I struggled with constipation as a toddler. Constipation is a very common problem in childhood and is a frequent reason children see the doctor. In majority of children with constipation, there is no medical cause identified, and is called functional constipation. Your doctor will diagnose constipation based on the history of symptoms, physical examination of your child and sometimes x-rays may be necessary.

Children struggling with chronic constipation tend to have a reduced quality of life and it can negatively impact school, social and home environments. Constipation can be exceedingly distressing for children, causing pain, decreased appetite and fecal incontinence. Fecal incontinence can lead to mood concerns and disruptive behaviours and additional parent-child conflict due to the stress of cleaning up accidents and resistance to toilet training.

Causes of Functional Constipation

Functional constipation can be influenced by many different factors including genetic predisposition, decreased dietary fiber consumption, inadequate fluid intake and immobility. 

One of the most common causes of constipation is withholding behaviour. This often results from a previous painful, hard stool leading to fear with future bowel movements. Persistent withholding can lead worsening of the problem. The longer stool sits in the bowel, the more water is absorbed making it harder, drier and in turn more difficult and more painful to pass, continuing the vicious cycle. This and avoiding passing stool can lead to incomplete bowel moments with retention of stool, impaction of stool and decreased sensation indicating the need to have a bowel movement. 

Symptoms of Constipation

The most frequent symptoms reported by children are infrequent and/or painful stools, hard stools, abdominal pain and fecal incontinence. Other symptoms may include bleeding with bowel movement, incomplete stool passage, nausea or vomiting, and decreased appetite. If your child experiences any of these symptoms, please check in with your health care provider to confirm the constipation is functional and not caused by an undiagnosed medical condition.

Some children will report loose watery stool with a history of constipation. This occurs because of a large bolus of stool blocking passage of solids, but watery loose stool can pass around the blockage. This is sometimes called overflow diarrhea. 

Symptoms may be difficult to assess in infants and non-verbal children and can be non-specific. A physical examination and a descriptive history of bowel movements including whether they are toilet trained, frequency of stools and consistency (often based on the Bristol stool chart) can lead the health care provider to the potential reason for constipation.

Management of Constipation

The first step in adequately treating constipation is to achieve a complete bowel clean out of the impacted stool. Increasing water and fiber intake may help resolve some cases of constipation. However, some children may need a laxative polyethylene glycol (PEG) 3350. PEG 3350 is safe and is used most often in children.  PEG 3350 works by pulling more water into the bowel and making stool softer to pass.  It is not a stimulant laxative. If unsuccessful, a rectal enema or suppository may be required.

Overall, multiple strategies are recommended in treating your child’s constipation, besides laxatives: 

• Education: Diary to track the frequency and consistency of bowel movements
• Behavioural: Toilet routine with scheduled toilet sits and rewards for efforts (not success).  Pelvic floor physiotherapy may be an asset. 
• Dietary: Sufficient dietary fibre intake from fruits, vegetables and whole grain fibers. Ensure adequate water intake daily.

Goals of Therapy

The goal is to have toilet training transition into a routine behavioural bowel habit with regular bowel movements occurring around the same time daily. The consistency should be soft (“soft-serve ice cream consistency”), non-painful and satisfactory (i.e. complete relief without retained stool). 

It’s important to recognize that management of your child’s chronic constipation is often a long journey. Even with aggressive treatment, some children still struggle with constipation that can carry into adulthood. Early intervention is important.  If you think your child is constipated, talk to your doctor.   

This post was authored by Allison Rau, Medical Student Class 2022. The post was reviewed by Stephanie Liu, MD, MSc, CCFP, BHSc and Erin Manchuk, BScPharm, BCGP.

References:

1. Vriesman et al. Quality of Life in Children with Functional Constipation: A Systematic Review and Meta-Analysis, Journal of Pediatrics. 2019; 214:141-50.
2. van Mill et al. Controversies in the Management of Function Constipation in Children. Current Gastroenterology Report. 2019;21:23.
3. Tabbers et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of Pediatric Gastroenterology and Nutrition. 2014;58(2):258-274.
4. Neal et al. Constipation. Pediatrics in Review. 2020. 41(8):379-392.