What causes chronic constipation in children?

The effects of chronic constipation can cause children discomfort, disruption to their daily routine and embarrassment. In this first of a series of articles on chronic constipation in children, highly esteemed consultant paediatric surgeon Mr Brian MacCormack offers expert insight on the most common causes of this digestive problem.

What is considered chronic constipation in children?

Constipation in children is generally considered when a child is passing fewer than three bowel movements each week. The condition is described as being chronic when these infrequent bowel movements or difficult passage of stools persist beyond several weeks.

What are the most common causes?

In children constipation occurs when stools move too slowly through the gastrointestinal tract (from mouth to bottom). This can quickly become a vicious cycle, where stools become harder and larger making them even more difficult to pass and therefore they move even more slowly through. There are many contributing factors that can contribute to constipation in children:

Poor water intake

National guidelines (NICE) recommend the children drink a certain amount of water each day (this increases with age).

One way to approach this is to aim for 6-8 cups of water each day. Many children don't drink enough water and if we are to effectively break the cycle of chronic constipation in children we must find ways to encourage our children to drink more water.

Poor diet

A common factor that contributes to childhood constipation is a poor, low-fibre, diet. One of the common reasons that children get constipated is a change from an entirely liquid-based diet (breast or bottle-fed infants) to one that includes solids.

Many of the children and young people that come to me with severe chronic constipation will not have a healthy, balanced, high-fibre diet. Often this is because they are so constipated that they just don't feel well most of the time and their appetite and behaviour is negatively affected by the fact that their intestines (and in particular the last bit of the bowel - the rectum) is always full and over-stretched. This makes improving the children's diet extremely difficult for them and their families.

Children with chronic constipation should be encouraged to try to include as much high-fibre, natural, healthy food (e.g. bran, porridge, fruits, vegetables, beans, nuts and seeds) in their diet as possible. Equally it is important to try and reduce the proportion of their diet that is made up of processed, low-fibre foods (e.g. processed cereals, white bread, crisps, sweets, chocolate, fast-food, white pasta).

Changes in a child's routine

Many children tend towards constipation when their daily routine is upset or altered. Common examples are around toilet training, starting nursery or primary school and summer holidays (travel and hot weather). Generally any period when the child is stressed in some way will be associated with an increased risk of constipation.

Stool withholding behaviour

This is not to be critical of or something that a child does on purpose. In fact, children display stool withholding behaviours (walking on tip-toes, crouching behind the sofa, pressing their heel in towards the bottom), because their bodies are naturally trying to avoid passing a large and hard stool because they are frightened that it will be painful and difficult to pass. These behaviours are tell-tale signs that a child is already constipated and that we need to intervene as soon as possible.

Cow's milk protein

Some children will have an allergy to the protein within cow's milk. Consuming too many dairy products (cheese, cow's milk etc.) can contribute to constipation in some children.

Medical conditions

Thankfully less than five per cent of children with chronic constipation have an underlying medical condition. Warning signs that a child may have an underlying condition would be a delayed passage (over twenty-four hours) of meconium (the first, black, sticky stool that a baby passes after birth), ribbon stools (very thin long stools), a tummy that is extremely distended or swollen, explosive watery stools, or any child that looks unwell or is failing to thrive. In these circumstances, an experienced specialist should assess the child to make sure there are no underlying conditions causing their constipation.

When does chronic constipation in children become a concern? Can it become an emergency?

Chronic constipation can literally ruin children's lives by dominating family life, leaving them soiling their pants, frequently considered smelly and dirty by their peers, and ultimately negatively affecting their behaviour and mental health. It is critical that childhood constipation is addressed before it reaches this point.

Chronic idiopathic constipation (where there is no underlying medical cause) will thankfully rarely lead to an emergency situation. However, if a child goes for a week or two without a bowel motion, sometimes hospital admission is required for urgent medical or surgical intervention.

If you are concerned about your child’s bowel movements or recurrent constipation, you can schedule a consultation with Mr MacCormack by visiting his Top Doctors profile.