Constipation is a common problem for children with special health care
needs. It can happen for different reasons and there are different ways to help.
This page will talk about normal bowel function, how to prevent constipation, when
to seek urgent medical attention, and tips for parents and caregivers for help with
costs of laxatives and diapers.
Normal Bowel Function
Normal bowel functions are part of the gastrointestinal (GI) system. To better
understand the GI system, imagine a long tube running through the body. The parts
along this tube include the mouth, esophagus, stomach, small and large intestines,
and the rectal vault and anus. Food and liquid that enter the body are digested in a
process that absorbs nutrients and fluids and eliminates wastes (stool, poop, or
bowel movement). This system includes coordinated muscle contractions and
relaxations in the walls of the GI tract. Food, stool, or gas in the GI tract
stimulate this system to work by sending messages through nerve receptors that then
lead to a bowel movement. This is why babies, puppies, and many mammals often have
bowel movements shortly after a meal (the gastro-colic reflex).
Constipation
Lower GI TractLower GI Tract
Indolences/Wikimedia Commons
Constipation is a pattern of delayed, painful, or hard bowel
movements. Most people have an occasional hard poop, but if this happens
frequently, it can cause problems. If the stools are thick, like clay, or hard
and large, or like pebbles, then stool may get backed up in the GI tract.
Constipation can cause pain, a swollen belly, loss of appetite,
gastro-esophageal reflux (heart burn), and even loss of ability to control bowel
movements. Pain from constipation in kids is usually crampy, sharp, or achy pain
around the belly button or the sides of the belly. Usually this pain occurs
while your child is awake and is worse after eating or with exercise. Although
the cramps or aches may keep children from falling asleep, the pain does not
usually wake them from sleep. Sometimes a child can accumulate so much poop in
their rectum that it keeps the anus open, resulting in leaking, which can
sometimes appear to be diarrhea or soiling.
Many children with special health care needs have trouble moving food
and stool through their systems. Sometimes this constipation is obvious—when
your child has painful, difficult-to-pass, hard, incomplete, or infrequent
poops. Sometimes constipation is not obvious, but you may notice your child is
having pain, nausea, or even vomiting, decreased appetite, a swollen abdomen,
leaking stool or stool accidents, or bloody streaks around their stool.
Constipation can happen for many reasons, including: high or low muscle tone,
diets without enough fiber or liquid, immobility, developmental delays, problems
with the nervous system, tube feedings or irregular meals, and use of certain
medications, formulas, and supplements. Constipation can also sometimes occur as
a result of illness, particularly if there has been fever, vomiting, diarrhea,
or reduced fluid intake and dehydration.
Some children have fears of the toilet or bathroom. Some children have
motor problems that make it hard for them to sit comfortably to poop; there are
toilet chairs for children with special needs that can help with this problem.
The best way to find the appropriate toilet chair for a child with limited motor
function is to consult with a physical therapist who can evaluate and make
suggestions. These chairs are also sometimes covered by
insurance.
Babies
In newborns, meconium (the first, dark, tarry stool) should be passed
promptly and completely within 2 days after birth. Once babies have established
feeding, their bowel movements can vary significantly. Their patterns may be
affected by nursing or formula use, how often and how much they feed, when they
are having growth spurts, and when new foods are introduced. Many infants cry
and appear to be in pain before they pass a stool. This is called infant
dyschezia. However, typically, an infant should not have a persistent swollen,
painful belly (abdominal distension). Infants should not routinely require
assistance (suppository, rectal stimulation, or enema) to pass stool, although
occasional episodes of constipation may occur after the newborn period. While
infant stools can have a range of colors (most common are yellow, green, brown,
and orange), blood in the stool, consistently tarry stools outside of the
newborn period, or stools that remain pale (like clay) are abnormal and should
be promptly discussed with the infant’s health care provider.
Toddlers and Preschoolers
Most children are able to toilet train when they are developmentally
between 2 and 4 years old, provided they have intact nerves and muscles and
access to a toilet. (See Toilet Training.) This happens because around the age
of 16–24 months, children start to learn how to hold the stool, and then learn
how to let it go. If stool is held too long, it becomes larger and harder,
making it too easy to hold, and it may result in constipation. If the rectum is
frequently full of hard stool, the muscles can weaken and lead to stool leaking
or incontinence. If there have been painful, difficult-to-pass, uncomfortable,
or anxiety-provoking bowel movements, the sphincter may remain chronically
contracted. This may establish a cycle of stool retention, with denser and
larger difficult-to-pass stools, rectal pain, rectal fissures, and further
retention.
School-Age Children
Many chronic gastrointestinal complaints in children and adolescents
can be explained by excessive stool retention. Despite being toilet-trained,
entering school can make some children feel shy about asking to leave the room
(embarrassed that it might take too long, afraid of a public restroom, etc.),
which can result in a stool withholding pattern that leads to constipation.
Parents may not realize this until the child has intermittent soiling, leaking,
or non-intentional stool release (encopresis). This reaction is caused by stool
that has stretched out the rectum, reducing the body’s ability to regulate bowel
movements, and occasionally resulting in liquidy stool leaking around hard stool
that is stuck in the rectum (think of flowing water passing around rocks in a
river). When stool is stuck repeatedly in the colon, it can also lead to pain,
nausea, or decreased appetite.
Prevention
You can help prevent constipation by making sure that your child gets adequate fluids and fiber in the diet, exercise, appropriate
positioning, and regular, unrushed toileting time after meals. These strategies are also good first steps to treat mild constipation.
Diet
Fluid intake—Inadequate fluid intake may contribute to
constipation. Try to make sure your child drinks enough water every day.
A child or teen should drink 5–8 cups of water per day; younger children
should have 3–4 cups daily. Increasing water may be helpful, but can be
difficult to do, particularly with a young child. Avoid using sweetened
beverages, especially sodas, to increase fluid intake. 1–4 oz. per day
of prune or apple juice can help with constipation in some children and
infants.
Fiber—Increasing fiber in the diet may reduce
constipation. The best sources of fiber include whole grains, fruits,
and vegetables. Avoiding highly processed and carbohydrate-rich foods
that lack fiber may increase appetite and motivation to eat foods that
are rich in fiber. If the child is tube-fed and using an enteral
formula, consider switching to one with fiber.
Stimulants—Some foods may stimulate the intestines to
move more quickly. Prunes are the most common of these, but children may
vary in which foods work best for them.
Foods to avoid—Some foods can slow down digestion.
Foods such as bananas, sweets, white breads, and fast food, foods that
are high in fat, and large amounts of dairy products all tend to slow
digestion and contribute to constipation. This varies among children.
Meals—Regular meals are helpful in keeping the bowels
moving. Timing opportunities to use the toilet to follow meals can
enhance the ease of passing bowel movements.
Less snacks—Snacking, particularly “grazing” (eating
small amounts of food, usually low in fiber, throughout the day), can
limit the amount of food eaten at meal times and result in a poor
gastro-colic reflex, resulting in poor gut motility and constipation.
Exercise—Kids who get plenty of exercise seem less
likely to get constipated. Assuring daily exercise has other benefits in
terms of fitness and weight control.
Behavioral issues—Positively reinforce all passage of
stool. For children who are toilet trained, ensure adequate time and
privacy for defecation (e.g., it isn’t going to happen in a public
school bathroom stall). Treat accidents with a neutral approach.
Toileting routine—It is helpful if your child goes to
the toilet and tries to poop after meals. This is particularly important
after breakfast on school days, when he or she may not have another
opportunity to poop till evening. See Toilet Training Children with Complex Medical Conditions
Positioning—Ensure child is adequately supported in an
upright position to allow optimal defecation. For children with mobility
issues, time in a stander or at a standing table may help with
evacuation. An adapted toilet seat may be necessary for proper
positioning. Speak with your child’s physical therapist or primary care
physician about the best options and how to obtain this equipment
through insurance or Medicaid.
Warm baths—A warm bath once a day can help to relax the
muscles of the rectum and make it easier for your child to have a bowel
movement.
Treatment
If good diet and bowel habits fail to relieve your child’s
constipation, he or she may need a prescribed bowel program, a “clean-out,” or
medication to help produce regular stools. Consult your child’s primary care
physician to talk about the treatment that is best for your child.
If your child has any problems with his or her bowel program or
medication, contact the primary care physician to address and modify the
treatment. No medication or clean-out should be initiated without consulting the
child’s physician first.
Maintenance Therapy
Sometimes children need to take medications for long periods of
time to manage constipation. In addition to fluids, diet, and lifestyle changes,
the daily use of medications may be necessary to keep some children regular;
this is called “Maintenance Therapy.” In children, these medications are usually
various kinds of laxatives. The most commonly used laxative in children is
polyethylene glycol (MiraLax, ClearLax, GlycoLax, etc.). Other laxatives include
stool softeners, lubricating agents, osmotic laxatives, stimulating agents,
rectal suppositories, and enemas. Your child’s primary care clinician in the
Medical Home can work with you to develop a tailored plan for your child’s
constipation if needed.
When to Seek Urgent Medical Attention
Pain doesn’t go away or is getting worse
Blood is in or around the stool (can be non-urgent, but check with your physician if this is new)
Swollen, firm abdomen that is painful to the touch (seek immediate medical attention) or associated with fever
Vomiting or dehydration related to the constipation or bowel problem
Stool is not able to be passed despite interventions
An enema has not come back out
Tips for Parents and Caregivers
Lowering Your Out-of-pocket Cost for Laxatives
While the cost of over-the-counter (OTC) laxatives may be relatively
low, when used chronically the cost adds up quickly. Check with your provider to
obtain a prescription if there is a medication that your insurance will cover.
Otherwise look for generics (store brands) or coupons, or shop online to compare
prices.
Help with Diaper Costs
Diapers are a huge health care expense. Generally, Medicaid will cover
the cost of diapers for the incontinent child after age 3 through a home care
company with a clinician’s prescription and Adaptive Equipment - Letters of Medical Necessity (Rifton). Less
frequently, private insurers can be convinced to do this.
Resources
Information & Support
For Parents and Patients
About Kids GI Health (IFFGD) Reliable digestive health knowledge, support, and assistance about functional gastrointestinal and motility disorders in children
and adults; International Foundation for Functional Gastrointestinal Disorders.
Constipation in Children (AAP) Learn how to know if your child is constipated and, if so, what to do about it; on HealthyChildren.org, sponsored by the American
Academy of Pediatrics.
Kids Need Fiber: Here’s Why and How (AAP) Printable website with information about fiber and reading nutrition labels to help prevent constipation and other health
problems; HealthyChildren.org.
Dietary Fiber (IFFGD) Information about different kinds of fiber, how to incorporate fiber into the diet gradually, and serving sizes to help prevent
constipation; International Foundation for Functional Gastrointestinal Disorders.
UCanPoopToo Program (BeHealth Solutions) Online program that provides education and ongoing tools to solve the physical, emotional and behavioral issues of encopresis.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization
or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited
to web-based services, provider locator services, and organizations that serve children from across the nation.
Authors & Reviewers
Initial publication: May 2016; last update/revision: December 2018
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