A significant number of infants and children become constipated. In fact, this is the reason behind 3 out of 100 visits to the pediatrician, and 1 in 4 visits by children to special gastroenterological clinics. Although there is no specific definition, constipation is usually difficulty or delay in passing stools or a tendency to produce hard, dry faeces which are difficult to pass. In all cases, the child feels uncomfortable, which adversely affects his/her quality of life and worries his/her parents.

Normally, in the first week of life, infants pass 1 to 9 stools per day. This reduces to 2 stools a day in the second year and 1 in the fourth year.
Breastfed infants rarely become constipated.

Causes of constipation in children

In most cases, constipation is functional (idiopathic), which means it is not due to any bodily misfunction but rather is due to genetic, environmental, psychological or dietary factors. The most common causes are:

• A diet which is low in fiber and does not contain sufficient water and other fluids, and inadequate physical activity.
• The deliberate retention of stools for a variety of reasons (e.g. the child is ashamed to go to the toilet, does not want to interrupt his/her play, or is afraid to go because of a previous painful experience). This condition can lead to anxiety, pain, abdominal distension, irritability and anorexia. In addition, diarrhea and soiling due to impacted stools are not uncommon.
• Some medicines, such as antacids or opioids.

In the first few weeks of life (usually up to 10 weeks of age) infants can display symptoms which, despite the fact that they can be confused with constipation, are actually due to the baby’s digestive system not being fully matured. This problem decreases with age (the increase in intra-abdominal pressure does not lead to the muscular system of the pelvis relaxing). In this case, the newborn becomes very red in the face, strains and cries for 5-10 minutes before passing a stool, but he/she does pass a stool every day and they have a normal colour and texture.

Often, babies become constipated in transitory periods (e.g. when the baby is changing from breast milk to formula or cow's milk, or from liquid to solid food, etc.).
Sometimes, constipation may be due to anatomical abnormalities, neurological disorders or diseases such as Hirschsprungs.

Symptoms of constipation

The most common symptoms of constipation are:
• no stools for a few days or hard and dry stools once a day
• large dry, hard stools
• stomach pains
• difficulty and pain on passing stools
• the presence of fluid or solid and dehydrated fecal matter in the child's underwear (a sign of impacted stools)
• the child making "odd" movements that indicate that it is holding in the stools (for example, he/she stands on his/her tip-toes and then shifts his/her weight to his/her heels, tightens his/her gluteal muscles etc.).

The child should definitely be taken to the pediatrician if he/she or she develops symptoms such as fever, vomiting, blood in the stools, severe swelling in the abdomen, painful stretch marks around the rectum ("striated" wounds), mucosal sections protruding from the anus and difficulty in passing stools despite the child’s efforts.

How is constipation treated?

Depending on the age of the child and the severity of the problem, changes to diet are the recommended treatment for constipation, along with adopting healthy habits. In some cases laxatives should be given (when the pediatrician deems it necessary).
Changes in the child's diet:

• Sufficient fluid intake. Breast-fed infants should be given 60-120 ml of fluids (e.g. water or chamomile) one or two times a day, between meals. Older infants (e.g., those over 4 months old) are usually given fruit juices e.g. plum, orange, apple or pear juice, as well as water or herb drinks. These juices are often diluted with water, depending on the infant’s age and with the consent of the pediatrician).
• It is recommended that the fibre intake of infants who are eating solid food (usually after 4-6 months) should be increased. Some foods which are rich in fiber are whole grain cereal (e.g. high-fiber breakfast cereals, porridge oats, etc., which can even be gradually added to purees), fruit (e.g. plums, pears, apricots, etc.) and vegetables (e.g. tomatoes, courgettes, etc., whole, pureed or in sauces accompanying the food), again depending on the age of the child.
• In recent years, many pediatricians have been recommending milk or foods with prebiotics which help the bowel to function properly and produce soft stools.

Helping children to develop regular bowel habits

To help your child develop regular bowel habits, you can ask him/her to sit on the toilet for at least 10 minutes at the same time each day, preferably after a main meal. The child should feel comfortable (for example, if his/her feet do not reach the floor give him/her a stool to rest them on) and be in a calm and safe environment. Sometimes giving rewards, for example a small sticker or toy, can make the child more eager to follow this daily routine.

Treatment with medicines

If the pediatrician deems it necessary, laxatives should be given. The treatment lasts for several months, and is always accompanied by an increase in the child’s fiber and fluid intake. The treatment stopped gradually.
Improving nutrition and teaching the child are the key measures used to tackle constipation in infancy and childhood. At the same time, it is equally important that parents are patient and good humoured when they apply these methods so they do not cause the children to react negatively or to refuse to cooperate.

Margarita Octoratou
Dietitian/Nutritionist
Health Counselor at the Institute of Social and Preventive Medicine (ISPM)