Constipation refers to delay or difficulty in passing stool for a period of at least 1 month in infants and toddlers and a period of 2 months in older children. Stools are harder and sometimes larger than usual and may be painful to pass. Constipation is very common among children. It accounts for up to 5% of children's visits to the doctor. Infants and children are particularly prone to developing constipation at three periods of time. The first period is when cereals and solid food are introduced into the infant's diet, the second period is during toilet training, and the third period is around the start of school.

The frequency and consistency of bowel movements (BMs) vary throughout childhood, and there is no single definition of what is normal. Newborns typically have four or more loose, yellow, seedy stools per day. During the first year, infants have 2 to 4 a day. Breastfed infants typically have more BMs than formula-fed infants and may have one after each breastfeeding. After a month or two, some breastfed infants have BMs less frequently, but the stools remain mushy or loose. After 1 year of age, most children have one or sometimes two soft but formed stools a day. However, some infants and young children typically have BMs only once every 3 to 4 days. Guidelines for identifying constipation in infants and children include no BMs for 2 or 3 more days than usual, hard or painful BMs, large-diameter stools that may clog the toilet, or drops of blood on the outside of the stool.

In infants, signs of effort such as straining and crying before successfully passing a soft stool usually do not indicate constipation. These symptoms are usually caused by failure to relax the pelvic floor muscles during passage of stool and typically resolve spontaneously.

Parents often worry about their child's BMs, but constipation usually has no serious consequences. Some children with constipation regularly complain of abdominal pain, particularly after meals. Occasionally, passing large, hard stools may cause a small tear in the anus (anal fissure). Anal fissures are painful and may result in streaks of bright red blood on the outside of the stool or on toilet paper. Rarely, chronic constipation can contribute to urinary problems such as urinary tract infections and bed wetting.

Causes

Common causes: In 95% of children, constipation results from

• Dietary issues
• Behavioral issues

Constipation that results from dietary or behavioral issues is called functional constipation.

Dietary issues that cause constipation include a diet that is low in fluids and/or fiber (as occurs in fruits, vegetables, and whole grains).

Behavioral issues that may be associated with constipation include stress (as may be felt when a sibling is born), resistance to toilet training, and a desire for control. Also, children may intentionally put off having BMs (called stool withholding) because they have a painful anal fissure or because they do not want to stop playing. Sexual abuse may result in stress or injury that causes children to withhold stool. If children do not move their bowels when the natural urge comes, the rectum eventually stretches to accommodate the stool. When the rectum has stretched, the urge to have a BM lessens, and more and more stool accumulates and hardens. A vicious circle of worsening constipation may result. If the accumulated stool hardens, it sometimes blocks the passage of other stool—a condition called fecal impaction. Looser stool from above the hardened stool may leak around the impaction into the child's underwear. Parents may then think that the child has diarrhea when the actual problem is constipation.

Less common causes: In about 5% of children, constipation results from a physical disorder, drug, or toxin. Disorders may be apparent at birth or develop later. Constipation that results from a disorder, drug, or toxin is called organic constipation.

In newborns and infants, the most common disorder that causes constipation is

• Hirschsprung disease (an inadequate nerve supply to the large intestine—see Birth Defects: Hirschsprung's Disease)

Other causes of organic constipation include

• Birth defects of the anus
• Cystic fibrosis
• Metabolic and electrolyte disorders, such as an abnormally high level of calcium (hypercalcemia) or low level of potassium (hypokalemia)
• Spinal cord problems
• Hormonal disorders, such as an underactive thyroid gland (hypothyroidism)
• Intestinal disorders, such as a cow's milk protein allergy or celiac disease
• Drugs, such as powerful pain relievers called opioids (for example, codeine and morphineSome Trade Names
  MS CONTIN ORAMORPH
  )
• Toxins, such as infant botulism or lead

Children with serious abdominal disorders (such as appendicitis or a blockage in the intestine) often do not have BMs. However, these children typically have other, more prominent symptoms, such as abdominal pain, swelling, and/or vomiting. These symptoms typically lead parents to seek medical care before the number of BMs decreases.

Evaluation

Doctors first try to determine whether constipation results from dietary or behavioral issues (functional) or from a disorder, toxin, or drug (organic).

Warning signs: Certain symptoms are cause for concern and should raise suspicion for an organic cause of constipation:

• No BMs during the first 24 to 48 hours after birth
• Weight loss or poor growth
• Decreased appetite
• Blood in the stools
• Fever
• Vomiting
• Abdominal swelling
• Abdominal pain (in children old enough to communicate this)
• In infants, loss of muscle tone (the infant appears floppy or weak) and reduced ability to suck
• In older children, an involuntary release of urine (urinary incontinence—see Incontinence in Children: Urinary Incontinence in Children), back pain, leg weakness, or problems with walking

When to see a doctor: Children should be evaluated by a doctor right away if they have any warning signs. If no warning signs are present but the child is passing infrequent, hard, or painful BMs, then the doctor should be called. Depending on the child's other symptoms (if any), the doctor may advise trying simple home treatments (see Symptoms in Infants and Children: Treatment) or ask the parents to bring the child for an examination.

What the doctor does: Doctors first ask questions about the child's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the constipation and the tests that may need to be done (see Table 1: Symptoms in Infants and Children: Some Physical Causes and Features of Constipation in Infants and Children).

Doctors determine whether newborns have ever had a BM (the first BM is called meconium). Newborns who have not had a BM within 24 to 48 hours after birth should have a thorough examination to rule out the possibility of Hirschsprung disease, imperforate anus, or other serious disorder.

For infants and older children, doctors ask whether constipation began after a specific event, such as introducing cereal or other solid foods, eating honey, beginning toilet training, or starting school. For all age groups, doctors ask about diet and about disorders, toxins, and drugs that can cause constipation.

For the physical examination, doctors first look at the child overall for signs of illness and measure height and weight to check for signs of delayed growth. Doctors then focus on the abdomen, the anus (including examination of the rectum using a gloved finger), and nerve function (which can affect how the digestive tract functions).

Testing: If the cause appears to be functional, no tests are needed unless children do not respond to treatment. If children do not respond or if doctors suspect that the cause is another disorder, an x-ray of the abdomen is taken, and tests for other disorders are done based on the results of the examination.

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Some Physical Causes and Features of Constipation in Infants and Children Cause Common Features* Tests Birth defects of the anus Abnormal position of the anus Opening of the anus that appears closer than normal to the genitals Measurements to determine the exact location of the anus's opening Anal stenosis (a narrowed anus) Delayed passage of the first BM (called meconium) during the first 24–48 hours of life Explosive and painful BMs A swollen abdomen Abnormal appearance or position of the anus A doctor's examination Blockage of the opening of the anus (imperforate anus, or anal atresia) A swollen abdomen No BMs A blockage of the anus detected during a doctor's examination A doctor's examination done soon after birth Spinal cord problems Meningomyelocele (the most severe form of spina bifida) A raw, red area on the back where the spinal cord protrudes, seen at birth A decrease in reflexes of the legs or in muscle tone Absence of the normal reflex of the anus (a tightening when lightly touched, called anal wink) Plain x-rays of the lower spine MRI of the spine Occult spina bifida (incomplete formation of the bones of the spine) A tuft of hair or dimpling on the skin over the defect, seen at birth MRI of the spine A tethered spinal cord (during fetal development, the spinal cord is stuck at the lower end of the spinal column and cannot move up to its normal position) Problems with walking, pain or weakness in the legs, and back pain Urinary incontinence MRI of the spine A tumor near the tailbone (sacral teratoma) or other spinal cord tumor Back pain, problems with walking, and pain or weakness in the legs Urinary incontinence MRI of the spine Infection of the spine or spinal cord Back pain, problems with walking, and pain or weakness in the legs Fever Urinary incontinence MRI of the spine Hormonal, metabolic, or electrolyte disorders Diabetes insipidus (due to problems with antidiuretic hormone, which helps regulate the amount of water in the body) Excessive thirst and excessive crying that is quieted by giving children water Excessive urination of dilute urine Weight loss and vomiting Urine and blood tests to measure how dilute urine and blood are (osmolality) Blood tests to measure antidiuretic hormone levels Hypercalcemia (an abnormally high calcium level) Nausea and vomiting, loss of appetite, weight loss, muscle weakness, and abdominal pain Excessive thirst and excessive urination Blood tests to measure the calcium level Hypokalemia (an abnormally low potassium level) Muscular weakness Excessive urination and dehydration Not growing as expected (failure to thrive) Possibly use of diuretics or certain antibiotics Blood tests to measure levels of electrolytes Hypothyroidism (an underactive thyroid gland) Poor feeding A slow heart rate In newborns, large soft spots (fontanelles) between the skull bones and slack muscle tone Dry skin, intolerance of cold, fatigue, and jaundice Blood tests to measure thyroid hormone levels Intestinal disorders Cystic fibrosis Delayed passage of the first BM Poor weight gain or failure to thrive Frequent bouts of pneumonia A sweat test Possibly genetic testing to confirm the diagnosis Hirschsprung disease Delayed passage of the first BM A swollen abdomen Green or yellow vomit, indicating that it contains bile A narrowed anus detected during a doctor's examination X-rays of the lower digestive tract after barium is inserted in the rectum (barium enema) Measurement of pressure inside the anus and rectum (manometry) Biopsy of the rectum Allergy to cow's milk protein Vomiting Poor feeding Weight loss, poor growth, or both Blood in stools Stool tests Symptoms that lessen when the formula is changed Possibly endoscopy, colonoscopy, or both Celiac disease Abdominal pain Bloating Weight loss Fatigue Blood tests Endoscopy Irritable bowel syndrome Long-standing (chronic) abdominal pain Diarrhea and constipation that come and go A feeling of incomplete emptying after a BM Evaluation of BM patterns and the timing and characteristics of pain Exclusion of other disorders by history, physical examination, and possibly blood tests, stool tests, imaging, or colonoscopy Pseudo-obstruction (which causes symptoms of a blockage but no blockage is detected) Nausea and vomiting Abdominal pain and a swollen abdomen X-ray of the abdomen Tests to assess how well the bowel functions (bowel motility studies) A tumor in the abdomen Weight loss, night sweats, and fever Abdominal swelling or pain An abdominal mass detected during a doctor's examination MRI Drug side effects Use of drugs with anticholinergic effects (such as antihistamines), antidepressants, chemotherapy drugs, or opioids Use of drugs that can cause constipation A doctor's examination Toxins Infant botulism A sudden reduction in the ability to suck Loss of muscle tone Sometimes consumption of honey before age 12 months A test for botulinum toxinSome Trade Names BOTOX in stool Lead poisoning Usually no symptoms Possibly abdominal pain, fatigue, and irritability Regression in development Blood tests to measure the lead level *Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. BM = bowel movement; MRI = magnetic resonance imaging. Some Physical Causes and Features of Constipation in Infants and Children Cause Common Features* Tests Birth defects of the anus Abnormal position of the anus Opening of the anus that appears closer than normal to the genitals Measurements to determine the exact location of the anus's opening Anal stenosis (a narrowed anus) Delayed passage of the first BM (called meconium) during the first 24–48 hours of life Explosive and painful BMs A swollen abdomen Abnormal appearance or position of the anus A doctor's examination Blockage of the opening of the anus (imperforate anus, or anal atresia) A swollen abdomen No BMs A blockage of the anus detected during a doctor's examination A doctor's examination done soon after birth Spinal cord problems Meningomyelocele (the most severe form of spina bifida) A raw, red area on the back where the spinal cord protrudes, seen at birth A decrease in reflexes of the legs or in muscle tone Absence of the normal reflex of the anus (a tightening when lightly touched, called anal wink) Plain x-rays of the lower spine MRI of the spine Occult spina bifida (incomplete formation of the bones of the spine) A tuft of hair or dimpling on the skin over the defect, seen at birth MRI of the spine A tethered spinal cord (during fetal development, the spinal cord is stuck at the lower end of the spinal column and cannot move up to its normal position) Problems with walking, pain or weakness in the legs, and back pain Urinary incontinence MRI of the spine A tumor near the tailbone (sacral teratoma) or other spinal cord tumor Back pain, problems with walking, and pain or weakness in the legs Urinary incontinence MRI of the spine Infection of the spine or spinal cord Back pain, problems with walking, and pain or weakness in the legs Fever Urinary incontinence MRI of the spine Hormonal, metabolic, or electrolyte disorders Diabetes insipidus (due to problems with antidiuretic hormone, which helps regulate the amount of water in the body) Excessive thirst and excessive crying that is quieted by giving children water Excessive urination of dilute urine Weight loss and vomiting Urine and blood tests to measure how dilute urine and blood are (osmolality) Blood tests to measure antidiuretic hormone levels Hypercalcemia (an abnormally high calcium level) Nausea and vomiting, loss of appetite, weight loss, muscle weakness, and abdominal pain Excessive thirst and excessive urination Blood tests to measure the calcium level Hypokalemia (an abnormally low potassium level) Muscular weakness Excessive urination and dehydration Not growing as expected (failure to thrive) Possibly use of diuretics or certain antibiotics Blood tests to measure levels of electrolytes Hypothyroidism (an underactive thyroid gland) Poor feeding A slow heart rate In newborns, large soft spots (fontanelles) between the skull bones and slack muscle tone Dry skin, intolerance of cold, fatigue, and jaundice Blood tests to measure thyroid hormone levels Intestinal disorders Cystic fibrosis Delayed passage of the first BM Poor weight gain or failure to thrive Frequent bouts of pneumonia A sweat test Possibly genetic testing to confirm the diagnosis Hirschsprung disease Delayed passage of the first BM A swollen abdomen Green or yellow vomit, indicating that it contains bile A narrowed anus detected during a doctor's examination X-rays of the lower digestive tract after barium is inserted in the rectum (barium enema) Measurement of pressure inside the anus and rectum (manometry) Biopsy of the rectum Allergy to cow's milk protein Vomiting Poor feeding Weight loss, poor growth, or both Blood in stools Stool tests Symptoms that lessen when the formula is changed Possibly endoscopy, colonoscopy, or both Celiac disease Abdominal pain Bloating Weight loss Fatigue Blood tests Endoscopy Irritable bowel syndrome Long-standing (chronic) abdominal pain Diarrhea and constipation that come and go A feeling of incomplete emptying after a BM Evaluation of BM patterns and the timing and characteristics of pain Exclusion of other disorders by history, physical examination, and possibly blood tests, stool tests, imaging, or colonoscopy Pseudo-obstruction (which causes symptoms of a blockage but no blockage is detected) Nausea and vomiting Abdominal pain and a swollen abdomen X-ray of the abdomen Tests to assess how well the bowel functions (bowel motility studies) A tumor in the abdomen Weight loss, night sweats, and fever Abdominal swelling or pain An abdominal mass detected during a doctor's examination MRI Drug side effects Use of drugs with anticholinergic effects (such as antihistamines), antidepressants, chemotherapy drugs, or opioids Use of drugs that can cause constipation A doctor's examination Toxins Infant botulism A sudden reduction in the ability to suck Loss of muscle tone Sometimes consumption of honey before age 12 months A test for botulinum toxinSome Trade Names BOTOX in stool Lead poisoning Usually no symptoms Possibly abdominal pain, fatigue, and irritability Regression in development Blood tests to measure the lead level *Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. BM = bowel movement; MRI = magnetic resonance imaging.

Treatment

Treatment depends on the cause. When constipation results from a specific disorder, a drug, or a toxin, that cause is treated or corrected. For functional constipation, measures include

• Changing the diet
• Modifying behavior
• Sometimes using stool softeners or laxatives

Changing the diet: Dietary changes for infants include giving them 1 to 4 ounces (30 to 120 milliliters [mL]) of prune, pear, or apple juice each day. For infants younger than 2 months, 1 teaspoon (5 mL) of light corn syrup can be added to their formula in the morning and evening.

Older infants and children should increase their consumption of fruits, vegetables, and high-fiber cereals and decrease consumption of constipating foods, such as milk and cheese.

Modifying behavior: Behavioral modification can help older children. Measures include

• Encouraging children who are toilet trained to sit on the toilet for 5 to 10 minutes after meals and encouraging them when they make progress (for example, noting progress on a wall chart)
• Giving children who are being toilet trained a break from toilet training until constipation resolves

Sitting on the toilet after a meal can help because eating a meal triggers a reflex to have a BM. Frequently, children ignore the signals from this reflex and put off having a BM. This technique uses the reflex to help retrain the digestive tract, establish a toilet routine, and encourage more regular BMs.

Stool softeners and laxatives: If constipation does not respond to behavioral modification and changes in diet, doctors may recommend certain drugs that help soften stool (stool softeners) and/or increase the spontaneous movement of the digestive tract (laxatives). Such drugs include polyethylene glycolSome Trade Names
TRILYTE
, lactuloseSome Trade Names
CONSTULOSE
, mineral oil, milk of magnesia (magnesium hydroxide), sennaSome Trade Names
SENOKOT
, and bisacodylSome Trade Names
DULCOLAX
. Many of these drugs are now available over the counter. However, doses should be based on the age and body weight of the child as well as the severity of constipation. Thus, parents should consult a doctor regarding the appropriate dose and number of doses per day before using these treatments. The goal of treatment is the passage of one soft stool per day.

If children have a fecal impaction, options include gentle enemas and agents (such as mineral oil or polyethylene glycolSome Trade Names
TRILYTE
) taken by mouth with large amounts of fluid. If these treatments are ineffective, children may need to be hospitalized to have the impaction removed.

Infants do not usually require any of these treatments. Typically, a glycerin suppository is adequate.

To maintain regular BMs, some children may require fiber supplements (such as psylliumSome Trade Names
METAMUCIL
), which may be obtained without a prescription. For these supplements to be effective, children must drink 32 to 64 ounces of water a day.

Key Points

• Usually, constipation is caused by behavioral or dietary issues (functional constipation).
• Children should be evaluated by a doctor if the interval between BMs has been 2 or 3 days more than usual, if their stools are hard or large, if stools cause pain or bleeding, or if children have other symptoms.
• If a newborn does not have a BM within 24 to 48 hours after birth, a thorough evaluation should be done to rule out the presence of Hirschsprung disease or another serious disorder.
• Addition of fiber to the diet or behavioral modification can help when dietary or behavioral issues are the cause.

Last full review/revision February 2013 by Deborah M. Consolini, MD