their muscles to function better. And in babies older than 6 months, you can introduce prune puree or finely chopped prunes, to stimulate bowel function.

If at-home remedies fail and constipation drags on for three weeks or more, this becomes chronic constipation. It will then be time to see your care provider, who will cover symptoms, fiber intake, hydration, activity, diet and life events, and track progress. If the care provider’s remedies also fail, then it is time to see a gastroenterologist.

Seeing a gastroenterologist

Sara Hassan, M.D., a pediatric gastroenterologist at Mayo Clinic Children’s Center, typically meets with children after they have been living with constipation for an average of two years. Her first task is to break through embarrassment.

“At Mayo Clinic, all pediatric doctors generally say poop,” Dr. Hassan says, ruminating on how best to talk about fecal matter with squirming children. “It’s less daunting for the child.”

With younger children, she then gets out pens and crayons.

“I ask them to draw the color of their poop so they can picture everything. I say while we’re drawing that constipation is really common, that it’s not their fault, and kids are always relieved when I say this.”

With preteens and teens, Dr. Hassan uses the Bristol stool scoring chart, which scores stools by type, depicting them as friendly visuals and assigns them a number. “That helps teenagers to think, ‘Hey I’m not talking about poop, I’m giving it a number.’ “

Dr. Hassan also checks to be sure that the child isn’t passing blood when going to the bathroom.

“We always screen for blood in the stools,” she says. “When they’re wiping, are they seeing any? If so, is it fresh? Is it mixed in? Bright red or darker? These distinctions help us with our differentials.”

Dr. Hassan will also ask a parent if the child passed a bowel movement soon after being born or on day one or two of life, as the latter can be indicative of a neurological issue where nerves that direct colon function are not working correctly. “If that first poop — which is called meconium — is delayed, that throws up a red flag. Then we will do a biopsy to look for those nerves specifically.”

With the child’s bowel habits established, Dr. Hassan takes a medical, dietary and social history, including a list of all current medications (some of whose side effects include constipation), and then moves to a physical assessment.

This involves a blood test, a back exam (to rule out neurological concerns), palpating the abdomen and a digital exam. And no, the digital exam is not an exam to test your grasp of BeReal, Snapchat or TikTok. It’s a painless, 90-second rectal exam. Dr. Hassan examines the rectum with a gloved, very lubricated finger (digit), while the child lies in the fetal position facing the other way.

“It’s very important to have a digital rectal exam if you’re constipated,” Dr. Hassan explains. “We need to make sure everything is aligned correctly, that there is a good rectal tone and that inside the rectum you actually feel poop, showing they’re not able to empty.”

If the constipation is severe, Dr. Hassan may order an X-ray to help the patient see how much needs to change.

“Sometimes I say, ‘You’re pretty constipated. I can feel it in your belly: This is poop. That is poop.’ It’s really noticeable in an exam. But I’ve found I have much more patient and parent buy-in when I show them an X-ray and say, ‘Here it is. It corresponds to your pain, and this is what we need to do.’ “

Ruling out more serious conditions

During the physical assessment and accompanying bloodwork, there are several conditions that have to be ruled out, including irritable bowel syndrome — common in female teenagers — celiac disease, hypothyroidism and other serious but rare problems.

In the unlikely event that a more serious condition is suspected, Dr Hassan will refer patients to ther medical departments, but in the majority of cases, the diagnosis is functional constipation, which is the name for a chronic constipation where any possible underlying conditions have been ruled out.

Treating functional constipation

Alongside recocmending lifestyle changes, Dr. Hassan usually needs to get things moving by prescribing the laxative MiraLax to soften stools. In stubborn cases, MiraLax and a stimulant such as Dulcolax or Senokot may be needed to get muscles contracting again, as long-standing constipation causes rectal muscles to become distended. Of note: Dr. Hassan doesn’t recommend using these nonprescription laxatives with your child without first talking to your health care provider to determine if it is appropriate and, if so, what the proper dose is for your child.

“We try not to only rely on medication,” Dr. Hassan says. “Because medications will only get us so far, for so long. And that’s not the point. The point is to have healthy bowels at the end.”

Far less easy to remedy is constipation whose onset relates to a distressing event.

“When I suspect it’s emotional, we have to figure out what triggered the constipation and break the loop, by identifying the inciting incident. We see kids whose constipation started when switching from bottle to formula or breastfeeding to formula. Or when they started toilet training. Or their constipation started when they were 5, and we’ll ask what was happening around that time, and the parents will say, ‘We got a divorce.’ And it turns out he doesn’t like to go to the bathroom at one of the parents’ homes. You dig in and you dig in until you figure out something that might have triggered it.”

In these cases, Dr. Hassan will use an enema to empty the child’s bowels entirely and match that with a prescription of MiraLax. Physical therapists will work with the child on understanding the child’s condition and reconditioning bowel function using a behavioral therapy called biofeedback. If a deeper psychological issue is present, a psychiatric consult may be added.

Accidents happen

The goal in the first three months of pediatric constipation treatment is simply to achieve one soft bowel movement a day. The only time Dr. Hassan moves faster with treatment is if the child is having stool accidents at school, leading to teasing or bullying.

“Accidents happen,” she says of fecal incontinence, an extreme symptom of constipation. “You have a large poop ball that’s sitting in the rectum, and then you have new poop sliding around an already distended rectum and no muscle function to contract and hold it back … and it just slides out.

It’s very tough because families want to be like, ‘Not again! It’s the eighth pair of underwear you’ve ruined today. The sheets, the bed, the clothes, the school is calling.’ It’s really frustrating and so easy to snap at the child. In those cases, I show the family a video called ‘The Poop in You,’ which helps parents to realize, ‘Oh, it’s not my child’s fault.’ “

Fortunately, controlled bowel movements can be restored in time, again using laxatives, enema evacuation, lifestyle changes and biofeedback.

Back in flow

Typically, it takes between 12 and 18 months to see full and lasting constipation improvement in kids under 18. The time frame is dependent on uptake of lifestyle change recommendations, severity of symptoms and effectiveness of treatment. Dr. Hassan will observe progress closely and finds that most children get back in flow within a year. By then, children of all ages see the that getting fiber in their diets from vegetables and fruits, drinking enough water, heeding the call of nature and getting lots of exercise leads to healthy, regular, pain-free bowel movements.

Relevant reading

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