Constipation in Children

Constipation is one of the most common digestive problems in babies and children. It does not only mean that a child passes stool infrequently. A child may have constipation even if they pass stool every day, if the stool is hard, painful to pass, very large, or if the child is holding it in.

Bowel habits vary with age. Some infants pass stool several times a day, while others may go several days between bowel movements. In breastfed babies, longer intervals between stools can sometimes be normal if the stool is soft and the baby is feeding and growing well.

Birstol stool chart Type 1 and Type 2 stools (hard pellets or a hard lumpy sausage) usually indicate constipation, as the stool has stayed in the bowel too long, become dry and hard, and may cause pain, straining, or stool withholding 

Common Signs and Symptoms

A child with constipation may have:

• Hard, dry, or pellet-like stools
• Pain or straining when passing stool
• Fewer bowel movements than usual for that child
• Very large stools that may block the toilet
• Tummy pain, bloating, or excessive gas
• Reduced appetite
• Withholding behaviour (crossing the legs, standing stiffly, hiding, becoming restless, or refusing to sit on the toilet)
• Small amounts of stool leakage or soiling in the underwear
• Relief of discomfort after passing stool

Stool leakage is often due to softer stool leaking around a larger mass of retained stool (overflow soiling) and is usually not intentional.

What Causes Constipation?

According to international guidelines, most childhood constipation is functional constipation, meaning there is no serious underlying disease.

Common Causes

• Not drinking enough fluids
• Low fibre intake
• Changes in diet (for example, starting solids or increased processed foods)
• Toilet training difficulties
• Previous painful bowel movement leading to stool withholding
• Avoiding school toilets
• Reduced physical activity
• Stress, travel, starting school, or changes at home
• Certain medications (such as some iron supplements, antacids, opioids, or anticonvulsants)

Less Common Medical Causes

A doctor may consider other causes when constipation is severe, starts very early in life, or is associated with red flags. These include:

• Hirschsprung disease
• Hypothyroidism
• Coeliac disease
• Neurological or spinal cord disorders
• Metabolic disorders (for example, high calcium levels)
• Anatomical abnormalities of the anus or rectum

What Parents Can Do at Home

1. Encourage Adequate Fluids

Offer water regularly throughout the day. Milk intake should be appropriate for age; excessive milk intake may contribute to constipation in some children.

2. Increase Fibre Gradually

Offer age-appropriate (For children & infants who have already started on weaning diet):

• Fruits (papaya, pear, kiwi, prunes, apples with skin)
• Vegetables
• Wholegrain bread, oats, and brown rice
• Beans and lentils

Increase fibre gradually and ensure adequate fluid intake.

3. Establish a Toilet Routine

• Encourage sitting on the toilet for 5-10 minutes after meals, especially after breakfast and dinner.
• Use a footstool so the knees are slightly higher than the hips.
• Keep the environment relaxed and unhurried.

4. Encourage Physical Activity

Daily active play and exercise help stimulate bowel movement.

5. Avoid Punishment

Do not scold, shame, or pressure a child about stool accidents or toilet refusal.

Should Laxatives Be Used?

Do not start suppositories, enemas, or laxatives without medical advice, especially in infants.

For significant or long-standing constipation, international guidelines recommend a two-step approach:

1. Disimpaction (clearing the accumulated stool)
   If a large amount of hard stool has built up, the first step is to clear the retained stool, usually with an appropriate laxative regimen.
2. Maintenance treatment
   After the bowel is cleared, maintenance laxatives may be needed to keep stools soft and comfortable, allowing normal bowel habits to be re-established and reducing recurrence.

The goal is soft, painless stools—not simply passing stool more frequently.

When Should Your Child See a Paediatrician?

What Happens During a Consultation?

The paediatrician will assess how long the constipation has been present, stool frequency and consistency, pain or straining, withholding behaviour, soiling, diet, fluid intake and toilet habits.

Most childhood constipation can be assessed clinically. Further tests or investigations are only needed when the history or examination suggests an underlying condition may be present.