For children, as with adults, constipation is characterized by either infrequent bowel movements or the passage of dry, hard stools. Though it can be uncomfortable or painful, it is usually easy to treat and only temporary.

In the Pediatric Healthy Gut & Constipation Program at Yale Medicine, families work with specialists trained to treat children. According to Danya Rosen, MD, a pediatric gastroenterologist at Yale Medicine, medication works quickly and can be helpful as a temporary solution, but “we are passionate about stressing the role dietary changes can make in establishing good health and regularity.”

Almost one out of every 20 visits children make to the doctor are related to constipation, but Yale Medicine’s Nadia Ameen, MBBS, says she believes that as many as 50 to 75 percent of children's visits to a pediatric gastroenterologist are related to constipation.

“The problem is widespread and has a lot of implications on a child’s wellbeing, including school attendance if a child is ashamed because they have soiling problems caused by constipation,” notes Dr. Ameen, a pediatric gastroenterologist. “But if we can get families to plan good meals and make any other necessary changes, we can eradicate it.” 

With bowel habits, what’s normal for one child may be very different for another. Most children over the age of 2 have one to two bowel movements a day, but others may go two or three days or longer without one. If a healthy child has normal stools without pain or discomfort every three days, then that is fine. A constipated child may have fewer bowel movements than is normal for him or her and/or the stool may also be hard, large, difficult or painful to pass.  

“Constipation is extremely common in children, especially during times of transition, says Dr. Rosen. The introduction of solid foods to babies, potty training, and starting school are examples of times when constipation may arise.

But if a child’s constipation goes on for a long time and isn’t treated, it may worsen. As stool stays in the lower GI tract, it becomes larger, firmer, and drier, and therefore more difficult to pass. It may also lead to fecal soiling, which is caused by leakage of soft stool around a hard stool. This condition is known as encopresis, and is not something your child can control, explains Dr. Rosen. 

Constipation is rare among infants, but may emerge once your child starts eating solid foods. Among children and teenagers, it might be because their diet doesn’t include enough high-fiber foods.

“With the younger kids, we often need to use medications, but with older kids, it’s more often a matter of changing their diet,” Dr. Ameen says. “They might be eating a lot of white bread and other foods that are low in fiber and high in carbohydrates—and no vegetables. We work with families to teach them how little things like adding flax to foods can help.” 

Most constipation is considered “functional,” meaning that there is no underlying condition that causes it, Dr. Rosen explains. This type of constipation may be related to changes in diet, including insufficient fiber or fluid. Other causes include fluctuations in routine or an illness.

Sometimes constipation has behavioral roots. If a child refuses to have a bowel movement, it’s called withholding. Your child may withhold to avoid passing a hard stool, which can be painful and possibly exacerbated by a diaper rash. 

In some cases, particularly in children between ages 2 and 5, they don’t go because they don’t want to interrupt playing, or they are exerting their own independence or control. Other times, a child may withhold at camp or school because they are uncomfortable or embarrassed using public toilets.

Occasionally, constipation is considered “organic,” which means it is caused by celiac disease (gluten intolerance), hypothyroidism (underactive thyroid disease) or an abnormality in the nerve fibers of the gastrointestinal tract.

Prediabetes and obesity often go hand-in-hand with constipation, notes Dr. Ameen, a professor of pediatrics and of cellular and molecular physiology at Yale School of Medicine. “If they aren’t eating well or exercising and they are gaining weight, this puts them at risk for fatty-liver disease, too,” she says. “In our Pediatric Healthy Gut & Constipation Program, we emphasize that having a healthy gut means having a healthy body, and we emphasize how that will benefit children in many ways.” 

Symptoms may include: 

• Many days without a normal bowel movement
• Hard stools that cause discomfort or pain
• Abdominal pain, including stomachaches, cramping or nausea
• Rectal bleeding from tears, which are called “fissures”
• Soiling
• Crankiness
• Poor behavior
• Crossing legs, making faces or clenching buttocks together—signs of trying to hold stool in

A pediatric gastroenterologist can provide your child with a tailored treatment plan. By the time your child is seen by a specialist, constipation may have been an issue for several months, if not years, Dr. Rosen says. In such cases, dietary modifications are not enough to establish a normal bowel pattern.

At the start, your child’s doctor may suggest what is called a “clean-out,” or the use of a high-dose laxative or rectal medication for several days. “We follow that up with a maintenance medication, such as Miralax,” Dr. Rosen says, noting that it is commonly used and safe for children, with very few side effects.  

Once the constipation is resolved, increasing fiber in the diet, drinking more water and possibly limiting dairy may help keep your child achieve regularity, Dr. Rosen says.

The American Academy of Pediatricians recommends that children between the ages of 2 and 19 consume 5 grams of fiber a day, plus their age. A 5-year-old, for example, should have 10 grams of fiber each day.

High-fiber foods include bran cereals, fruit (pears, strawberries, apples, dried fruit, peaches, plums), beans (pinto, kidney, lima or black beans) and vegetables (sweet potatoes, lentils, peas).

“We also talk to families about incorporating regular exercise into their lives,” Dr. Ameen says. “We’ll even show them how to do proper sit-ups and leg-lifts.”

Behavioral modifications are also key to preventing constipation. That includes offering your child frequent “toilet time” after meals or establishing some other routine for bathroom use, suggests Dr. Rosen.

“Most people will have a bowel movement after a meal or in the morning, but many parents don’t instill a habit for their children,” Dr. Ameen says. “We encourage them to wake their child up 10 minutes earlier in the morning, or to find a time after school.”

These details are not always obvious to families, Dr. Ameen notes. “Sometimes they have their kids sit down 10 times a day, and that isn’t effective either,” she says. “I take the opportunity to talk to the child or teen directly. Often, they are hearing it from their families, but if I say, ‘This is part of your homework and what you need to do,’ that can work.”

In most cases, constipation is diagnosed based on your child’s symptoms and a physical exam, which might include a rectal exam. But if your child requires high doses of medication to relieve constipation or there are concerning symptoms, your doctor might want to rule out other causes.

Tests may include:

• Blood test: This is done check for celiac disease or hypothyroidism.
• Barium enema: This is an X-ray of the large intestine and is performed to look for Hirschspring’s disease, a disorder caused by an abnormal migration of nerve cells to the colon and or rectum.
• Motility testing: This assesses the motor coordination of the anal muscles.
• Abdominal X-ray: This lets doctors see the amount of stool your child has in the colon. 

“If constipation has been present for several months or years, it can take that long to reverse the process,” Dr. Rosen says. “We work with families to establish an appropriate plan that often involves long-term use of a maintenance medication, with gradual weaning. If medication is stopped too soon, the ‘clean-out’ phase often has to be repeated, which is not fun for anyone.”

But the hope, Dr. Ameen notes, is for children to ultimately avoid constipation by eating well and incorporating a healthy lifestyle.

“I don’t like using chronic medications on my patients and I truly believe if we educate children and their families about good eating habits, they can carry those on for a lifetime and prevent many diseases,” she says. 

At our dedicated Pediatric Healthy Gut & Constipation Program, we offer comprehensive care geared specifically toward children. Our board-certified pediatric gastroenterologists work closely with surgeons, a registered dietitian, a nurse coordinator and a social worker.

“We spend a lot of time explaining to patients that this problem did not happen overnight, and we can’t fix it overnight either,” Dr. Ameen says. “We talk about how it will require regular attention and follow-up visits with us and changes in diet, lifestyle and behavior. But at the end of the day, your child will be much healthier and everyone will be happier.”

And if your child’s constipation requires more advanced treatment or is caused by an underlying medical condition, our Pediatric Colorectal Disorders Program specializes in complicated cases.