Constipation: Your Step-By-Step Guide
As parents, keeping your child healthy and comfortable is a top priority, but sometimes they face common issues like constipation that can be uncomfortable and distressing. Constipation in young children is fairly common, and often it’s manageable at home with a few lifestyle adjustments. However, it’s essential to know when to seek help, what questions to ask your healthcare team, and what to expect from treatments. This step-by-step guide will help you understand childhood constipation and when to reach out to your child’s pediatrician for support.
what to know
In young children, constipation usually means having fewer bowel movements than usual, hard stools, or straining to go. Everyone has different patterns, but a change from their regular pattern (i.e. your child used to go every day and now only goes once a week, etc.) can indicate constipation. Your child may also complain of belly pain, or you might notice they’re avoiding the potty or appear uncomfortable.
common causes of constipation:
Constipation in children can result from a combination of physical, dietary, and behavioral factors. Some of the most common causes include:
Diet low in fiber: Fiber helps keep stools soft and easy to pass. Diets low in fruits, vegetables, and whole grains can lead to harder stools.
Not enough fluids: Staying hydrated is essential to soften stools. Kids who drink minimal water or fluids may experience harder stools that are difficult to pass.
Holding it in: Sometimes, children ignore the urge to go to the bathroom, often due to fear of the toilet, pain during a previous bowel movement, or distractions like play. This “holding” can lead to larger, harder stools over time.
Change in routine: Changes like starting daycare, potty training, or stressful life events can sometimes impact a child’s regular bathroom habits.
daily hydration + fiber goals by age:
Staying hydrated and getting enough fiber are essential for preventing constipation and promoting healthy digestion in children. Here are general hydration and fiber guidelines by age, along with examples of fiber-rich foods suitable for each stage.
Infants (6 months to 1 year old): Once infants start solids around 6 months, they can gradually incorporate more fiber into their diet. At this age, infants typically need 2-4 ounces of water per day in addition to breast milk or formula. When introducing fiber, start with small amounts of fruits and vegetables, as too much can be hard on an infant's digestive system. Examples of fiber-rich foods: pureed pears, applesauce, pureed prunes, peas, and small amounts of whole grains like oats.
Toddlers (1-3 years old): Toddlers need about 1 to 4 cups of water per day, alongside milk. A good rule of thumb for fiber intake is to aim for 19 grams of fiber daily. Toddlers are ready for more variety in fiber sources, so you can start introducing more textures and whole foods. Examples of fiber-rich foods: small pieces of apple with the skin, raspberries, half a banana, cooked carrots, sweet potatoes, and whole-grain cereal or oatmeal.
Children (3 years and older): Preschool-aged children and older need approximately 4-5 cups of water daily and about 25 grams of fiber per day. As their diet becomes more varied, you can introduce a range of fiber sources. Examples of fiber-rich foods: oranges, apple slices, berries, broccoli, beans (such as black beans or chickpeas), lentils, whole-wheat pasta, and brown rice.
Ensuring your child has a balanced intake of fiber-rich foods and water helps promote smooth digestion and reduce the likelihood of constipation. Introduce fiber gradually, especially for younger children, as a sudden increase may lead to gas or discomfort. Combining fiber with adequate hydration is crucial, as water helps fiber move smoothly through the digestive tract.
common medications:
Common Medications for Childhood Constipation
When dietary and lifestyle changes aren’t enough to relieve constipation, pediatricians may recommend medications to help soften stool or stimulate bowel movements. Here are some of the most commonly recommended options, along with their forms, typical dosing, and how they work.
Fiber Supplements (e.g., Metamucil, Benefiber): Fiber supplements are often available in powders that can be mixed with liquids, or as chewable tablets. These supplements add bulk to stool, making it easier to pass. For young children, pediatricians may suggest adding a small amount of fiber powder to water or juice, usually starting with a low dose and gradually increasing. For example, half a teaspoon mixed with water or juice once daily can be a starting dose for toddlers, but parents should confirm the specific dose with their pediatrician. It’s essential to give extra water with fiber supplements, as fiber requires fluid to work effectively.
Polyethylene Glycol (PEG 3350) (e.g., MiraLAX): MiraLAX is a commonly recommended over-the-counter laxative for children with constipation. It usually comes as a tasteless powder that can be dissolved in any liquid, making it easy for kids to take. MiraLAX works by drawing water into the colon, which softens the stool and makes it easier to pass. Pediatricians often start with a low dose, such as ½ to 1 capful per day, adjusting as needed based on the child’s response. MiraLAX is typically well-tolerated, but as with any medication, parents should follow their pediatrician's guidance on the exact dose.
Lactulose: Lactulose is a prescription liquid laxative that works as an osmotic agent, drawing water into the bowel to soften the stool. It can be given as a liquid mixed with water or juice, and it has a sweet taste that most kids find acceptable. The typical dose ranges from 5 to 10 milliliters (mL) once or twice daily, depending on the child’s age and severity of constipation. Lactulose is generally safe for long-term use, but parents should be aware that it may cause gas or bloating in some children.
Senna (e.g., Ex-Lax): Senna is a stimulant laxative that works by directly stimulating the intestines to encourage bowel movements. It’s available in various forms, including chewable tablets and liquid, making it easy for children to take. Pediatricians may suggest Ex-Lax for short-term relief, especially if other options haven’t worked. Dosing is typically weight-based and starts with a low dose (for example, half a chewable tablet for younger children), as senna can cause cramping if overused. It’s best used for short-term relief rather than as a long-term solution, so parents should only use it as directed by their pediatrician.
Glycerin Suppositories: Glycerin suppositories are small, waxy inserts that are placed into the rectum. They work by drawing water into the stool and stimulating the rectum to encourage a bowel movement. Suppositories are often recommended for children who need quick relief from hard or impacted stools. Pediatric versions are available in smaller sizes for easier use, and they are generally given once as needed. They are effective within about 15-60 minutes, making them ideal for urgent relief. Parents should discuss with their pediatrician if a suppository is appropriate and how often it should be used, as they are usually best for occasional, not daily, use.
Each of these medications works differently, and your child’s pediatrician can help guide you on which is best based on your child’s age, symptoms, and response to previous treatments. Remember to always follow dosing instructions and consult with the pediatrician before starting or changing any medication.
what to ask your care team
If your child experiences constipation frequently, here are a few questions that you can ask your care team:
How often should my child be having bowel movements and what should they look like? Understanding what’s typical for your child’s age can help you gauge what’s normal versus what might be constipation.
Could diet changes help? Discussing dietary improvements can sometimes be the simplest and most effective approach. See above for hydration and fiber ideas by age.
When should I use medication and what are the goals of treatment? Your healthcare provider can recommend safe products for your child’s age, if necessary, and advise on appropriate use. Make sure to have goals for use - medication is a valuable tool in our toolbox, but you should know: what your goals are (how often should they be stooling, what should it look like, etc.), when you can wean off of medication, and what side effects, if any, might you expect.
Are there any underlying conditions to consider? Rarely, constipation can be a symptom of other health conditions that may need further investigation. Here are a few conditions that can lead to constipation in children:
Celiac Disease: This is an autoimmune condition where the body cannot tolerate gluten, a protein found in wheat, barley, and rye. In children with celiac disease, consuming gluten can lead to intestinal damage, which affects nutrient absorption and can cause gastrointestinal symptoms, including chronic constipation. Other symptoms may include poor growth, stomach pain, bloating, and diarrhea.
Hypothyroidism: An underactive thyroid gland, or hypothyroidism, means the body isn’t producing enough thyroid hormone, which plays a crucial role in regulating metabolism. In children, low levels of this hormone can slow down digestion, leading to constipation. Other symptoms of hypothyroidism may include fatigue, dry skin, cold intolerance, and poor growth.
Hirschsprung’s Disease: This rare condition is present at birth and occurs when nerves in a part of the intestines are missing. Without these nerve cells, the affected portion of the intestine can’t relax and allow stool to pass through, causing a blockage. This results in severe constipation or an inability to pass stool, often noticed shortly after birth. Symptoms include bloating, vomiting, and, in severe cases, failure to thrive. Treatment for Hirschsprung’s disease typically involves surgery to remove the affected section of the intestine.
Neurological Conditions: Conditions like cerebral palsy or spina bifida can affect the muscles and nerves involved in digestion. In children with these conditions, constipation may result from difficulty with muscle coordination and control, making it challenging to pass stool. Additionally, neurodiverse kids may face sensory challenges with using the bathroom, feeling stool, or dealing with painful stools.
What other interventions can help? Research has shown that pelvic floor physical therapy may be beneficial for children experiencing chronic constipation, especially when related to pelvic floor dysfunction. The pelvic floor muscles play a crucial role in bowel movements, and sometimes children develop habits, like holding in stool, that cause these muscles to tighten or become uncoordinated. Pelvic floor PT focuses on strengthening and coordinating the muscles involved in bowel movements. It can be particularly beneficial for children who have difficulty coordinating the muscles needed to pass stool, or who experience constipation related to pelvic floor dysfunction. Evidence suggests that pelvic floor PT can improve bowel habits, reduce straining, and address any underlying muscle issues that may contribute to constipation. Pelvic floor PT can teach children to relax and properly engage these muscles, making bowel movements easier and more comfortable. Pediatric pelvic floor therapists use gentle, age-appropriate exercises, often through play-based techniques, to help children learn control over these muscles. If your child experiences ongoing constipation, you can ask your pediatrician whether pelvic floor PT might be a suitable addition to their treatment. It’s a valuable option that could provide long-term relief without relying solely on medication.
At CHOP, we have this amazing multi-disciplinary Integrative Health program for kids with constipation that includes PT, nutrition, acupuncture, and biofeedback therapies. Be sure to talk with your care team about these types of options to see if they might be a good fit for your child.
what tests might be recommended
In most cases, constipation doesn’t require extensive testing. However, if it persists despite at-home measures or if your child has additional symptoms like weight loss, vomiting, or severe pain, your pediatrician might suggest tests. Possible tests could include:
Physical exam: Often, a gentle abdominal exam will help identify any immediate concerns.
X-rays: An abdominal X-ray can provide a better look at the stool in the intestines and help rule out other causes of pain.
Blood tests: If there’s a concern about an underlying issue, blood tests might be done to rule out other health conditions. We may check for things like Celiac disease, thyroid conditions, etc.
what to do
Most constipation treatments focus on diet, hydration, and creating a regular routine. Here are some treatments your healthcare provider might recommend:
Increasing fiber intake: Fiber-rich foods like fruits (pears, apples, berries), vegetables, whole grains, and beans can improve bowel movements. Avoid giving your child foods that might contribute to constipation, like excessive dairy or highly processed foods.
Encouraging more water: Hydration is key. Young children don’t always recognize when they’re thirsty, so regular sips of water throughout the day can make a difference.
Regular bathroom routine: Set regular times, like after meals, for your child to try using the bathroom. This routine can help them become more comfortable and reduce the habit of holding it in.
Exercise and movement: Physical activity helps stimulate the digestive system, so keep your child active with age-appropriate play.
Stool softeners or laxatives: Sometimes, your healthcare provider may suggest a gentle stool softener or laxative. Never use these without your pediatrician’s guidance.
when to see your doctor
While constipation can often be managed at home, there are times when medical guidance is important:
If constipation lasts more than two weeks without improvement.
If your child is consistently in pain, especially if it’s preventing them from eating or playing.
If there’s blood in the stool.
If constipation is accompanied by symptoms like vomiting, unexplained weight loss, or fever.
If your child experiences recurrent constipation despite lifestyle changes.
Constipation can feel uncomfortable and stressful for your child, so reassurance is key. Encourage open communication and let them know that it’s okay to talk about their bathroom needs. Help them understand that their body works in its own way, and sometimes a little help is needed. With patience and support, most children recover from constipation without lasting issues.
Remember, every case is unique, so trust your instincts and seek care whenever you feel it’s necessary.