Constipation is a common temporary gastrointestinal problem that occurs when the colon absorbs too much water or the colon muscle is slow or sluggish and the stool becomes hard and dry. Common symptoms of constipation include: fewer than 3 bowel movements per week, stool is difficult to pass, hard, dry and large, abdominal pain, stool soiling in underwear and/or a decreased appetite.

Not having a bowel movement every day doesn’t mean you are constipated. Most people who have constipation don’t go to the doctor. Some use over the counter laxatives to relieve their constipation. However, using laxatives too much can cause your body to depend on them and become habit-forming. Chronic constipation, however, may lead to complications or be a sign of a serious underlying disorder.

Causes

There may be several causes for constipation in a child. Some of these include:

• too little fiber in the diet
• not drinking enough fluids
• not enough exercise
• some medications
• eating too many processed foods
• not taking time away from playing to try to have a bowel movement
• Changing from breast milk or formula to whole milk or from baby food to solid food.
• Anxiousness or tiredness

In cases of chronic constipation it can begin from one large stool causing a crack in the anus, making bowel movements painful so the child resists the urge. This starts a vicious cycle where your child holds their stool to avoid pain, but the longer it is held the stool gets larger and harder. This makes bowel movements even more painful.

In children who have constipation frequently, behavior changes are recommended to help the child develop normal bowel habits. Children may become constipated if they are afraid or don’t want to go to the bathroom. This often happens at school because children would rather use their toilet at home. If this behavior happens often enough it can become difficult for your child to tell when they need to use the bathroom.

Chronic constipation and allergies

Some cases of chronic constipation in children may be caused by allergic reactions inflaming the colon or killing off healthy gut bacteria, resulting in difficult bowel movements. The allergen that causes chronic constipation the most is milk allergies. Usually symptoms of constipation appear within 48 hours of eating the allergen, but in some cases they can take up to a week to appear. Your provider may begin to consider allergens as a cause if the most common constipation treatments do no work in a normal time frame. If your provider identifies allergens as a possible cause they will likely ask your child to start an elimination diet to over time take foods out and see if their symptoms improve.

Autoimmune disease and Constipation

In some cases constipation may be caused by autoimmune diseases slowing the movements of your stomach and colon. This autoimmune disease could also attack the healthy bacteria in your gut,(as seen in Crohn’s disease) which can also slow your bowel movements. This slower movement can lead to difficulties with passing stool. There are many different autoimmune disease that could effect the gut and cause constipation, two of the most common in children are Celiac disease and Crohn’s disease. These autoimmune diseases require specific tests in order to diagnose and treatments vary for each case and can range from dietary changes, medications, and infusions.

Hypothyroidism

Hypothyroidism (a condition where your Thyroid gland is not producing enough hormones) can cause constipation. The lack of hormones in your body can cause your colon muscles to slow down. Since it takes longer for stool to pass through your colon, more water is taken out of the stool than normal. This causes the stool to harden and become very difficult to pass. This condition has many other symptoms such as tiredness, weakness, rough skin, dry skin, and many others. In infants it can cause feeding problems, building near the belly button, yellowing of the skin (jaundice), poor growth, etc. These symptoms can sometimes take years to appear and worsen. Hypothyroidism can be caused by being born without a thyroid or a thyroid that does not function properly, a lack of iodine, autoimmune disease, or inflammation of the thyroid. Your provider may prescribe medications that contain levothyroxine that can replace the hormones the thyroid is not producing, it is important to follow their instructions on how to use these medications.

Irritable Bowel Syndrome (IBS)

IBS is a condition that the cause is not exactly known and a flare up of IBS can be caused by different things in different people. Commonly, flare ups can be caused by stress or diet, but it can also be caused by your gut and brain not working together properly for normal bowel function. It is very common to experience pain with flare ups as the contractions of your intestine muscles can be extremely tense and long lasting. People with IBS can experience Constipation and Diarrhea. In cases of IBS causing constipation the muscles of your intestines can slow down dramatically, causing stool to be inside your colon for much longer than normal. This causes an excess of water to be removed from the stool, hardening the stool, and making it difficult to pass. Treatments for IBS vary wildly for every patient, but many patients find a routine that controls their flare ups by managing their stress, diet, and sometimes with the help of medications.

Treatment/Prevention

Some of the same things that can be done to treat constipation can be done regularly in order to prevent a child from becoming constipated again. It is important to be consistent and patient with treatment, it may take many months for the intestine to regain strength and feeling. Constipation is a problem that takes time to develop, it is unrealistic to expect it to be solved overnight.

• More fiber in the diet. The US Dietary Guidelines  recommend children eat their age + 5 grams of fiber each day (e.g. a 10 year old needs 10+5=15 grams fiber). Examples of foods that contain fiber are:

• Whole grain breads, whole grain pasta, bran cereals and brown rice
• Fresh vegetables and fruits and fruit juices
• Nuts and seeds
• Pinto beans, kidney beans, black-eyed peas
• Limit bananas, cheese, chocolate, and fried foods.
  • It should be noted that for constipation there is a difference between soluble and insoluble fiber. Soluble fiber is absorbed by water and as your body digests it, it becomes gel-like. Insoluble fiber does not dissolve in water and latches on to other pieces of your stool. This has a natural laxative effect that can help cases of constipation.

• Plenty of fluids. It is very important for children to drink plenty of fluids to help soften the stool—at least 8 cups a day. Fluids include drinks, soups, fruit juice, etc.

• Regular exercise. Physical activity helps stimulate the intestines so the child can go to the bathroom.

• Take time to go to the bathroom. Children should learn when to go to the bathroom and have enough undisturbed time when they need to go.

• Behavioral modification. A regular bowel habit is key to avoiding constipation. Children who are toilet trained (or in the process of learning) should sit on the toilet for 5-10 minutes following meals. Meals are often followed by contractions in the colon so the body can get rid of stool, and sitting on the toilet can take advantage of this movement.
• Pelvic floor therapy. The muscles in your pelvic floor (the area around and inside your hips) help control movements in your bowels and your bladder. Constipation or trouble controlling the bladder may be caused by the pelvic floor becoming weak or being too tight. Pelvic floor therapy is a type of physical therapy that aims to bring the pelvic floor muscles back to their normal function.
• Medications.  Your doctor may recommend a home clean out in order to remove the stool that has collected in the intestine. Once the stool has been removed it is important to make sure your child can use the bathroom easily so that stool does not collect again. In order to make using the bathroom easy for your child your doctor may recommend stool softeners such as milk of magnesia, miralax, lactulose. These medications work by drawing water into the stool, making it softer, easier to pass, and cause less pain during bowel movements.
  Laxatives such as Amitiza and Linzess may be prescribed so your child feels the urge to go and work by causing the intestine to move stool faster through the body.
• Medications called prokinetic agents may be used to encourage the muscles in your stomach and throat to move more efficiently, helping move the stool. Examples of these prokinetic agents would be Erythromycin and Prucalopride. Your doctor will give the dosage and for how long you should use any prescribed medications. Although these medications all help treat constipation, they work in different ways and the specific symptoms of your child’s constipation will affect which medication your doctor prescribes.
• Anorectal Manometry In order to tell if your child’s anal nerves are working properly your Doctor may decide to perform an Anorectal Manometry. This is a painless test that lasts 5-10 minutes where a lubricated tube and a balloon are inserted into the anus. The balloon will inflate with air and deflate several times throughout the test. Your child may feel the need to poop but this will only last a few seconds. Older children may be asked to squeeze the muscles in their butt. Afterwards your child can return to normal activities.
• Peristeen If the other treatments for chronic constipation have not worked, your doctor may prescribe the use of Peristeen. This treatment is a form of anal irrigation using an anal cathader where the Peristeen flushes out fecal matter from the colon. This can remove blockages making it easier for future bowel movements to pass through. It is often used daily or every other day depending on how often your provider prescribes. This irrigation should not be painful and if it is contact your provider, cramps in the stomach are common but should not be intense. Often these cramps are a sign the Peristeen is working since that means your intestine muscles are doing their job.
  • Vagus Nerve Stimulation The vagus nerve connects directly from your brain to your digestive system. In some cases of constipation the vagus nerve is not functioning properly, causing the stomach and colon to slow down. This can lead to stool staying inside the colon for too long, causing an excess of water to be removed from the stool which makes the stool a lot harder to pass. Vagus nerve stimulation is most commonly used in cases of IBS caused constipation. By exciting the Vagus nerve it can begin to bring back ordinary function of the digestive muscles, and can help balance the healthy bacteria living inside your gut. Some ways to stimulate the Vagus nerve include:
• • Deep breathing 
    • Inhale for 6 seconds, briefly hold your breath, and exhale for 8 seconds.
  • • Humming, singing, or gargling water.
      • Gargle water vigorously for 30-60 seconds, you can also hum deeply or sing loudly.
  • Cold Therapy
    • Put an ice pack on your neck for a few minutes or splash cold water on your face.
  • Abdominal massage
    • Rub around the belly button using circular motions,clockwise, for about 5 minutes.
  • Specific Yoga Movements
    • Using positions such as downward dog or child’s pose before eating can help get your gut into motion for regular bowel movement. 
  • Sacral Nerve stimulator
    • In some cases an electrical implant can be put into the lower back around the spine. This device will send electrical signals to the Sacral nerve, working similarly to a pacemaker, and will help keep bowel movements regular.

Please visit the Nutrition section of the website for further information, or contact one of our dieticians for nutritional help. Call (865) 546-3998.

When to contact the Doctor

If you try the above suggestions and your child does not improve within 3 days, contact your doctor before giving the child any medication or an enema. Also, contact your doctor if your child is having increased abdominal pain, blood in the stools, or fever.

Further Information

Behavior problems are common in children who have constipation. Consider meeting with one of our psychologists for support in dealing with the various stressors and emotional issues related to your child’s constipation issues.