Help! My little one is constipated…
As a GP, we often get asked about constipation in babies and children. It is very common. As mums, we can completely sympathise that it’s not very nice to see your little one uncomfortable! So here is a mini overview of why constipation can happen, what parents can do to help and when to seek medical advice.
Constipation is the most common bowel problem and affects up to 30% of ALL children under the age of 5! The one thing we always tell parents is that they need to have patience with poo; it takes a lot of perseverance and a LOT of patience to treat constipation. One of our children (now 8) suffered with it for years and it made weaning and potty training a total nightmare. So, we really get how tough it can be!
What is Constipation and how do I know if my baby or child is constipated?
The National Institute for Health Care and Excellence (NICE) defines constipation as “A decrease in the frequency of bowel movements characterised by the passing of hard stools which may be large and associated with straining and pain”.
The reality is, as parents, you will get an idea of what a ‘normal’ poo pattern is for your little one. It’s important to identify constipation as early as possible and treat it, to prevent unnecessary suffering and pain!
Typical symptoms include:
- Pooing less than 3-4 times a week
- Hard, large/long poos or smaller “rabbit droppings”
- Distress or pain when passing stool
- Sometimes bleeding from the bottom due to the hard poo (often bright red and seen on wiping)
- In those who are potty training – a reluctance to go to the toilet/sit on potty, appearing to try to hold onto their poo
- Complaining of tummy pain/cramping in older children
- Food refusal in children
- Smelly farts that happen regularly
- ‘Skid marks’ in underwear or soiling
Kirans Top Tip: if you think your little one is constipated, try the SWEETCORN CHALLENGE!
Step 1: Don’t eat any sweetcorn for 1 week and then give your child a handful of sweetcorn to eat
Step 2: Make a note of the time(don’t forget to write it down)
Step 3: Watch their poo (fun times!) and see how long it takes to come out the other end.
The ideal or normal time for the ‘sweetcorn challenge’ is 12-36 hours and suggests your little one’s bowels are in working order!
If it takes more than 36 hours, constipation needs to be considered!
WHY oh WHY does constipation happen?
In order to understand why constipation happens, it’s important to know how poo is made and what happens normally.
Once we eat food, it is partially digested by the acids in the stomach and then passes into the small bowel or intestine. Here the body takes out all the nutrients it needs and produces watery/soft poo which then passes to the large bowel. The larger bowel is the body’s muscles and it squeezes the poo along the entire bowel. As the poo moves along, the body absorbs water until the poo gets to the rectum. Here a message is sent to the brain that you need to poo and off you go! If any part of this process is disturbed, constipation happens!
Sometimes children don’t act on this signal to poo (either due to fear, anxiety, painful poo in the past or they’re too busy playing) and the poo sits in the rectum/large bowel. The longer the poo sits there, the more water is absorbed, and the bigger and harder it gets. Eventually the poo gets so big and hard, it stretches the rectum and that ‘I NEED A POO’ signal to the brain is lost. Children may still pass watery stool, known as overflow/soiling, as some watery poo leaks around the hard lumps and out the bottom
In order to treat the constipation, we need to soften ALL of the hard lumps AND retrain the rectum to send that important message to the brain, which can take a while!
Is constipation in children something to worry about?
In 95% of children the cause of constipation is ‘functional’ meaning there is not underlying disease. Causes of constipation in children include:
- Diet lacking in fibre
- Inadequate fluid intake
- Emotional stress/Anxiety: e.g. new nursery, school, bullying
- Fear of the potty/toilet
- Lack of physical activity
- Poor pooing hygiene
- Withholding poo
In 5% of children constipation is ‘organic’ meaning it’s due to underlying problems or a side effect of drugs. Common drugs that cause constipation in children are iron supplements, Gaviscon and other specialist medications. Children that have organic constipation may have signs such as constant bloating, vomiting, blood in stool, weight loss and constant tummy pain. Some of these can also happen quite frequently in functional constipation, which is why early recognition and treatment is the key to getting on top of constipation.
When does constipation happen?
In reality, constipation can happen at any time during childhood but there are three periods when children are prone to developing constipation: weaning, potty training and starting nursery/school. In addition sometimes if your little one isn’t having enough fibre in their diet, not drinking enough fluids or feeling worried or anxious about something, this can also cause constipation.
Toddlers are also particularly susceptible to constipation, especially if they are going through a food refusal phase (yes we all have them!) and drinking a lot of milk. Cow’s milk in particular is high in fat and if children are drinking more than 500ml a day, it can lead to constipation.
Teenagers are also notorious for being really constipated, opening their bowels maybe once every few days or even once in a week! This is traditionally due to poor dietary intake of fibre, water and generally eating more junk food than they should! If you have a teenager, please ensure they are getting the right foods in! They may say they are ‘FINE’ but in my experience, once we ask the right questions, most are constipated!
So why does poo change when weaning?
Let’s talk about the changes that can happen during weaning. It is so common for babies to experience some constipation and naturally, as parents, we worry. But why does this actually occur? Switching from a milk-only diet to include solids means the digestive system has to adapt. It will become more similar to adult poo – thicker, usually darker in colour and smellier too (don’t we know about it…!).
The appearance can change depending on what food they are given and some foods (e.g. sweetcorn) may be difficult to digest at first and appear practically unchanged in their poo. How often your baby poos may also change and in general frequency decreases as they get older. On average a 1 year old poos twice a day but again this varies between babies. The most important thing is what is normal for *your* child so try not to compare with others.
Reassuringly, for the majority of children there is no underlying physical reason for what is causing their constipation.
How can I help if I think my baby or child is constipated?
The best thing you can do is understand WHY constipation happens (see above) and how you can prevent it. The earlier we identify it, the easier it is to treat and the less there is need for medical therapy and hospitalisation!
The ERIC website has fantastic resources on educating kids about constipation and making poo fun! It’s also a great way to empower children about their body and how they can feel better.
Constipation in teens – Eric
Generally, I always tell parents that constipation can often take as long to treat as how long their child has had it. It isn’t simply about getting ‘rid of poo’ but also retraining your gut and bottom to respond to your body’s cues to poo, which is often the hard bit and can take months.
Here are some things you can try:
- Give babies over 6 months old sips of water with meals (can be tap water) or encourage regular fluids in toddlers. See Charlotte’s blog on recommended water intakes for babies.
- For older children you could give them a fun bottle or get them to decorate one with stickers so it makes it fun for them.
- For teenagers, there are apps to remind them to drink or giving them a bottle with marks on when to sip are great
- Increase the fibre content of their diet
- Things like brown rice, oats, pulses, beans, vegetables (e.g. sweet potato, broccoli, carrots, green beans), high fibre cereals (such as Weetabix) can help.
- Many parents find that the “P” fruits such as prunes, pears, plums really help with softening the stool and making it pass easily. This is because these fruits are high in sorbitol which acts as a natural laxative. However other fruits like raspberries also have a high fibre content so can certainly help too. Make sure these are prepared in a safe manner that is appropriate for your child’s stage of development e.g. for babies you could make a puree and give alone or mix into yoghurt.
- You might have heard a theory that bananas (especially unripe ones) and apples are not as helpful with constipation but there isn’t anything conclusive confirmed. I would say that it’s just something to bear in mind but there is no need to avoid them completely. They both still have many nutritional benefits. If your little one absolutely loves them you could perhaps still offer alongside some of the other fruits mentioned above.
- Limit their milk intake
- Milk is high in fat and calories and drinking excessive amounts can be a cause for both constipation and iron deficiency in toddlers!
- Babies over 12m should ideally be having three portion of dairy a day and no more than 400ml/13oz of milk a day. You can find out more about milk and dairy recommendations in Charlotte’s factsheet ‘All About Baby’s Milk’.
- Bicycle legs (moving baby’s legs in a bicycle motion can help stimulate the bowel) and tummy massage can help.
- Plenty of physical activity throughout the day can also help. Exercise sends blood to the gastrointestinal tract which helps to stimulate bowel movements.
- For babies who aren’t walking, tummy time, practicing rolling over or crawling all count as physical activity and they should have 30 minutes each day (does not all have to be in one go!).
- For children aged 1-5 years old, they need 3 hours of physical activity per day. This can sound like a lot but encompasses things like standing up, moving around, playing, as well as skipping, jumping, running, outdoor activities.
- For children >5y, 20-30minutes of activity is recommended. Walking, running, riding a bike are all great ways to keep active and build healthy habits.
Kiran’s Top Tip! What is the correct toilet position for children?
For a complete, healthy bowel movement, children (and adults!) should be in a squatted position over a toilet. Squatting encourages the pelvic floor to relax, and prevents straining.
Children and adults can achieve this by raising their feet on a stool, a stool stool if you will(!), so that their knees are higher than their bottom. This is a good habit to form early on and will help your little one well into adulthood!
When to worry and when should I see my GP?
If you have tried these measures at home but don’t see much improvement over the course of a couple of weeks then I would recommend seeing your GP. They can ask some detailed questions and decide on the best management plan. On occasion this may include prescription of laxatives which can certainly be very helpful in some scenarios.
You should also seek medical advice if you notice the following colour changes of poo:
- Red (indicates bleeding)
- Black (except for meconium, indicates blood from higher up the gut that has been altered and turned this colour, or if your child is on iron supplements)
- White/pale (could indicate a liver problem). These should be discussed with your GP immediately.
For helpful resources:
NHS website – Constipation in children
Patient UK – Constipation in children leaflet
Eric – The Children’s Bowel and Bladder charity – www.eric.org.uk (for older children). Some very helpful leaflets for children here.