Constipation in Toddlers

by Dr. Pamela Bandelaria, pediatrician

Having a toddler is one of the most fun, memorable yet challenging moments of your parenting journey. It is a time where your child is very interactive, curious, and energetic. However, as they become more independent and acquire new skills, they may sometimes be frustrated and struggle with their emotions when things don't go their way, more commonly known as the toddler tantrums.  Often when children are hard to soothe, it's because they are experiencing painful symptoms that they cannot express.   One of these symptoms is constipation. In this article, you will find out why constipation occurs, the signs and symptoms of constipation, and how it can be treated.  

When your child was a baby, their bowel patterns were different.   As your baby grows, the gastrointestinal tract matures, and the number of bowel movements per day decreases. Some sources say that children should generally have at least one bowel movement per day or a bowel movement at least three to four times a week. Therefore, it is essential to identify your child's usual bowel pattern so that if it deviates from their typical pattern, you will be aware that something might be wrong or cause you to observe your child more.

More important than the frequency of bowel movement in babies and children is the consistency of the stool. Your child’s poop may come in many shapes, colors, or sizes. However, certain things will trigger a warning signal that there may be a problem. For example, children's stool is usually soft or with a consistency similar to ice cream, or it may be slightly firmer. However, it is not normal for stool to be pellet-shaped or for it to be too watery either. Stools should also not be green or foul-smelling and should not be red or tinged with blood.

What is constipation?

Now that you know what your child's stool should and should not look like and what your child's bowel patterns should be, it is now time to discuss one of the most common complaints of parents, constipation.  Constipation is usually a cause for a doctor's consult because it can be distressing for both the child and the parents. Constipated children can experience extreme discomfort and even pain, so much so that some children can develop a fear of bowel movement because of the difficulty that they experience. Unfortunately, there is no specific definition of constipation, but it is described as the difficulty in passing stool, painful passage of hard stool, or infrequent passage of stool.

Why is my child getting constipated?

Constipation can be a condition in itself, or it can be a symptom of another illness. It can also be caused by other conditions, such as anatomic or congenital diseases, or even be an effect of medications. When constipation has no underlying cause, it is called functional constipation. Functional constipation occurs in around 10-20% of American children.  Functional constipation can be a chronic condition, defined by the American Association of Pediatrics as:

• pooping less than three times a week

• straining while pooping

• the presence of hard stools,

• feeling of incomplete bowel movement or feeling of blockage,

• and the use of manual maneuvers to help get the stool out.

It is also important to look for other symptoms aside from difficulty passing stool that may signify that your child has an underlying condition aside from functional constipation.

Your next question might be, why does functional constipation occur?  There are several reasons why functional constipation can occur. Usually, functional constipation occurs due to a child's withholding of stool. This can disrupt the normal bowel pattern and lead to constipation. In children, this usually occurs with a precipitating event. For example, some children experience pain during a bowel movement, usually caused by a  tear (medically termed an anal fissure) from passing a large stool. This experience will create a negative association with pooping in some children, making them scared to pass a stool.  Another example is when a significant change happens in your child's life - either moving to a new region or your child starting at a new school.     They might not be comfortable pooping in a new environment, disrupting their regular bowel pattern and leading to constipation. Early toilet training can also cause constipation in children. Some children may not feel comfortable or ready for toilet training, so they try to avoid it. This can also lead to constipation.

Sometimes diet can also affect a child's bowel movements. For example, a diet low in fiber which is found in fruits,  vegetables, and whole grains, can make stools hard to pass.  Constipation also may occur in infants when they transition to more solid foods.

How can I tell if my child is constipated?

In addition to the criteria described by the American Academy of Pediatrics, there are also some ways you will be able to tell that your child has constipation.  They may be fussy or irritable and sit uncomfortably or change their body positions frequently. You may also see them arching their backs, clenching their buttocks, or crossing their legs as a sign of withholding. They may isolate themselves or hide. Sometimes they might hold on to objects such as the leg of a table to stop themselves from pooping. When you accompany them to the toilet, you can observe them straining, which can be seen if their face turns red and they clench their fists. Sometimes they might cry or show signs of pain while pooping.  If you see these signs and symptoms, it’s best to check if your child is constipated.

As mentioned previously, functional constipation is usually triggered by an event. For example, it can be triggered when your child starts eating solid food, toilet training, and going to school. During these times, patience and understanding toward your child are of utmost importance.

How can I treat my child's constipation?

In order to treat constipation, it is essential to find the cause of constipation. For example, is your child going through a transition that may cause them to withhold their poop (travel, going to school, starting toilet training, etc.)?Have there been any changes in their diet?  It is also essential to keep a stool diary for your child that keeps track of when they pass stool, the consistency, their diet (fluid/meal intake), and other factors that can affect bowel movement.

• If there are difficulties in toilet training, empathy, patience, and support are essential. You can delay toilet training when your child is experiencing constipation or let them go through it at their own pace. It is vital to give your child the time and space to be comfortable, especially when trying to poop. However, you can try to instruct your child to sit in the toilet after meals, as most children usually poop after meals, and you can reward them if they comply, even if they don't poop. This can establish routines and make pooping a positive experience for them, encouraging them to try again.

• If they have difficulty passing stool, you can help them by assisting their position, which can better let stool pass. For example, lifting and bending your child's hips and legs toward the abdomen can relax the muscles making it easier for stool to pass. If your child is trying, give positive reinforcement or words of encouragement even if they are not successful. Punishing your child may even cause further fear of bowel movement.

• If you see signs of avoidance, talk to your child. For example, sometimes, they might feel uncomfortable or conscious when using the bathroom and be afraid. Reassure them that it is okay to use the bathroom and emphasize that bowel movement is essential and is healthy. It can also help in preparing them for when they transition to school.

• If there have been changes in diet and you suspect that your child's diet contributes to constipation, you can make simple changes by adding more fruits, vegetables, and whole grains.   Increasing fluid intake may also help. It can be quite challenging, especially if your child is a picky eater, but patience and encouragement are critical. Examples of high fiber fruits include apples, peaches, prunes, or pears, and green leafy vegetables.

• If your child has started school and has problems with going to the bathroom out of fear that they may get teased, try to create new bowel habits wherein your child poops before going to school or after school once they get home.

It is important to be caring, reassuring, and encouraging with your child in all these situations. Pooping can be a traumatizing experience for them, especially if they withhold their stool. Giving emotional support and reassuring them that you are there to help will go a long way in lightening their burden.

When should you bring your child to the doctor for constipation?

You should bring your child to the doctor if your child has chronic constipation.   Additionally, it is best that a doctor sees your child if remedies at home do not lead to improvement or alleviation of symptoms. Furthermore, if your child experiences severe abdominal pain, it may be an emergency and must be checked by a doctor immediately. Other signs and symptoms that indicate a more severe condition include weight loss or poor appetite, which can signify other disorders. A doctor must also be called to check on a large distended abdomen accompanied by constipation and vomiting because these are signs of gut obstruction. Another serious symptom is blood in the stool and persistent episodes of hard pellet-like stools. Doctors may prescribe certain medications and laxatives that can help in the smooth passage of stool. Healthcare providers can also create a plan of management in treating your child's constipation. Functional constipation may sometimes be hard to treat and may persist for months and years.  Your child should not be afraid of bowel movements.   Knowing when to seek help is essential so that pooping will not become a traumatizing experience for them.