Definition

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

Causes

• High milk or cheese diet
• Low fiber diet
• Postponing stools
• Slow intestinal transit time (genetic differences)

Imitators of Constipation

• If breastfed and over 1 month old: Infrequent stools 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 stool is normal in young infants. (Reason: difficult to pass stool 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 stools – Size relates to amount of food consumed and stool frequency. Large eaters have larger stools.
• Hard or dry stools are also normal if passed easily without straining. Often relates to poor fiber intake. Some children even have small, dry rabbit-pellet-like stools.

When to Call Your Doctor for Constipation

Call Your Doctor Now (night or day) If

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

Call Your Doctor During Weekday Office Hours If

Parent Care at Home If

Home care Advice for Constipation

1. Normal Stools:
   • Once children are on a regular diet (age 1 year), the normal range for stoolss 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 usually drift into longer intervals and then develop symptoms.
   • Passing a stool should be fun, or at least free of discomfort.
   • Any child with discomfort during stool 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 ounce (30 ml) per 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).
   • If on finger foods, add cereal and small pieces of fresh fruit.
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) 3 or more times per day.
   • 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.)
   • Limit 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 stools.
   • 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 stool. 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 stool). It’s difficult to have a stool 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 “When to Call Your Doctor” symptoms.

References

1. Abi-Hanna A and Lake AM. Constipation and encopresis in childhood. Pediatr Rev. 1998;19:23-31.
2. Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology. Evaluation and treatment of constipation in infants and children. J Pediatr Gastroenterol Nutr. 2006;43(3):e1-13.
3. Felt B, Wise CG, Olson A, Kochhar P, Marcus S, Coran A. Guideline of the management of pediatric idiopathic constipation and soiling. Arch Pediatr Adolesc Med. 1999;153:380-385.
4. Liptak GS with Baker SS, Colletti RB, Croffie JM, DiLorenzo C, Ector W, Nurko S. Constipation. In: Moyer V, Davis RL, Elliott E, et al, eds. Evidence Based Pediatrics and Child Health. London, England: BMJ Publishing Group; 2000. p. 264-272
5. North American Society for Pediatric Gastroenterology and Nutrition. Constipation in infants and children: Evaluation and treatment. J Pediatr Gastroenterol Nutr. 1999;29:612-26.
6. Nurko S, Baker SS, Colletti RB, Croffie JM et al. Managing constipation: Evidence put to practice. Contemp Pediatr. 2001;18(12):56-65.
7. Schmitt BD and Mauro RD. 20 common errors in treating encopresis. Contemp Pediatr. 1992;9(5):47-65.
8. Youssef, NN, Di Lorenzo, C. Childhood constipation: evaluation and treatment. J Clin Gastroenterol. 2001;33(3):199-205.

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: 8/1/2010

Last Revised: 9/30/2010 12:14:33 PM

Copyright 1994-2011 Barton D. Schmitt, M.D.