Division of Pediatric Gastroenterology and Nutrition
Constipation
Information for families
What is constipation?
Constipation is infrequent and difficult passage of stool. Chronic or ongoing constipation is a
common problem for children. If a child repeatedly resists the urge to defecate (pass stool or
“poop”) and withholds stool in the rectum, a large mass of stool may collect in the rectum. The
frequency of bowel movements among normal healthy children varies greatly. The stool of
constipated children may be very hard, but oddly, may be soft.
Bowel habits vary widely in healthy individuals. The main goal is a soft, easy to pass stool.
What controls defecation (passing stool
or “pooping”?
Defecation is a complex process dependent
upon the successful interaction of learned and
involuntary behavior. The rectum, the lowest
part of the colon, collects and solidifies stool
as it is formed. The fecal material is retained
in the rectum by two muscles, the internal and
external anal sphincters. The external
sphincter is the muscle you can voluntarily
squeeze shut when trying not to defecate.
Under normal conditions both sphincters are
closed, but when stool enters the rectum and
places pressure on the nerves in the colon
wall, the internal sphincter relaxes
automatically. Stool also presses on the
external sphincter, creating the urge to have a
bowel movement. When it is convenient and
the child wants to poop in the toilet, both
sphincters relax and stool is pushed out by
other muscles. If a child does not wish to
defecate, he/she can tighten the external
sphincter and withhold the stool.
How does chronic constipation and
fecal soiling develop?
Retained stool in the rectum and colon
becomes less easy to pass as it becomes large
or dry. The child may be unable or unwilling
to pass the stool due to discomfort associated
with passage. The rectal muscles and the
external sphincter become fatigued with the
effort of retaining stool and in time relax.
Liquid stool from high in the colon may ooze
around the mass of stool in the rectum and
leak uncontrollably into the child’s underwear.
The child has no sensation of the passage of
this liquid, sticky stool and no control over this
action. This fecal soiling is also called
encopresis. Children often deny that they
have soiled their underwear.
Many children who experience soiling display
a loss of appetite and decreased physical
activity that improves after passing a very
large bowel movement. Once the soiling
pattern is established the problem recurs, with
cycles of stool withholding leading to the
inability to have a bowel movement.
What are the causes of constipation in
children?
 Pain. Constipation may result in pain when
stools are large and hard. Cracks in the
skin, called fissures, may develop in the
anus. These fissures can bleed or increase
pain, causing a child to withhold stool.
 Illness. A child who has a brief illness with
poor food intake, fever, and no physical
activity may develop constipation, which
may persist after the illness is over.
 Poor bowel habits. Ignoring the urge to
defecate can start a cycle of constipation.
Older children may be fussy about using
bathrooms other than those at home, and
may become constipated by refusing to use
school or public facilities. Children may
ignore the urge because they are “too busy”.
After a period of time the child may stop
feeling the urge to defecate because of rectal
retention.
 Emotional. Sometimes children, because of
emotional problems or inappropriate
attempts at toilet training, will voluntarily
withhold stool until the problem of fecal
soiling results. Refusing to defecate may be
used as a powerful tool to control authority
figures. The effort to retain may be
associated with agitated behavior,
stiffening, hiding and crying as if in fear or
pain. This behavior can be frightening to
parents and siblings.
 Travel. Often constipation occurs when
traveling. The reason for this is not clear,
but may be related to changes in lifestyle,
schedule, diet and drinking water.
 Poor diet. Constipation may result from
inadequate intake of high-fiber foods,
including vegetables, fruits, and whole
grains. Some studies have shown that highfiber diets may help constipation. It is rare
that diet is the sole cause or cure of
childhood constipation.
 Muscle or nerve damage. Some children
with muscle disease or neurologic disorders
have weakness or poor coordination of
nerves and muscles, and may struggle longterm with constipation.
 Unknown. There is a large group of
constipated children in whom no cause can
be found.
Is constipation harmful?
The colon normally contains stool; it is not
poisonous to the body. Occasionally children
who have a large fecal collection in the colon
will be tired or irritable, with poor appetite or
abdominal pain. These symptoms usually pass
with relief of constipation. A large fecal mass
may press on the urinary bladder causing
some children to have urinary frequency or
wetting.
How is constipation treated?
The goal of your child’s bowel program and
medications is to retrain the bowel, which has
become stretched out and inefficient due to
ongoing fecal retention. There are four main
components to treatment:
1.
Bowel Cleanout. Some children with large
amounts of retained stool require a
“cleanout”. In this case, medications are
increased for a few days. In some older
children the cleanout may include
suppositories or enemas.
2. Maintenance Stool Softening. Once the
colon is empty, the “maintenance plan” is
designed to assure a soft stool daily. This
may include stool softeners such as
Miralax and Ex-Lax.
3. Increasing Dietary Fiber. We recommend
that you select only breads and cereals
with at least 2 grams of fiber per serving.
Benefiber may be helpful in older children.
Many children like Fiber One bars.
4. Bowel Retraining. Your child should sit
on the toilet for 10-15 minutes after
breakfast and dinner. If your child’s feet
do not touch the floor, supply a footstool
to help your child maintain balance and to
maintain more of a squatting position with
knees higher than the hips. Do not allow
use of games or activities while sitting on
the toilet. Toilet sitting should be limited
to no more than 15 minutes at a time.
Regular exercise also improves bowel
function.
The goal in bowel retraining is to keep the
colon as empty as possible to improve muscle
tone. We suggest a soft, mushy, oatmeal
consistency stool.
Retraining the bowel may take 9 to 18
months
Treatment for constipation requires patience
and persistence. After the intensive retraining
period, a gradual reduction in medication can
be attempted. Some children require stool
softening long-term to make a soft, easy to
pass stool.
Your medicine plan will be:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
(Continued)
Your maintenance medicine plan will be:
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
If you have any questions, please call
Pediatric Gastroenterology and Nutrition at
206-215-2700.
Pediatric Gastroenterology and Nutrition
1101 Madison, Suite 800
Seattle, WA 98104
©2008 SWEDISH HEALTH SERVICES
GI-103 R 01/09