SYMPTOMS

What is childhood constipation? What are the manifestations of childhood constipation?

Childhood constipation refers to a decrease in a baby's bowel movements, meaning no bowel movement for more than three days, painful defecation, or hard, thick stools with excessive straining. Compared to reduced frequency of bowel movements, hard stools, painful defecation, and straining are stronger indicators of constipation. Therefore, when a baby exhibits one or more of the following signs, constipation should be considered ^[1]:

1. No bowel movement for more than three days, accompanied by pain during defecation;

2. Hard or unusually thick stools that are difficult to pass;

3. Pain during defecation or abdominal pain, with infants arching their backs and crying;

4. Unexplained loss of appetite, irritability, and restless sleep;

5. Abdominal bloating, vomiting, or increased spitting up in infants;

6. Children may report symptoms such as itching, swelling, or pain around the anus.

It is important to note that if a child has a bowel movement every 2–3 days with normal stool consistency and volume, and no other discomfort, it should not be considered constipation.

How to distinguish between childhood constipation and "storing belly"?

"Storing belly" is a folk term and not a clinical medical term. It generally refers to a change in an infant's bowel movement pattern without other discomfort. For infants under six months who have not started solid foods, "infrequent bowel movements" are usually due to storing belly, while true constipation is rare. In simple terms, storing belly means "nothing to pass for now," while constipation means "wanting to pass but unable to." The two can be distinguished in three ways:

1. Observe the child's mood: Normal activity or irritability
   Storing belly is normal. Although it may be accompanied by a temporary decrease in milk intake, the baby remains emotionally stable, with normal activity and sleep. In contrast, constipation causes discomfort and irritability, with "accumulated waste" in the belly, leading to significantly reduced milk intake and frequent crying.

2. Observe defecation behavior: Smooth or painful
   A child with storing belly passes stools smoothly without signs of pain, while a constipated baby strains visibly, with facial expressions of effort or even turning red.

3. Observe stool consistency: Soft yellow stools or hard stools
   A child with storing belly passes soft yellow or mushy stools, while a constipated child may pass dry, hard, pellet-like stools, sometimes with blood streaks or mucus.

What is chronic functional constipation in children?

Chronic constipation is classified as chronic functional constipation when symptoms persist for at least six months and cannot be entirely attributed to another medical condition. Long-term constipation can lead to discomfort such as dizziness, fatigue, loss of appetite, irritability, bitter or foul breath, mouth ulcers, restless sleep, anxiety, depression, and abdominal bloating due to toxic substances like phenols, amines, and indoles in the stool ^[2,3].

Childhood constipation is a common clinical symptom in pediatrics, particularly in infants and toddlers, and is more prevalent in boys than girls. There are significant individual differences among children. Over 95% of cases are functional constipation, which can be relieved or cured with conservative treatment. Less than 5% of constipation cases are due to organic causes (pathological changes in organs or tissues), such as Hirschsprung's disease or congenital anal stenosis, which may require surgical intervention ^[3].

TREATMENT

What to Do About Infant Constipation? How to Care for Infant Constipation?

Addressing the Cause

1. Infants often experience constipation during the transition to new complementary foods or formula.

   • Pause introducing new complementary foods or formula for 3–5 days while addressing constipation until bowel movements return to normal. Then reintroduce the new foods or formula to observe whether constipation recurs. If constipation reappears, seek medical attention.

   • When adding complementary foods, pair protein-rich foods with high-fiber options and ensure adequate fluid intake. Otherwise, stools may become dry and hard, leading to constipation.

   • Supplement with appropriate amounts of water based on the type of food. For example, meat, poultry, and eggs require about twice their weight in water; grains need roughly five times their dry weight; and fruits and vegetables, which are lower in energy, require about one-third of their weight in water^[4].

2. Toddler constipation due to poor bowel habits.

   • Start toilet training early (using books or guides as references), choose a comfortable potty, and avoid forcing the child if they resist. Begin training only when the child is ready.

   • Establish a regular bowel movement routine. Infants over three months can begin training. After morning feedings, assist them in sitting on the potty for 15 days to a month^[1]. Avoid distractions like toys during training.

3. School-related constipation in children.

   Children may avoid using school toilets due to discomfort, schedule changes, or environmental/psychological factors. Parents should regularly ask about their child’s bowel movements at school, encourage post-meal bathroom breaks, and request teacher support if needed.

Treatment Recommendations

If the above measures fail, consult a doctor. For infants four months and older, 50–100 mL of juice (e.g., prune or pear) daily may help, starting with small amounts and stopping once symptoms improve. For younger infants, 25–50 mL of juice is recommended, but follow medical advice, as early complementary feeding may increase allergy risks^[5].

For persistent constipation, medications like lactulose may be used under medical guidance. Acute cases can taper off once resolved, while chronic cases may require months to years of treatment^[6].

Early constipation (e.g., 1–2 days without bowel movements but no discomfort) can often be resolved with dietary adjustments before considering medication.

Baby Massage/Exercise

Inactivity worsens constipation. Movement and abdominal massage stimulate bowel activity. For infants:

• Gently massage the abdomen clockwise around the navel (10 rotations, 5-minute breaks, repeated three times). Repeat as needed.

• Lay the baby on their back and gently move their legs in a bicycling motion (10 reps per leg) to aid digestion^[1].

Can Glycerin Suppositories Treat Infant Constipation?

Yes, but sparingly. Suppositories are not first-line treatments. Use only for hard stools stuck at the rectum causing pain. Overuse may cause dependency or irritation^[7].

Does Drinking More Water Treat Infant Constipation?

Water aids bowel motility, especially with high fiber intake, but it only alleviates symptoms and prevents constipation—it doesn’t cure it if dehydration isn’t the primary cause^[8].

Can Probiotics Treat Infant Constipation?

Probiotics are not primary treatments. Effects vary, and they may worsen constipation^[8]. Short-term use is acceptable if previously effective, but long-term use isn’t advised.

Can Yogurt Treat Infant Constipation?

No. For infants under one, breast milk or formula should dominate. Yogurt’s high protein/minerals strain kidneys, and its probiotics lack sufficient evidence for constipation relief.

Can Bananas Treat Infant Constipation?

No. Unripe bananas contain tannins that worsen constipation. Even ripe bananas are low in fiber. Prunes, apricots, pears, and high-fiber veggies like broccoli are better options^[8].

How to Prevent Infant Constipation?

1. Ensure fiber intake: Age (years) + (5–10) grams/day. Balance fruits (50–350 g by age), veggies, and whole grains. Avoid excess unripe fruits.

2. Maintain fluid intake:

   • Under 10 kg: 100 mL/kg.
   • 10–20 kg: 1000 + 50 × (weight – 10) mL.
   • Over 20 kg: 1500 + 25 × (weight – 20) mL.
   Limit milk to 360–500 mL/day for children over one; prioritize water^[6].

3. Include gas-producing foods (e.g., mushrooms, radishes, sweet potatoes) to stimulate bowel movements^[6].

DIAGNOSIS

When should a child with constipation seek medical attention?

For babies who have not yet started solid foods, if formula is ruled out as a cause, recurrent constipation without obvious triggers—especially in infants or newborns—requires medical evaluation to check for potential organic causes, such as Hirschsprung's disease or anorectal malformations. Additionally, seek prompt medical attention if any of the following occur:

1. Constipation lasting longer than 4 weeks, or no bowel movement after 1–2 days of following treatment, care, and prevention recommendations.
2. Recurrent constipation of unknown cause.
3. Oral medications or other methods are ineffective, requiring frequent use of glycerin enemas.
4. Blood in the stool, underwear, or diaper.
5. Constipation accompanied by bloating, abdominal pain (severe pain), nausea, or vomiting.
6. Constipation severely affects daily life, such as slow weight or height gain.

Examinations such as physical checks, stool tests, or abdominal ultrasounds may be needed during the visit.

Which departments should parents visit for childhood constipation?

Neonatology, Pediatrics, Gastroenterology

1. Infants under 28 days old may visit Neonatology or Gastroenterology.
2. Children under 14 years old may visit Pediatrics or Gastroenterology.

POTENTIAL DISEASES

What are the common causes of constipation in children?

• Dietary habits: This is the primary cause of constipation in children.

  • Inadequate food intake: Infants consuming too little food may experience reduced stool volume and increased thickness due to fluid absorption during digestion. Additionally, insufficient sugar content in milk can weaken intestinal motility, leading to dry stools. Prolonged inadequate nutrition may also cause malnutrition, reducing the tone of abdominal and intestinal muscles or even atrophy, worsening constipation.
  • Improper food composition: Stool consistency is closely related to food composition. For example, consuming large amounts of calcified casein results in stools containing insoluble calcium soaps, increasing stool volume and the likelihood of constipation. Carbohydrates like rice flour and wheat-based foods are more likely to cause constipation compared to whole grains.
  • Poor dietary habits: Children often prefer refined foods, are picky eaters, favor meat, and consume little or no vegetables or fruits. A diet low in fiber also increases the risk of constipation ^[1].

• Bowel habits: Irregular lifestyles and failure to establish a regular bowel movement routine can disrupt the body's natural reflex for defecation, commonly leading to constipation. Additionally, school-age children often avoid morning bowel movements due to class schedules, further contributing to constipation ^[1].

• Disease factors: Conditions such as congenital megacolon, congenital myasthenia, dermatomyositis, congenital anal stenosis, congenital anorectal malformations, rectoperineal fistula, rectal intussusception, and rectal mucosal prolapse can all cause constipation due to anatomical abnormalities ^[1].

• Endocrine disorders: Hypothyroidism or hyperparathyroidism in children can lead to constipation. Insufficient insulin secretion may also weaken intestinal motility, causing constipation. Increased total indole levels in the sigmoid colon are also associated with constipation.

• Neurological factors: Studies suggest that 20% of pediatric constipation cases are psychologically induced, termed psychogenic constipation. Poor mood, anxiety, depression, or behavioral disorders in children may inhibit peripheral autonomic nerve control over the colon, leading to constipation ^[1].

• Maternal factors: Breastfeeding mothers consuming overly salty or spicy foods may contribute to infant constipation. Certain formula brands may also cause constipation.