Constipation

Pediatric HouseCalls Online

DEFINITION

• Pain or crying during the passage of a bowel movement (BM) OR  
• Unable to pass a BM after straining or pushing longer than 10 minutes OR
• 3 or more days without a BM (Exception: Breastfed and over 1 month old)

Imitators of Constipation

• If breastfed and over 1 month old: Infrequent BMs every 4-7 days that are soft, large and pain-free can be normal. Before 1 month old, infrequent stools usually means an inadequate intake of breastmilk. 
• Grunting or straining while pushing out a BM is normal in young infants. (Reason: difficult to pass BM lying on back with no help from gravity). Infants commonly become red in the face during straining.
• Brief straining or pushing for less than 10 minutes, can occur occasionally at any age.  
• Large BM's - Size relates to amount of food consumed and BM frequency. Large eaters have larger stools.
• Hard or dry BM's are also normal if passed easily without straining. Often relates to poor fiber intake. Some children even have small, dry rabbit-pellet-like stools.

Causes

• High milk or cheese diet.

• Low fiber diet 

• Postponing bowel movements 

• Slow GI transit time (genetic differences)

See More Appropriate Topic (instead of this one) If

• Doesn't meet the definition of constipation, see ABDOMINAL PAIN.

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WHEN TO CALL YOUR DOCTOR

Call Your Doctor Now (night or day) If

• Your child looks or acts very sick.
• Persistent abdominal pain over 1 hour (includes persistent crying).
• Persistent rectal pain over 1 hour (includes persistent straining).
• Vomiting over 3 times in last 2 hours.
• Age under 1 month old and breastfed.
• Age under 12 months with recent onset of weak cry, weak suck or weak muscles.

Call Your Doctor Within 24 Hours (between 9am and 4pm) If

• You think your child needs to be seen.
• Age under 2 months.
• Bleeding from anal fissures (tears).

• Needs to pass stool BUT afraid to release OR refuses to go

• Child may be "blocked up"

Call Your Doctor During Weekday Office Hours If

• You have other questions or concerns.
• Leaking stool.
• Suppository or enema needed recently to relieve pain.
• Infrequent stools continue after dietary changes  (EXCEPTION:  normal if breastfed infant over 1 month old AND BMs are not painful).
• Toilet training is in progress.

• Painful stools occur 3 or more times

• Constipation is a recurrent chronic problem.

Parent Care at Home If

• Mild constipation and you don't think your child needs to be seen.

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HOME CARE ADVICE FOR CONSTIPATION

1. Normal BMs:
   • Once children are on a regular diet (age 1 year), the normal range for BMs is 3 per day to 1 every 2 days.
   • The every 4 and 5 day kids all have pain with passage and prolonged straining.
   • The every 3 day kids usally drift into longer intervals and then develop symptoms.
   • Passing a BM should be fun, or at least free of discomfort.
   • Any child with discomfort during BM passage or prolonged straining at least needs treatment with dietary changes.
2. Diet for Infants Under 1 Year:
   • For infants over 1 month old only on breast milk or formula, add fruit juices 1 oz./month of age per day.   Pear or apple juice are OK at any age.(Reason: treating a symptom)
   • For infants over 4 months old, also add baby foods with high fiber content twice a day (peas, beans, apricots, prunes, peaches, pears, plums).
3. Diet for Children Over 1 Year Old:
   • Increase fruit juice (apple, pear, cherry, grape, prune) (note: citrus fruit juices are not helpful).
   • Add fruits and vegetables high in fiber content (peas, beans, broccoli, bananas, apricots, peaches, pears, figs, prunes, dates).
   • Increase whole grain foods (bran flakes, bran muffins, graham crackers, oatmeal, brown rice, and whole wheat bread.  Popcorn can be used if over 4 years old.)
   • Decrease milk products (milk, ice cream, cheese, yogurt) to 3 servings per day.
4. Stop Toilet Training:  Temporarily put your child back in diapers or pull-ups.
   • Reassure him that the poops won't hurt when they come out.
   • Praise him for the release of BMs
   • Avoid any pressure, punishment or power struggles about holding back poops, sitting on the potty or resistance to training.
5. Sitting on the Toilet (if toilet trained):   Establish a regular bowel pattern by sitting on the toilet for 10 minutes after meals, especially breakfast.
6. Warm Water for Rectal Pain: Warmth helps many children relax the anal sphincter and release a BM. For prolonged straining, have your child sit in warm water or apply a warm wet cotton ball to the anus.

7. Flexed Position:

   • Help your baby by holding the knees against the chest to simulate squatting (the natural position for pushing out a BM). It's difficult to have a bowel movement while lying down.

   • Gently pumping the lower abdomen may also help.

8. Call Your Doctor If:
   • Constipation continues after making dietary changes
   • Your child becomes worse

And remember, contact your doctor if your child develops any of the "Call Your Doctor" symptoms.

Disclaimer: This information is not intended be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D.

Last Reviewed: 1/19/2009

Last Revised: 6/12/2008

Content Set: Pediatric HouseCalls Online

Copyright 1994-2009 Barton D. Schmitt, M.D.