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Understanding Constipation
Constipation is one of the most common complaints in childhood, affecting about 30% of children. In 95% of cases, no "organic" cause can be identified, meaning there are no measurable, biological changes or structural changes. This leaves many families struggling to find answers and effective treatments.
When constipation goes untreated, physical and emotional complications can arise. Physically, children may develop hemorrhoids, anal fissures, rectal prolapse and encopresis (stool leakage or incontinence). Emotionally, children can experience anxiety, poor school performance and isolation. Without adequate treatment, children can go on to develop chronic digestive symptoms that last into adulthood.
In this comprehensive guide, I will break down the presentation of constipation, how it develops, common causes, diagnostic testing, treatment options and practical tips for parents.
Presentation
Constipation is characterized by infrequent and hard stools that can cause pain and require straining to pass. Some commons signs and symptoms of constipation are:
Hard, pellet-like stools
Large stool (thick diameter that can clog toilet)
Discomfort or pain with bowel movements
Taking or taking a long time to pass stool
Blood on toilet paper when wiping
Abdominal pain
Nausea
Loss of appetite
Withholding behaviors and anxiety
Stool leakage
Urine leakage
Pathophysiology of Constipation
Normal Bowel Function
In a healthy digestive tract, food is digested and nutrients are absorbed throughout the small intestine. Once at the large intestine, the undigested food and waste material solidifies to form stool. As the stool reaches the rectum, the pressure causes the sensation and urge to have a bowel movement.
How Constipation Progresses
When stool becomes small and hard, having a bowel movement can be painful and require straining. Due to this discomfort, kids can start withholding, trying to avoid this stressful and painful process. As more stool accumulates over time, the rectum stretches out, reducing urge and causing stool to back up in the colon. This backup can lead to impaction, when stool becomes drier, larger and ultimately more challenging to pass, resulting in stomach pain, loss of appetite and abdominal distention or bloating. In some cases, only soft and diarrhea-like stool can pass around the impacted stool, creating the illusion of diarrhea instead of constipation.
Common Causes of Childhood Constipation
There are a handful of reasons why constipation can occur in children. While sometimes a single cause can be identified, it's not uncommon for there to be multiple causes.
Dietary Factors
Among the common contributors to childhood constipation are dietary habits, and fortunately, dietary adjustments can often be quite effective. Although making dietary changes can be simple, it isn't always easy.
Low Dietary Fiber: Fiber creates the bulk of stool, which presses on the wall of the colons and helps stimulate bowel movements. Without adequate fiber, stools can become hard and difficult to pass.
Poor Hydration: Adequate water intake is crucial for keeping stools soft and facilitating their passage through the intestines.
Lifestyle Factors
Our bodies crave routine, so external factors that disrupt routine can cause constipation to develop. This can happen even if there are no concerns with diet or water.
Poor Toilet Habits: It's important to give your child time to sit on the toilet, and ideally at regular intervals. Without predictability, withholding can occur as kids may not initiate going to the bathroom.
Stress & Trauma: Major life changes, such as a big move or a new sibling, can result in toilet training regression and withholding behaviors due to new stress and anxiety.
Digestive Disorders
There are several ways in which digestion can go wrong. This can be congenital (something your child is born with) or can develop over time.
Food Sensitivities: There are several reasons food sensitivities can occur, such as missing enzymes (lactose intolerance) or immune reactions (gluten sensitivity). Food sensitivities can also be temporary, when they arise from dysbiosis.
Intestinal Dysbiosis (Microbiome Imbalance): The microbiome plays a critical role in digestion, immune function and gut integrity. An imbalance causes a myriad of downstream effects, ultimately affecting bowel function. Dysbiosis can result from dietary and lifestyle factors, present after infections or result from medication use.
IMO (Intestinal Methanogen Overgrowth): This is a specific type of dysbiosis, similar to SIBO, in which there is an overgrowth of methane-producing bacteria. Methane gas, in excess, causes constipation
H. Pylori: This is a specific bacteria that lives in the stomach. It decreases stomach acid, which negatively impacts digestion and can lead to intestinal dysbiosis.
Celiac Disease: This is an autoimmune condition in which gluten causes damage to the small intestine. While this typically presents with diarrhea and weight loss, constipation can occur as well.
Other Causes
In very young children, constipation may be caused by structural abnormalities or neurological conditions, and in though less common, may also be caused by conditions like hypothyroidism and diabetes.
Diagnosing the Root Cause of Constipation
As parent's, you can often determine if your child is constipated by tracking how frequently they have a bowel movement, how long it takes each time, and asking about discomfort or pain. In some cases, however, a child may appear to have regular bowel movements, though have symptoms like tummy aches and poor appetite.
A pediatrician can help with the diagnosis when symptoms are less clear. While the diagnosis of constipation may come simply through a thorough history and physical exam, identifying the root cause can sometimes require some additional testing.
Here are some of the most common tests used:
Comprehensive Stool Analysis (CSA)
This test details the composition of the microbiome, including the "good" bacteria we expect and the presence of pathogenic bacteria and viruses (organisms that cause disease), H. pylori, Candida and parasites. It also provides additional information about digestive enzymes, immune function and inflammation. This is typically a great starting point for many digestive concerns in children, as it provides very comprehensive results.
IMO Breath Testing
Breath testing involves drinking a solution of lactulose (a carbohydrate/sugar solution) and then measuring how much methane gas is produced. IMO is diagnosed when methane is elevated. Although a CSA cannot make this diagnosis, it is a great tool to use with positive breath tests to create a more individualized treatment plan.
Food Sensitivity Testing
This helps determine potential food sensitivities, though it is always recommended to review these results with a healthcare professional, as positive results do not always mean there is a true sensitivity! For example, when there is gut inflammation or abnormal immune function, food sensitivity testing may be falsely positive.
Treatments and Management
Dietary Adjustments
Fiber & Water: The best sources of fiber are vegetables, fruits, legumes, whole grains, nuts and seeds. The exact requirements for fiber and water vary by age and individuals needs. Generally:
Ages 1-3: 19 grams fiber, 4 cups water (8 oz)
Ages 4-8: 25 grams fiber, 5-6 cups water
Older kids: 30 grams fiber, 7-8+ cups water
Prune (Fruit) Juice: Fruit juices have sugars that encourage regular bowel movements. A half cup (4 oz) one to two times a day can help keep stools soft and regular.
Elimination/Challenge Diet: This is the best way to identify food sensitivities, and can be done with or without testing. It involves eliminating suspected trigger foods for 4+ weeks, then reintroducing one at a time, monitoring for adverse reactions. Food sensitivity can assist in guiding elimination diets.
Lifestyle Changes
Bathroom Routine: Establishing a consistent bathroom routine can help with bowel regularity. This includes setting aside specific times for your child to try using the bathroom and allowing them ample time to sit comfortably.
Stress Management: This may take the form of therapy, mindfulness and meditation practices or natural therapies to alleviate anxiety and stress. In more severe cases, medications can also be considered.
Natural Remedies
There are many natural remedies that can be used to treat constipation, and you should always discuss with your doctor prior to adding in any new therapies, even if supplements or over-the-counter. Here are some of the most common supplements used:
Magnesium: Magnesium (oxide, hydroxide, citrate) acts as an osmotic laxative, pulling water into the digestive tract to soften stool. This is a great tool to keep stools soft and regular, though requires increased hydration as well.
Fiber Supplement: Supplemental fiber can be helpful when dietary fiber isn't enough. This can be in the form of a powder or gummy. However, not all fiber supplements are created equal! Psyllium husk is the most common form found in grocery stores, though this can often cause worsening digestive upset. Other examples are acacia, partially-hydrolyzed guar gum, inulin, etc.
Glycerin Suppositories: In severe cases, rectal glycerin suppositories can provide immediate relief. It is important that these not be used more than once a day, and to seek professional help if more is needed.
Disease Specific Treatment
Celiac Disease: Requires the complete elimination of gluten from diet.
Food Sensitivities: Remove offending foods either temporarily or permanently. This should be determined with the help of a trained professional. The goal is to alleviate symptoms, while allowing children to eat the most diverse diet possible.
Dysbiosis (including H. pylori and IMO): There is no "one size fits all." Treatment plans are individualized and generally involve dietary changes, gut-supportive therapies, and antimicrobials. These can include prescription antibiotics or herbal remedies, depending on the specific condition.
Practical Tips for Parents
As a parent, there are several effective strategies you can use to support your child's digestive health and manage constipation. Establishing a consistent routine helps in developing good habits that promote regular bowel movements.
Encourage Healthy Eating: Provide a variety of colorful vegetables and fruits to your child. Reintroduce foods that they might initially refuse, as taste preferences can change frequently during childhood. Persistence with healthy options can lead to better acceptance over time.
Promote Adequate Hydration: Ensure that water is readily available throughout the day. Children, like adults, can often forget to drink enough water, so having it accessible and offering reminders can help maintain proper hydration.
Establish a Bathroom Routine: Create a regular schedule for bathroom use, especially in the morning, after meals, and before bed. Allow ample time for your child to sit comfortably without feeling rushed, which can support relaxation and encourage regular bowel movements.
When to Seek Professional Help
If constipation persists despite home remedies and dietary adjustments, it’s important to consult a doctor. A healthcare professional can diagnose potential underlying causes, order necessary tests, and develop a treatment plan to address your child's specific needs.
Also seek medical attention if you notice any of the following: blood in the stool, refusal to eat, weight loss, severe abdominal pain, constipation with inability to pass gas, or no bowel movements for 3-5 or more days. Addressing these symptoms promptly ensures that any serious conditions are identified and treated effectively.
If your child is struggling with constipation and you're seeking a comprehensive, holistic approach, I’m here to help. As a naturopathic pediatrician with extensive experience in treating childhood constipation, I offer personalized care to address the root causes and develop effective treatment plans for your child's unique needs.
Don’t let constipation disrupt your child’s well-being any longer—learn more about working together and take the first step towards a healthier, happier digestive system for your child.
Disclaimer
The information provided in this blog and throughout the website is intended for educational purposes only and should not be considered, or used as a substitute for, medical advice. The content is not meant to diagnose, treat, or cure any medical condition. This blog does not constitute the practice of any medical, nursing or other professional health care advice, diagnosis or treatment. Always consult with a qualified healthcare provider before making any changes to your health regimen or starting new treatments, and never disregard professional medical advice or delay seeking care because of something that you have read on this blog, website or in any linked materials. Your individual needs and circumstances should be evaluated by a medical professional to ensure safe and appropriate care. If you are experiencing a medical emergency, please call 911 or call for emergency medical help on the nearest telephone immediately.
References
HealthyChildren.org. “Constipation in Children.” Accessed August 14, 2024. https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Constipation.aspx?gad_source=1&gclid=Cj0KCQjwq_G1BhCSARIsACc7NxoO8nf_uW_lyKOd0zQzY7n6kvh5qrNgmHEWi_ejGCl6gaTv_G4FqNAaAtdxEALw_wcB
Mulhem, Elie, Faiza Khondoker, and Sanjiv Kandiah. “Constipation in Children and Adolescents: Evaluation and Treatment.” American Family Physician 105, no. 5 (May 2022): 469–78.
National Institute of Diabetes and Digestive and Kidney Diseases. “Constipation in Children - NIDDK.” Accessed August 14, 2024. https://www.niddk.nih.gov/health-information/digestive-diseases/constipation-children.
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