Constipation In Children and Young People

The exact cause of constipation is not fully understood but factors that may contribute to it include pain, fever, dehydration, dietary and fluid intake, psychological issues, toilet training, medicines and family history of constipation.

If a child has experienced passing a hard stool, they may try to avoid having another poo in case it hurts. This can also lead to the child becoming constipated.

An illness that increases the child’s temperature (such as tonsillitis or chickenpox) may cause a child to become constipated – more water is absorbed back from the bowel to cool the body down. Other illnesses can sometimes cause the bowel to become a bit sluggish.

If your child usually has regular bowel movements but you have not changed a dirty nappy for some time or noticed them going to the toilet, look out for some of these other symptoms, which could be a sign of constipation:

• opening their bowels less than three times a week
• foul smelling wind and stools
• painful, enlarged tummy
• poo looks like hard pellets, is gritty or very loose
• very large stools
• pain when pooing
• straining
• withholding poo (sometimes mistaken for straining)
• poor appetite
• lack of energy
• unhappy, angry or irritable mood
• soiling (this can be small skid marks or large stools in pants)
• constipation behaviour – infants may extend their legs and squeeze their buttock muscles to try to prevent opening their bowels
• toddlers and school age children may rise up on their toes, rock backwards and forwards, holding their legs and buttocks stiffly.

Your nurse or doctor may ask you and your child to indicate which type of stools they pass. This can be identified from the ‘Bristol Stool Chart’ (shown later in this digital leaflet).

Dietary changes are generally not used alone to treat constipation but can aid in the prevention and treatment of it. It is essential for your child to have a good fluid intake of water, juice or squash. Too much milk can be a problem for those who have constipation – one glass of milk per day is adequate for a child. 

Fibre is the dietary group which aids in digestion and bowel movement. Foods which contain good amounts of fibre include wholemeal bread, green vegetables, fruit and grains.

Keeping mobile and active can help reduce the occurrence of constipation.

Where: Whatever your child prefers to use, whether a potty or the toilet, should be in the bathroom/toilet. Ensure that the environment is comfortable, warm and well-lit.

Positioning: See diagram.

When: It is beneficial to introduce a toilet regimen approximately 20- 30 minutes after your child has had a meal, as this is when the bowel is most likely to empty, The child should be encouraged to sit on the toilet for ten minutes (children aged eight years and older) and five minutes for the under eights. If this is difficult, consider giving him or her a toy, book or an activity that is only for toileting time and will last for the ten minutes!

Activities that will help them use their abdominal muscles to aid a bowel movement: 

• blowing a balloon, blowing bubbles or having pictures of candles on a cake to blow out
• laughing and coughing
• moving backward and forward whilst sitting on the toilet.

There are many different types of medication for the treatment of constipation. The treatment chosen will be based on your child’s individual requirements. These will be prescribed by your hospital doctor, nurse specialist or GP.

Some examples are:

• osmotic laxatives, such as a macrogol (Movicol, Laxido, CosmoCol) or lactulose. These products can take 24-48 hours to act. Their role is to soften the stool, to make it easier to pass
• stimulant laxatives, such as Senna or sodium picosulfate.
  These products can take 8 – 12 hours to act and will stimulate the bowels to move the stool along
• bulk forming laxatives, such as Fybogel.

Sometimes two or more different types of laxatives are used together to optimise treatment.

These work by ‘binding’ with the water and delivering it to the large bowel. It is essential, therefore, to mix it with the correct amount of water or it will not work. Each sachet of powder is to be mixed with 62.5 ml of water or 125 ml of water for the adult formula.

Each sachet needs to be made up with the water first, mixed well and after this you can also add squash (double concentrate can work well), juice, hot chocolate, milk or milkshake for a better taste.
The solution can be tried chilled by making it up and chilling in the fridge and it will last for six hours after mixing (Laxido) or 24 hours (Movicol and CosmoCol).

They are quite salty to taste so some children find it beneficial to eat something slightly salty while taking their medication.

Macrogol laxatives are not absorbed into the bloodstream, so are very safe to use.

If you have been told that your child is loaded with stool (often called faecal loading), you may be asked to carry out a ‘disimpaction regime’ to clear the bowel. The type of medication used for this is called a macrogol which is usually Movicol, Laxido or CosmoCol.

The following table shows the disimpaction regime:

The dose needs to be increased as shown above until all the backlog of faces (poo) has been cleared. The only way to be sure this happened is to continue until your child is passing watery poo – brown water with bits in. You may feel worried about giving such large doses but as long as you follow the regime you will not hurt your child. Macrogol laxatives are not absorbed into the bloodstream.

The child may poo a large quantity all at once or several small poos. If your child is still wearing nappies, buy lots of nappies and wipes. If they use the toilet, warn other members of the family that the bathroom is going to be busy and stock up on toilet paper and moist toilet tissue.

If your child is experiencing soiling (leaking poo into their pants) explain that this may well get worse to start with as first of all the poo will be softened, then evacuated.

If your child has a tummy full of poo, whatever laxative is used they should expect some discomfort as it starts to move along the bowel. Plenty of reassurance will help, and perhaps a dose of paracetamol.

Continue on the maximum dose until the bowel is empty, which is when the stools are watery with only flecks of stool.

After this, halve the number of sachets per day, for example, if your child showed clear watery stools at the day of six sachets, the ‘maintenance’ dose will be around half – three sachets. The dose can be increased or decreased to find the dose that enables your child to be able to pass a soft formed stool everyday, which can sometimes mean some trial and error!

You will be reviewed either in person or via a telephone consultation to monitor your child’s progress and bowel changes, and given advice on reaching the optimum maintenance dose.

Medication at the maintenance dose will be continued for several weeks after a regular bowel habit has been established, which may take several months and can often change. Children who are toilet training should remain on laxatives until toilet training is well established.

Do not stop the medication abruptly – this should be guided by your healthcare professional, who will gradually reduce the dose over a period of months in response to stool consistency and frequency.

Some children may require laxative therapy for several years. A minority may require ongoing laxative therapy.

If your child finds it difficult to relax on the toilet it may be worth giving them something to distract them at the same time, such as a magazine or portable gadget.

A reward system/chart may also be beneficial. These should be only small rewards/treats and for doing things to help relieve their constipation.

Soiling affects one in 30 children between three and four years of age and one in 100 children aged 10 and over. Faecal soiling can be caused by ‘overflow’, if the child is constipated and the liquid poo is bypassing harder stools further up the bowel.

This is an involuntary action which the child has no control over-if the constipation is on-going, the bowel stops giving signals that it needs emptying, so the child is not aware that they have soiled. It may also be caused by an incomplete bowel movement, (rushing back to their game/friends) or not wiping properly after a bowel movement.

Soiling can occur several times a day, as the child may be unaware that the poo has come out. Poo can appear runny (like diarrhoea), in small lumps or can be around the bottom and difficult to wipe away. A condition called encopresis is sometimes described as soiling. This, however, is the passing of a normal poo but in an inappropriate place, for example in the pants or behind the sofa.

If the child gets a sensation that they need to open their bowels they are not usually constipated. Their difficulty can be related to some behavioural issues or emotional upset. Constipation is the most common cause of soiling, so your child will need to be assessed to see if they are constipated. Prevention and management is similar to that for constipation.

Try not to let the child think he or she is being dirty. Be pleased that they have passed some poo, even if it is in the wrong place. In some cases children may require some help with their behavior or their emotional wellbeing. Children at school could take a spare set of clothes and cleaning materials, which can be stored discreetly. The school support staff or school nurse could support this.

Constipation/Stool withholding is very common in children and can often be the result of just one painful poo.

Withholding behaviours to prevent the passage of painful poos are often confused with straining to pass a poo. Some of these behaviours can be hiding in a corner and facially looking like they are straining, squatting, leg crossing, kneeling with feet crossed against the buttocks or standing stiffly holding on to something, such as a table.

A vicious circle can develop whereby the more a child holds on the more painful opening their bowels becomes, which makes the child want to hold on even more.
This can develop into a habit or reflex, which can become deeply ingrained. Instead of constipation, it is actually trying to stop the poo or ‘stool withholding.

Sometimes, stopping the poo is not entirely successful and the child may be incontinent. If there is a big hold-up of poo, sometimes liquid poo seeps through, causing some leakage – this is called overflow or soiling. As stopping the poo becomes harder and harder it will begin to dominate your child’s life and probably everybody else’s as well.

You may find that your child becomes increasingly irritable, unsettled and short tempered.
There may be lots of straining, which is actually trying not to go, and the child often looking like they are in discomfort as they fight their body’s urge to pass the stool. Stool withholding can be treating successfully with a combination of medication and time, perseverance and patience.

For a variety of reasons, some children will have control over their bowel movements but will only open their bowels if wearing a nappy. Initially, this habit needs to be allowed because they are less likely to become constipated if they are still opening their bowels.

The general rules about toileting should be followed:

• good fluid input is 6-8 x 200 ml drinks per day. Avoid milk being the dominant drink
• two-hourly daytime toileting. Encourage bowel movements 20-30 minutes after a meal.

If your child insists on needing a nappy for toileting, allow this but:

• toileting should happen in the bathroom or toilet area. You may need to be creative to encourage this – a toy or activity for use only in the bathroom/toilet at the time of toileting. A small reward/treat may help in achieving this.
• once this has been achieved, still allow a nappy to be wor as long as they sit on the toilet, (with the nappy on) and with the seat down. Gradually increase the time sitting to a maximum of five minutes.

Ensure they feel ‘safe sitting on the toilet: do they need a smaller seat, a potty, a step for their feet? To enable your child to be ‘part’ of the toileting, put the nappy on and off with them standing up and guide them to help clean themselves after toileting is finished (hand on hand):

• once the above has been achieved, nappy still on, sitting on the toilet with the seat up, encourage a good sitting position and increase to five minutes. Once they have passed their poo they should be encouraged to empty the poo into the toilet and flush it away (that is where the poois supposed to go!) and then they wash their hands give lots of praise
• once the above has been achieved on a consistent basis, start to remove the nappy.

There are a number of strategies:

• place the nappy under the toilet seat, so that it can still be felt
• using increasingly smaller sized nappies, which may help your child think that they are ‘growing’ out of nappies ” put the nappy on with less fastening, so it feels looser, then replace it with kitchen towel, then toilet roll instead of a nappy
• cutting a hole in the nappy, gradually increasing in size, until they actually poo through the hole!

These can take a variable length of time to work. The important thing is to be consistent and give them time. Give your child lots of praise as they progress and consider small rewards or treats for achieving each small step.

Most children will get constipated from time to time but usually it will go away.

Constipation that does not go away may need treatment. You should not postpone seeking extra help because the problem may get worse.

More serious symptoms may also occur, including:

• irritability
• loss of appetite
• soiling of clothes
• nausea
• stomach aches.

If these occur, please seek advice from a healthcare professional.

There is a website called ‘the poonurses’, on which is a good video describing constipation, soiling and how a macrogols work – www.thepoonurses.uk/index.php

ERIC – good resource site for support and information for children – www.eric.org.uk

Bladder and Bowel UK – www.bladderandboweluk.co.uk

When your child attends hospital you will be asked for his or her NHS number and other information, such as your address. Please be patient with this procedure as it is to ensure our records are kept up to date and to protect your child’s safety.

If vou do not know his or her NHS number, please don’t worry, he or she will still receive care.

To find out how to give us feedback on your visit or healthcare experience, please visit www.esneft.nhs.uk and search for ‘PALS’ or ‘Your views matter’, or speak to a member of staff on the ward or department you are in.