Should Your Child See a Doctor?
This Care Guide Covers
- Pain or crying when passing a stool (bowel movement or BM) or
- Can't pass a stool after straining or pushing longer than 10 minutes or
- 3 or more days without passing a stool (Exception: Breastfed and over 1 month old)
See Other Care Guide If
- Breastfed and questions about normal stools. See BREAST-FEEDING QUESTIONS.
- Formula-fed and questions about normal stools. See BOTTLE-FEEDING QUESTIONS.
- Doesn't meet the definition of constipation and over 1 year of age. See ABDOMINAL PAIN.
Causes of Constipation
- High Milk Diet. Milk and cheese are the only foods that in high amounts can cause constipation. It causes hard pale stools. This is why you want your child to eat a well-balanced diet.
- Low Fiber Diet. Fiber is found in vegetables, fruits and whole grains. Fiber keeps stools soft, bulky and easy to pass. A low fiber diet causes hard, small stools.
- Low Fluid Intake. This can also cause stools to be dry and harder to pass. It's rarely the only cause of constipation.
- Lack of Exercise. Exercise also keeps the bowel from slowing down. Not a cause in children unless they are confined to bed.
- Holding Back Stools Because of Pain. If passing a stool causes pain, many children will hold back the next one. This can happen with a Strep infection around the anus. It can also occur with a bad diaper rash or anal fissure (tear).
- Holding Back Stools Because of Power Struggles. This is the most common cause of recurrent constipation in children. Most often it's a battle around toilet training. If they are already trained, it may begin with the start of school. Reason: some children refuse to use public toilets. Some children postpone stools because they are too busy to sit down.
- Slow passage of food through the intestines. Most often, this type runs in families. Called slow transit time.
Stools: How Often is Normal?
- Normal Range: 3 per day to 1 every 2 days. Once children are on normal table foods, their stool pattern is like adults.
- Kids who go every 4 or 5 days almost always have pain with passage. They also have a lot of straining.
- Kids who go every 3 days often drift into longer times. Then, they also develop symptoms.
- Passing a stool should be free of pain.
- Any child with pain during stool passage or lots of straining needs treatment. At the very least, the child should be treated with changes in diet.
Imitators of Constipation: Normal Patterns and Stools
- Breastfed and Over 1 Month Old. Stools every 4-7 days that are soft, large and pain-free can be normal. Caution: Before 1 month old, not stooling enough can mean not getting enough breast milk.
- Straining in Babies. Grunting or straining while pushing out a stool is normal in young babies. It's hard to pass stool lying on your back with no help from gravity. Babies also become red in the face during straining. This is normal.
- Brief straining under 10 minutes can occur at times at any age.
- Large Stools. Size relates to the amount of food eaten. Large eaters have larger stools.
- Hard or Dry Stools. Also can be normal if passed easily without too much straining. Often, this relates to poor fiber intake. Some children even have small, dry rabbit-pellet-like stools.
When to Call Your Doctor
Go to ER Now If
- Vomiting bile (green color) (Exception: Stomach juice which is yellow)
Call Your Doctor Now (night or day) If
- Stomach pain goes on over 1 hour (includes crying) after using care advice
- Rectal pain goes on over 1 hour (includes straining) after using care advice
- Vomits 2 or more times and stomach looks more swollen than normal
- Age under 1 month old and breastfed
- Age under 12 months with recent onset of weak suck or weak muscles
- Your child looks or acts very sick
- You think your child needs to be seen, and the problem is urgent
Call Your Doctor Within 24 Hours If
- Age under 2 months (Exception: normal straining and grunting)
- Bleeding from anus
- Needs to pass a stool but afraid to or refuses to let it out
- Child may be "blocked up"
- You think your child needs to be seen, but the problem is not urgent
Call Your Doctor During Weekday Office Hours If
- Leaking stool
- Suppository or enema was needed to get the stool out
- Infrequent stools do not get better after changes to diet. (Exception: Normal if breastfed infant over 1 month old and stools are not painful.)
- Toilet training is in progress
- Painful stools occur 3 or more times after changes to diet
- Constipation is a frequent problem
- You have other questions or concerns
Parent Care at Home If
Care Advice for Constipation
- What You Should Know About Constipation:
- Constipation is common in children.
- Most often, it's from a change in diet. It can also be caused by waiting too long to stool.
- Passing a stool should be pleasant and free of pain.
- Any child with pain during stool passage or lots of straining needs treatment. At the very least, they need changes in diet.
- Here is some care advice that should help.
- Normal Stools:
- Normal range: 3 per day to 1 every 2 days. Once children are on a regular diet, their stool pattern is like adults.
- Kids who go every 3 days often drift into longer times. Then symptoms start.
- Kids who go every 4 and 5 days almost always have pain with passage. They also have lots of straining.
- Diet for Infants Under 1 Year:
- Age over 1 month old only on breast milk or formula, add fruit juice. Give 1 ounce (30 ml) per month of age per day. Pear or apple juice is okay at any age. (Reason: Treating a symptom.)
- Age over 4 months old, also add baby foods with high fiber. Do this twice a day. Examples are peas, beans, apricots, prunes, peaches, pears, or plums.
- Age over 8 months old on finger foods, add cereals and small pieces of fresh fruit.
- Diet for Children Over 1 Year Old:
- Increase fruit juice (apple, pear, cherry, grape, prune). Note: Citrus fruit juices are not helpful.
- Add fruits and vegetables high in fiber content. Examples are peas, beans, broccoli, bananas, apricots, peaches, pears, figs, prunes, or dates. Offer these foods 3 or more times per day.
- Increase whole grain foods. Examples are bran flakes or muffins, graham crackers, and oatmeal. Brown rice and whole wheat bread are also helpful. Popcorn can be used if over 4 years old.
- Limit milk products (milk, ice cream, cheese, yogurt) to 3 servings per day.
- Stop Toilet Training:
- Put your child back in diapers or pull-ups for a short time.
- Tell him that the poops won't hurt when they come out.
- Praise him for passing poops into a diaper.
- Holding back stools is harmful. Use rewards to help your child give up this bad habit.
- Avoid any pressure or punishment. Also, never force your child to sit on the potty against his will. Reason: It will cause a power struggle.
- Treats and hugs always work better.
- Encourage Sitting on the Toilet (if toilet trained):
- Set up a normal stool routine, if your child agrees to sitting.
- Have your child sit on the toilet for 10 minutes after meals.
- This is especially important after breakfast.
- Once he passes a normal stool, he doesn't need to sit anymore that day.
- Warm Water to Relax the Anus:
- Warmth helps many children relax the anus and release a stool.
- For straining too long, have your child sit in warm water.
- You can also put a warm wet cotton ball on the anus. Move it side to side to help relax the anus.
- Flexed Position to Help Stool Release:
- Help your baby by holding the knees against the chest. This is like squatting for your baby. This is the natural position for pushing out a stool. It's hard to have a stool lying down.
- Gently pumping the lower stomach may also help.
- Stool Softeners (Age Over 1 Year Old):
- If a change in diet doesn't help, you can add a stool softener. Must be over 1 year of age.
- Use a stool softener (such as Miralax). It is available without a prescription. Give 1-3 teaspoons (5-15 ml) each day with dinner.
- Fiber products (such as Benefiber) are also helpful. Give 1 teaspoon (5 ml) twice a day.
- Stool softeners and fiber work 8-12 hours after they are given.
- Safe to continue as long as needed.
- What to Expect:
- Most often, changes in diet helps constipation.
- After your child is better, be sure to keep him on high fiber foods.
- Also, have your child sit on the toilet at the same time each day.
- These tips will help to prevent the symptoms from coming back.
- Call Your Doctor If:
- Constipation lasts more than 1 week after making changes to diet
- Your child becomes worse
Contact your doctor if your child develops any of the "When to Call Your Doctor" symptoms.
- Abi-Hanna A and Lake AM. Constipation and encopresis in childhood. Pediatr Rev. 1998;19:23-31.
- Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology. Evaluation and treatment of constipation in infants and children. J Pediatr Gastroenterol Nutr. 2006;43 (3):e1-13.
- Felt B, Wise CG, Olson A, Kochhar P, Marcus S, Coran A. Guideline of the management of pediatric idiopathic constipation and soiling. Arch Pediatr Adolesc Med. 1999;153:380-385.
- Liptak GS with Baker SS, Colletti RB, Croffie JM, DiLorenzo C, Ector W, Nurko S. Constipation. In: Moyer V, Davis RL, Elliott E, et al, eds. Evidence Based Pediatrics and Child Health. London, England: BMJ Publishing Group; 2000. p. 264-272
- North American Society for Pediatric Gastroenterology and Nutrition. Constipation in infants and children: Evaluation and treatment. J Pediatr Gastroenterol Nutr. 1999;29:612-26.
- Nurko S, Baker SS, Colletti RB, Croffie JM et al. Managing constipation: Evidence put to practice. Contemp Pediatr. 2001;18 (12):56-65.
- Schmitt BD and Mauro RD. 20 common errors in treating encopresis. Contemp Pediatr. 1992;9 (5):47-65.
- Youssef, NN, Di Lorenzo, C. Childhood constipation: evaluation and treatment. J Clin Gastroenterol. 2001;33 (3):199-205.
This information is not intended be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.
Author: Barton D. Schmitt, M.D.
Last Reviewed: 9/1/2014
Last Revised: 4/4/2014 10:31:09 AM
Content Set: Child Symptom Checker
Version Year: 2014
Copyright 1994-2014 Barton D. Schmitt, M.D.