Constipation a condition of hard, infrequent, slow moving or compacted stools, is a fairly common occurrence throughout life, causing discomfort, pain, misery and anxiety for children (and their parents).
There are two types of constipation: Idiopathic constipation (unknown cause, but possible causes listed below), where children become constipated for no known reason. If this persists it will be called chronic idiopathic constipation. Secondly, constipation can be due to underlying disease or condition (but this is not common).
Every child is different and “normal” can vary quite a bit as bowel habits are dependent on a child’s age and what they eat. In general, constipation is defined as having 3 or less bowel movements per week and / or having stools that are hard or difficult to pass.
Infants pass soft stools up to four times per day in the first couple of months and then as little as twice per week from the first year of life. From the age of 2 most children will have two formed bowel movements per day and from 4 years onwards, toddlers normally have similar bowel movement patterns to adults, going once a day (but ranging from 3 times per day to three times per week). The Bristol Stool Chart is a great help to identify the type of bowel movement your child is having.
In general breastfed babies tend to have softer, yellower and more frequent bowel movements when compared to formula-fed infants, as breast milk is easier to digest with its perfect nutrient balance. Some cows milk or soya milk formula milks cause harder bowel movements and where others e.g. hydrolysed milk proteins can lead to softer motions.
When constipation is severe it can cause impaction (a very large stool being stuck in the rectum), causing soft or liquid stools to leak through; this is referred to as soiling, mostly affecting toddlers and older children. If this happens, it is best to take your child to see a Paediatric Gastroenterologist.
Constipation is mostly caused due to a combination of factors:
• Fever, dehydration and immobility as a result of an infection or illness can all cause dry, hardened stools.
• Dehydration, due to low fluid intakes can also lead to constipation.
Inactivity, mostly due to a sedentary lifestyle will cause constipation.
• Formula milk is often more difficult to digest, leading to fewer bowel movements that can be thicker in consistency and often have a greenish colour.
• Another reason is that formula fed babies are not able to drink more than the amount offered to them, which can lead to slight dehydration.
• Weaning difficulties are one of the most common causes of constipation. Inadequate dietary fibre, increased milk intake, low fluid intake, over feeding and fussy eating can all trigger constipation.
• Delayed or inappropriate toilet training, bad positioning whilst on the toilet and changes in daily routines will also contribute to constipation.
When pain is experienced with passing large or hard stools, this can lead to a pattern of withholding. Passing large or hard stools can also cause a painful anal fissure (a small tear in the lining of the anal canal); this is very common in infants and toddlers, especially between 6 – 24 months and in turn can lead to a negative cycle of withholding stools to avoid further pain.
Some children avoid passing stools (withholding) in an attempt to control their environment; this leads to harder stools that hurt when passed. Stressors are usually a new sibling, starting at a new school, moving house or unfamiliar bathrooms, as emotional upsets and anxiety can all affect the digestive system. Food allergies or intolerances can also cause constipation.
Lastly a family history of bowel related problems, where parents or siblings are constipated can increase the likelihood of developing constipation.
Symptoms and signs of constipation include;
• Irregular and infrequent bowel movements
• Foul smelling wind and stools
• Abdominal pain and discomfort
• Alternating stool textures (some hard and others soft)
• Straining when passing a bowel movement
• Decreased appetite
• Lack of energy, grumpy or irritable
• Blood on toilet paper (can be an indication of an anal fissure)
How to prevent and / or treat constipation
If constipation is recognised early, simple interventions i.e. dietary changes may be adequate and effective. But in some cases a combination of nutritional, medical and behavioural interventions will be required.
It is vital to implement and encourage a well-balanced varied diet early on to optimise bowel function and establish good habits. Regular meals along with planned snacks will provide a steady flow of nutrients to your growing child.
Fibre promotes the growth of healthy bacteria in the colon, which in turn can assist in preventing constipation. Sufficient amounts of fibre can be consumed by including:
• A variety of fruits and vegetables (pureed or chopped depending on your child’s age and ability to chew)
• Best fruits for preventing and treating constipation in babies are; P-letter fruits - pears, prunes, plums and peaches. Apples, apricots, raspberries, strawberries and grapes are great too. Prune or pear juices are also great for dealing with constipation.
• Beans, pulses and lentils are also very good sources of fibre.
• Cereals and grains (white and wholegrain varieties as appropriate for age and weaning stage)
Keep in mind that whole grains, lentils, beans and pulses may fill your child up before they have eaten enough other foods, thus take care not to serve too large portions.
A sudden increase in fibre intake can cause abdominal discomfort, bloating and wind, so rather aim to gradually increase the fibre content of your child’s diet.
If your baby or toddler is a fussy eater, you should take extra care to ensure adequate fibre intake is achieved. Never force your child to eat, if they do not want to. Forcing them to eat can turn mealtimes into a battle and become a source of frustration, seek help form a Dietitian if needed.
Probiotic supplements can be used for both infants and toddlers to improve the friendly bacteria in the colon. Speak to your Dietitian or health care professional about suitable products.
Hydration is another key point for preventing and treating constipation, as water makes up a large part of stools. A lack of water in the diet will cause hard stools. Exclusively breastfed babies are less likely to be dehydrated as they regulate how much they want to drink and when.
Formula-fed babies on the other hand are only able to drink the amount offered to them, even though they would like to drink (or need to drink) more. Aim to always make an extra 30 – 60 ml (1 – 2oz) of formula milk or offer additional water between their regular milk feeds. Remember that formula milk should always be made to the manufacturer’s directions and not diluted.
For older infants and toddlers aim to offer 6 – 8 drinks per day, containing 100 – 120ml of fluid each. These can be offered with each meal and one in between meals or with a snack. Remember more fluid will be required when your child is more active, during hot weather or when your child is taking laxatives.
Although water, diluted juice or age appropriate milk will all count towards the daily fluid intake, plain water remains the best option. Smoothies are a great way to combine fluid and fibre intake, especially for children that are not too keen at drinking fluids on the whole.
Take note that excessive milk intake will lead to a decreased consumption of other foods (including fibre) which can increase the risk of constipation. Aim to limit milk-based drinks to 3 per day.
Encourage physical activity in toddlers and allow infants to have some “tummy time” on a play mat, to encourage movement. Alternatively gently massaging your baby’s tummy or moving their legs in a bicycle motion may help to stimulate their bowel movements.
Toilet training is an important milestone in a child’s development. Ensuring the right environment, providing motivation and encouragement as well as teaching the correct position for passing a stool are all helpful to establish a positive toilet routine and habit.
Toilet time should be between 5 – 10 minutes and is best to be after a meal e.g. breakfast, making sure your child is not rushed and comfortable. Children’s toilet seats or footstools can provide additional support. If your child is afraid to go to the bathroom, distractions such as reading a book, iPad games or blowing bubbles can help.
A laxative may be prescribed if the constipation persists for more than a couple of days, even after the necessary changes in your child’s diet have been implemented. Laxatives should always be prescribed by a medical professional and the dose depends on your child’s age, previous treatments and the severity of the constipation. Once your child is taking laxatives, regular review by a medical professional is required, as the dose and type of laxative should gradually be adjusted as needed.
It is important to not abruptly stop giving the laxatives to your child once their bowels have returned back to normal, as this might cause the constipation to return. Always follow your medical professional’s advice.
Just a note on loose bowel movements; these should not be mistaken for diarrhoea; they are only looser than normal but not more frequent. Loose bowel movements are often diet related; too much fresh or dried fruit, high sugar consumption, rich (spicy, creamy or fried) foods and sometimes even following a course of antibiotics.
Diarrhoea is loose bowel movements occurring more than four times per day.
In summary a happy and healthy bowel will:
• Pass a stool approximately half an hour after a meal (especially breakfast), bearing in mind that this can vary from child to child.
• Be able to hold on for a short while, allowing your toddler time to get to the toilet.
• Move stools within about one minute from sitting down on the toilet, without any pain, excessive straining, struggling or blood. Brief occasional straining is perfectly normal and should not cause concern.
• Completely empty with each movement, without the need to go back to the toilet soon after, to pass more.
If you think your baby or child is constipated, do not be afraid to seek help – the sooner help is provided, the sooner your little one will be back to him/herself.
About the Author
Bianca is a Specialist Paediatric Dietitian offering expert advice and guidance to children and their families with a friendly yet professional approach. After graduating from the University of the Free State she started her career in South-Africa.
Since relocating to the United Kingdom she’s worked at various NHS hospitals and health centres across the country. She is very passionate about helping infants, children of all ages and families develop a healthy attitude towards food whilst meeting their nutritional requirements to sustain optimal growth and development.
Currently practicing in the private sector, her main interests are prenatal nutrition, weaning and feeding difficulties, gastroenterology, allergies and intolerances, poor weight gain and weight control.
In addition to private consultations, Bianca does consultancy work and she is a spokesperson for Bupa on nutrition related topics. She also writes peer reviews and articles for various publications.