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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.
Constipation Does Not Simply Mean Infrequent Stools
A child may have constipation even if they pass stool every day. Hard, painful, very large stools or stool withholding can indicate constipation.
Bristol 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:
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.
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?
Urgent Care
- Failure to pass the first stool (meconium) within 48 hours after birth
- Poor weight gain or weight loss
- Persistent vomiting, especially green (bilious) vomiting
- Severe abdominal swelling
- Blood in the stool without an obvious anal fissure
- Fever or a child who appears significantly unwell
- Abnormal position or appearance of the anus
- Weakness of the legs, abnormal reflexes, or spinal abnormalities (dimple, tuft of hair, swelling)
- Constipation that does not improve despite appropriate treatment
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.
FAQs
1. How do I know if my child is constipated?
Constipation does not only mean passing stool infrequently. A child may be constipated if their stools are hard, painful to pass, very large, or if they are withholding stool. Signs can also include tummy pain, bloating, reduced appetite, soiling or withholding behaviours.
2. Is it normal for a child to poop every day but still be constipated?
Yes. A child can pass stool every day and still have constipation if the stool is hard, painful, very large, or associated with stool withholding.
3. What does constipation look like in babies?
Bowel habits vary between babies. Some infants pass stool several times a day, while others may go several days between bowel movements. In breastfed babies, longer intervals can sometimes be normal when the stool remains soft and the baby is feeding and growing well.
4. What causes constipation in children?
Most childhood constipation is functional, meaning there is no serious underlying disease. Common triggers include inadequate fluids or fibre, dietary changes, toilet training difficulties, previous painful bowel movements, stool withholding, avoiding school toilets, reduced physical activity, stress and certain medications.
5. Why is my child soiling their underwear?
Small amounts of stool leakage can occur when softer stool leaks around a larger mass of retained stool. This is called overflow soiling and is usually not intentional.
6. What can I give my child for constipation?
Encourage adequate fluids, gradually increase age-appropriate fibre, establish a relaxed toilet routine and encourage daily physical activity. Do not start suppositories, enemas or laxatives without medical advice, especially in infants.
7. Does my child need laxatives for constipation?
Some children with significant or long-standing constipation may need laxatives. When a large amount of stool has accumulated, treatment may first involve clearing the retained stool, followed by maintenance treatment to keep stools soft and reduce recurrence. This should be guided by a doctor.
8. When should I take my child to a paediatrician for constipation?
A paediatric assessment is important if constipation does not improve despite appropriate treatment or is associated with poor weight gain, weight loss, persistent vomiting, green vomit, severe abdominal swelling, blood in the stool, fever, significant illness or other warning signs.
Urgent medical care is needed for concerning symptoms such as bilious vomiting, severe abdominal swelling, significant illness, or neurological or spinal abnormalities.
Key Takeaways
- Constipation does not simply mean passing stool less often.
- Hard, painful, very large stools or stool withholding can indicate constipation even when a child passes stool every day.
- Most childhood constipation is functional constipation and does not have a serious underlying cause.
- Adequate fluids, gradual increases in fibre, regular toilet routines and physical activity can help.
- Stool withholding can maintain the cycle of painful bowel movements and constipation.
- Soiling is often caused by overflow around retained stool and is usually not intentional.
- Do not start laxatives, suppositories or enemas without medical advice, especially in infants.
- Significant or long-standing constipation may require disimpaction followed by maintenance treatment.
- The treatment goal is soft, painless stools, rather than simply passing stool more frequently.
- Persistent constipation or red-flag symptoms should be assessed by a paediatrician.
Constipation is usually manageable, but recognising stool withholding and treating retained stool early can help prevent ongoing pain, soiling and recurrence.
Need a Paediatric Assessment?
Constipation in Children in Johor Bahru
If your child has hard or painful stools, stool withholding, frequent tummy discomfort, large stools, soiling or constipation that keeps coming back, a paediatric assessment can help identify the cause and guide appropriate treatment.
At Southern Child Specialist Clinic in Johor Bahru, our paediatric team assesses children with constipation, stool withholding, soiling, abdominal discomfort and related bowel problems. The assessment considers your child's bowel habits, stool consistency, diet, fluid intake, toilet routine, growth and any warning signs that may require further investigation.
Parents in Johor Bahru and surrounding areas can contact Southern Child Specialist Clinic to arrange a paediatric consultation for childhood constipation.
Evidence & Guidelines
This article is based on recommendations from:
- NASPGHAN/ESPGHAN Guideline for Functional Constipation in Infants and Children (2014)
- NICE Guideline CG99: Constipation in children and young people
- American Academy of Pediatrics (HealthyChildren.org)
Dr. Derreck Ng Yang Jein
Consultant Paediatrician
Southern Child Specialist Clinic Johor Bahru
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