Functional constipation is a worldwide issue affecting children of all ages. While it's difficult to say how many kids suffer from ongoing constipation, it could be as high as 31% of the population, and it's one of the most common reasons parents seek out gastroenterologists.
Periods of constipation can be completely normal for kids and often accompany changes in routine, like switching from breast milk to solid food or going to school for the first time. But if constipation becomes a chronic problem, it not only affects behavior and mood but can lead to a lower quality of life and other health issues that are carried into adulthood.
Conventional treatments often include oral laxatives, diet changes, and toilet training. An integrative approach to pediatric constipation takes it a step further and may include mind-body interventions, manual manipulation, and nutritional supplements to get things moving in the right direction.
In this article, we'll discuss what pediatric constipation is, how it's treated, and what therapies integrative providers can use to support healthy, normal bowel movements in kids.
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What is Constipation?
Constipation results when kids hold stools or stool simply accumulates in the colon. According to the World Journal of Clinical Pediatrics, this type of functional constipation is characterized by infrequent stools, painful bowel movements, fecal incontinence, stool withholding, and at times, large-diameter stools. Kids can even experience what's known as encopresis, or the leakage of soft stool around a hard stool.
Encopresis results when stool stays in the GI tract longer than it should. Since water reabsorption occurs in the colon, retained stool can become very hard and dry as time goes on. The stool can increase in size, making it more difficult to pass, and the smooth muscles of the intestines may also become affected. Softer, newer stool can seep around the larger stool mass and exit the anus, which a child has no control over. This process can be painful, so kids may try to avoid defecating at all costs, which further complicates the situation.
If there aren't any structural or biochemical causes of constipation, then functional constipation can be diagnosed using the Rome IV criteria. The criteria for diagnosis differ depending on the age of the child.
How Common is Constipation in Pediatrics?
Pediatric constipation is very common worldwide and is a top reason kids visit their pediatrician or a gastroenterologist. It's estimated that roughly 30% of kids deal with chronic constipation. The majority of constipation cases (96%) can be attributed to functional issues like poor diet, limited physical activity, or poor toilet training. But there are organic causes of constipation like Hirschsprung disease, hypothyroidism, and celiac disease, which can be ruled out with conventional testing.
When it comes to bathroom habits, every child is different. Generally speaking, one to two solid bowel movements each day are considered normal for most kids over the age of 2. One study found 96% of children have bowel movements ranging from up to three times per day to once every other day. But some kids can go up to three days without a bowel movement and still be completely fine. If a child has pain-free, normal bowel movements every few days, there’s probably no cause for concern.
Constipation Symptoms
Periods of constipation are normal for kids, especially when there are changes to their normal routine, a stressful event, or changes in diet. These periods of constipation often resolve on their own. But if your child experiences fewer bowel movements than they normally do on a consistent basis or displays any of the following symptoms, it's probably time to seek out a professional:
- Going several days without a bowel movement
- Complaints of discomfort or pain with bowel movements due to hard stools
- Abdominal pain
- Cramping
- Nausea
- Rectal bleeding (related to tears from hard stools)
- Fecal incontinence (soiling themselves after being toilet trained)
- Behavior changes and poor behavior
- Crossing legs, clenching buttocks, or making faces to try to hold in stool
- States they're afraid to have a bowel movement
Causes of Constipation in Children
Functional constipation may be the result of the interplay between the gut and the brain. Risk factors for constipation can be broken down into two main categories, centrally-mediated and gut-health mediated.
Centrally-Mediated Factors
The following risk factors are considered centrally-mediated:
Stress
One cross-sectional survey of 10 to 16-year-olds found higher rates of constipation among those with stressful life events. The researchers concluded that stressors (like separation from a best friend, frequent punishment by parents, family unrest, and failing an exam) likely impact the gut-brain axis, which can alter motility and colon transit time.
Abuse, Strict Parenting Styles, and Altered Mental Health
Childhood physical, emotional, and sexual abuse, as well as anxiety, have been found to be associated with functional constipation in kids. And kids with overprotective parents who have strict disciplinary tactics may have an increased risk.
Toilet Training
Poor toilet training, meaning training too early, inconsistent training, or too much pressure from parents, may create fear around toileting, which can lead to stool-withholding behaviors.
Gut-Health Mediated Factors
The following risk factors are considered gut-health mediated:
Diet and Physical Activity
The standard American diet, which is low in produce and high in ultra-processed foods, may contribute to the development of functional constipation. One observational study found kids who consumed less than three servings of fruits and vegetables per day and less than 500mL of water per day were at higher risk of functional constipation. Similarly, another study found lower consumption of fruits and vegetables to increase constipation risk. Other observational research has found kids who eat fast food more frequently and who eat at later hours to be more constipated. And finally, higher consumption of milk or the presence of cow's milk protein allergy may also contribute to constipation.
Along the same lines as diet, physical inactivity has been linked to constipation. Kids who spend more time in front of screens may be more at risk, whereas increased physical activity seems to be protective.
Altered Gut Microbiota
The gut microbiome is quickly becoming a target of therapy for a myriad of conditions, including constipation. While most of the research studies are small, kids with functional constipation seem to have an altered gut microbiome when compared to healthy controls. One study found fecal samples of kids with functional constipation had higher levels of the species Bacteroides fragilis, Bacteroides ovatus, Bifidobacterium longum, Parabacteroides and lower levels of Alistipes finegoldii. Another small study found kids with constipation to have higher levels of Clostridia and Bifidobacteria. In addition, small intestinal bacterial overgrowth (SIBO) may be a contributor to constipation in children.
Functional Medicine Labs to Test for Root Cause of Constipation in Kids
Conventional testing for constipation in kids may include blood testing, barium enema, and motility testing to rule out underlying causes like celiac disease, hypothyroidism, and Hirschsprung's disease. Functional medicine labs can also be used to help uncover underlying causes of constipation, like dysbiosis, SIBO, and cow's milk allergy.
Comprehensive Stool Analysis
The Comprehensive Stool Analysis by Doctor's Data is a valuable test for evaluating gut health. This test analyzes stool samples for various markers of gastrointestinal health, including microbial balance, digestive enzyme levels, and inflammation. By identifying potential imbalances and digestive issues, the Comprehensive Stool Analysis can help uncover the root causes of constipation and guide targeted treatments to improve bowel function.
Organic Acids Test
The Organic Acids Test (OAT) by Great Plains Laboratory is a comprehensive metabolic assessment that measures over 70 markers in a urine sample, including those related to gut health, nutrient absorption, and detoxification. The OAT can provide insights into potential imbalances or deficiencies contributing to constipation by evaluating these markers. Certain organic acids can indicate dysbiosis in the gut, which could be underlying constipation.
SIBO Testing
The SIBO Breath Test by Genova Diagnostics is a non-invasive test that measures hydrogen and methane gases in the breath to assess the presence of small intestinal bacterial overgrowth (SIBO). SIBO can cause various gastrointestinal symptoms, including constipation. If SIBO is identified as a contributing factor to a child's constipation, targeted treatment with antibiotics, probiotics, or dietary changes may help restore gut balance and improve bowel function. *Please note this test is not appropriate for children under 25 pounds.
Food Sensitivity Testing
The Cyrex Array 10 - Multiple Food Immune Reactivity Screen by Cyrex Laboratories is a food sensitivity test that measures your body's immune response to various foods. This test analyzes your blood samples for IgG and IgA antibodies against common food proteins. Cow's milk allergy is a common culprit for kids with constipation, but there may be other food sensitivities to address, so identifying them and making the necessary diet-related adjustments can help to relieve constipation and support improved digestion.
Conventional Treatment for Pediatric Constipation
Addressing functional constipation early on is important to prevent complications. If your child has suffered from constipation for quite some time, an abdominal X-ray can give an idea of how much stool is in the colon. If significant amounts of stool are present, conventional treatment may include initial disimpaction with high-dose laxatives to help clean out the colon. Once the excess stool is removed, a maintenance laxative medication may be recommended while you're working on nutrition and physical activity-related changes and toilet training.
Conventional nutrition-related recommendations for constipation typically involve adding more fiber, addressing cow's milk allergy, and ensuring adequate fluid intake. We'll get into more specific nutrition recommendations later on. Other conventional treatments are centered around consistent toilet training and physical activity.
Toilet Training Tips for Constipation
Stool withholding behavior may be a significant contributor to functional constipation in a large percentage of cases. It's important to take the stress out of toileting. Parents can encourage kids to sit on the toilet for several minutes immediately after waking and after meals to get them into the habit and more comfortable with toileting. Training videos can be helpful for showing kids how to sit properly and how to expel stools effectively.
Physical Activity for Constipation
Research has found kids who move for more than 60 minutes per day tend to have less constipation, so it's important to encourage daily activity. Avoiding excessive screen time and planning active play time for kids of all ages can improve overall health and GI tract function.
Functional Medicine Treatment for Constipation in Children
Integrative providers focus on dietary-related changes, toilet training, and physical activity as well, but have a variety of other tools at their disposal for improving GI tract function and quality of life.
Diet for Constipation in Kids
There isn't one specific diet to recommend for kids with constipation. Avoiding the standard Western diet in favor of a personalized Mediterranean-type diet can certainly be helpful. Since cow's milk allergy is common in kids with constipation, assessing for this type of allergy and trialing a cow's milk-free elimination diet may be helpful for kids who don't respond to laxatives. But it's important to avoid strict elimination diets and food rules with this population.
Fiber intake is a significant consideration, as low-fiber diets have been found to contribute to constipation. Up to 90% of children may not be consuming the recommended amount of fiber daily, which for kids over the age of two is their age plus 5 to 10 grams per day. Research is mixed on whether adding various types of fiber like acacia, psyllium, and inulin provides benefits, but they may be considered if your child isn't willing to eat adequate amounts of fiber.
While simply increasing water intake alone hasn't been shown to improve constipation significantly, it's important to make sure your child is drinking an appropriate amount of fluid, especially when you're working to increase fiber intake. Fluid requirements can be calculated using the following formula:
For the first 10 kilograms (kg), provide 100 milliliters (mL)/kg per day. For the next 10 to 20 kg, add an additional 50mL/kg per day. For remaining weight over 20 kg, add 20mL/kg per day. For example, a 50-pound child (22.7kg) would need about 1554 mL of fluid per day (or approximately 6.5 cups).
Supplements for Constipation That Are Safe for Children
There are very few studies on the effects of nutritional supplements, herbal and botanical preparations, and probiotics in children with constipation. One 2019 systematic review concluded there's no reason to recommend probiotics for kids with functional constipation. But probiotics have been found to improve stool frequency, intestinal transit time, and lead to more complete bowel movements in adults. Studies on probiotics in kids have found them to be extremely safe, they're low-cost, and have a variety of other positive health effects, so it may be worth it to try probiotics in conjunction with other recommended therapies.
Complementary and Alternative Medicine for Constipation
Conventional treatments for childhood constipation can be very successful. But the addition of complementary therapies that address stress and motility can often enhance the overall outcome.
Mind-Body Interventions and Stress Management
Kids may benefit from cognitive behavioral therapy (CBT), which can help them feel more confident and remove the fear that can surround passing stools. Play therapy has been found in a small study to improve encopresis (although the study participants didn't have a constipation diagnosis). And while studies assessing the benefits of yoga in kids with functional constipation are lacking, yoga has been found to improve IBS symptoms in adolescents, so it may be an option to consider.
Physiotherapy and Manual Manipulation
One study of kids aged 4 to 18 with constipation found physiotherapy that included isometric (contraction without movement) training of the abdominal muscles, deep breathing exercises, and abdominal massage increased defecation frequency. Another study found six weeks of abdominal massage for twenty minutes a day improved constipation and decreased laxative use.
And pelvic floor retraining has been shown to reduce the need for laxatives, as well as improve constipation and quality of life in kids with constipation.
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Summary
Constipation has become a common occurrence for kids and teens for a variety of reasons, many of which are lifestyle and nutrition-related. When constipation becomes chronic, kids can experience changes in mood and behavior, but they also have a reduced quality of life with an increased risk of long-term complications.
Conventional therapies like laxatives, changes in diet and physical activity, and appropriate toilet training can be effective for some kids but may not always lead to complete healing. Additionally, parents may worry about the potential side effects of using medications like laxatives for extended periods.
An integrative approach to constipation in pediatrics combines conventional therapies with complementary options like additional testing to help determine root causes, mind-body techniques, physiotherapy, manual manipulation, and possibly probiotics. This type of approach allows for a more personalized treatment plan, which may help to improve outcomes.
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