Constipation in Children

Stool or “poo” is a subject that most people avoid, considering it dirty and smelly. However, parents of young children will often pay close attention to their child’s poo every day. Parents can often get very concerned about their child’s bowel habits, as they worry about constipation and toilet training.

What exactly is a normal stool? Parents may have different understandings. When taking the child for a vaccination, parents sometimes should ask a doctor to show them a stool chart. What constitutes a normal stool differs in each age group. When
the baby is younger than 6 months old and is being fed with breast milk, it is normal for the stool to be liquid or loose with curds like. Once the baby starts to eat supplement foods at 6 months old, the stool may become creamy, but still not hard.
It is not normal for a child under the age of 2 years to pass stool that resembles a very thick paste in tube shaped, like toothpaste being squeezed out of a tube. This occurs when the child resists emptying his or her bowels, causing stool impacted in the colon. It is a symptom of constipation.

What is constipation? Some children pass a soft stool every 2 days. Some children empty their bowels every day or even 2 times a day. Constipation can be classified in terms of both the characteristics and the amount of the stool.

Bowel movements in children normally take place every other day or 3 times a week. In general, 2 or fewer normal bowel movements per week is a sign of constipation. If a child passes a large volume of stool every 2 days without difficulty, it does not
mean that the child is not constipated. It is likely that stool is being impacted in the colon until the child cannot hold it back any longer. When the child empties his or her bowels in such cases, the first part is hard and then the later part is soft. When bowel movements are difficult or painful, the child will often hold off from going to the toilet for 2-3 days, causing impacted stools to collect in the colon until the child reaches a point where he or she cannot hold them in any longer. Parents should monitor their children’s bowel habits to look for signs of constipation.

If a child passes stool daily, but it is hard and only a small volume, this is also a symptom of constipation. The colon is very long and can store a large volume of stool. When the child passes stool that is hard but in small volumes, it is likely that there is still stool left inside the intestines, but it will not come out. It is like when rocks are piled on top of each other until the stack becomes too high and some, but not all, of the rocks fall.

Constipation in children is not a serious condition. In most cases, the constipation is caused by behavior problems. Nevertheless, parents should not leave it untreated. Chronic constipation can lead to mental and physical health problems. However, parents should not buy laxatives or enema device without seeking professional medical advice because there are potential side effects. Taking the child to see a doctor is the recommended course of action.

An Enema is administered when the stool is impacted in the colon, causing abdominal discomfort and vomiting as the stool backs up. Administering an appropriate and accurate dose is very important. For instance, the applicator must not be too hard for the child’s rectum. Parents who buy an enema themselves run the risk of giving their child the wrong dose. Use of enemas is often traumatic for children. Most children do not like to have a applicator inserted into their rectum and so their parents have to grab them tight, causing fear and emotional problems.

Laxatives must be used under certain conditions and for specific durations due to the possibility of side effects. Constipation can be difficult to treat which needs to tune into emotional, mental and physical symptoms. Untreated constipation requires a longer treatment period – 3 months, 6 months or even years in some children. The medications need to be adjusted or changed from time to time, so parents should not buy them over the counter, especially for young children under the age of 6 years. While pharmacists are professionals, they will not have all the necessary patient information that a doctor would have, such as duration of received medications, drug resistance, and other conditions regarding certain medications that should not be taken together due to complex interactions and toxicity.

The use of enema or laxatives is not ideal. It is better for parents to monitor their young children’s bowel habits and establish bowel training by the following methods:

  1. Press on the child’s left side above the pelvic bone to check if the stool is impacted in the colon. If the stool is firm and can be moved around by pressing on it, this means that the stool has accumulated in the bowel for too long and it needs to be
    excreted.
  2. Check to see if there is a tear or small skin tag at the edge of the anus that causes the pain. In case of a tear, ointments such as antibiotic creams or Vaseline should be applied to facilitate smoother bowel movements.
  3. Encourage your child to adopt the correct position when using the toilet. The child should sit on a proper-sized toilet with both feet resting on the floor with foot support to raise the knees higher than the hips. The child should also lean forward slightly. The rectum position will straight up which help facilitate smooth bowel movements. Special toilet seats specifically for children are available at Samitivej Hospital. The special toilet seats can be used at home and a small chair can be placed for the child to rest his or her feet on if they cannot touch the floor. The best time to do toilet training is 15-30 minutes after the breakfast. The urge to defecate arises from the reflex contraction of the colon. The colon muscles usually contract aggressively in the morning so it is easy to pass the stool.
  4. Do not put any pressure on the child as it may cause him or her to develop a toilet phobia. Parents may train their child to use the toilet, but they should not have too high expectations that the child will be able to do it immediately. The child may need some time, so be patient with him or her and don’t make a big deal of it. Toilet training does not happen within just 1-2 days. Sometimes it may take months.
  5. A child’s stool can be softened by:
    • drinking orange or prune juice
    • drinking sufficient water
    • eating fruits and vegetables for fiber
    • drinking sufficient milk. A child over the age of 1 year who has 3 meals a day should drink 24-30 ounces of milk each day or about 8 ounces each meal.
    • drinking milk with prebiotics which are the soluble food fibers that feed the healthy bacteria in the colon and soften the stool. Prebiotics are important in milk products for children.

Finally, I would like to add that creating a food plan for healthy bowel movements in young children is not always easy, but also not too difficult. Constipation can be prevented. A mother with young children should not leave hard stools or irregular bowel movements untreated. It is important to treat the constipation at a young age as chronic constipation requires a longer treatment period. When taking your child for a vaccination, please consult with the doctor about the appropriate amount of food and milk to be consumed. Enemas are not recommended. If the conditions of constipation appear, please consult with a doctor and don’t do the enema. Most importantly, please monitor your child’s toilet behavior.

At Samitivej, we have a toilet training program with toilet seats made especially for children and therapeutic exercises called the Balloon Exercise and the Breathing Exercise. Parents who have a child experiencing constipation can consult with our
doctor to determine the best course of action.

Samitivej, We Care
Boosba Vivatvakin, Professor, M.D.
Pediatric Gastroenterology and Hepatology
Samitivej International Children’s Hospital

For further information, please contact:

Samitivej International Children’s Hospital Samitivej International Children’s Hospital
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Professor Boosba Vivatvakin, M.D. Summary: Pediatrics Pediatric Gastroenterology And Hepatology