As a pediatric urologist, I treat children of all ages with a variety of toileting difficulties, including bedwetting, daytime wetting, encopresis (poop accidents), chronic urinary tract infections, urinary urgency, and urinary frequency.
These kids have two things in common: Number one, the root cause of their symptoms is chronic constipation, aka a clogged rectum; and number two, their constipation went overlooked or under-treated for years.
Childhood constipation, the top cause of stomachaches, is so common that it’s become normalized and is treated as a harmless, temporary condition. In fact, constipation is often chronic and can cause distressing symptoms, such as bedwetting, that can linger into adulthood.
Why Is Constipation in Kids Downplayed?
There are two reasons why many don’t take childhood constipation seriously: the conventional definition of constipation is inadequate, and common diagnostic methods are unreliable.
Many folks define constipation as “infrequent pooping.” In reality, many severely constipated children poop daily, even twice a day. They just don’t fully evacuate — and that’s what matters. This causes fresh poop to ooze around the hard stool mass, so the child appears “regular.” Meanwhile, stool is accumulating in the rectum.
In some children, the bulging rectum aggravates the nearby bladder nerves, triggering random, forceful bladder contractions. That’s enuresis — daytime or nighttime wetting.
In other kids, the rectum stretches to the point of losing tone and sensation. The child doesn’t sense the urge to poop, so even more stool piles up. Eventually, stool falls out of the child’s bottom without the child noticing. That’s encopresis.
Given all that, my preferred definition of constipation is “incomplete evacuation.”
Constipation Symptoms in Kids
So how can you tell if a child is harboring excess stool?
Feeling a child’s belly is worthless. Records I receive from referring physicians often state, “No masses palpable,” when an X-ray reveals a softball-sized rectal mass. Also misleading, due to incomplete evacuation, are “colon transit” studies, such as the DIY “corn test” or more sophisticated versions.
So how can you accurately diagnose constipation? And as parents, what signs should you be looking for?
Red flags for constipation include frequent/urgent peeing, daytime or nighttime wetting, poop accidents, and chronic UTIs. Other telling symptoms: extra-large stools, formed stools (poop should resemble frozen yogurt, not sausage or nuggets), underwear skid marks, and hiding to poop.
At my clinic, we X-ray enuresis patients to confirm constipation (and help rule out the rare neurological conditions that cause wetting in the absence of constipation). The X-rays inevitably show a mondo mass of poop, with a rectal diameter more than twice the normal 3 centimeters.
Causes of Constipation in Kids
Stunned parents often ask: How did my child become so constipated?
Diet plays less of a role than most folks think. Sure, a highly-processed diet can contribute by making stool firmer and more painful to pass. The digestive system, unfortunately, wasn’t designed to handle chicken nuggets. However, many kids develop constipation no matter how much kale they eat.
In my observation, genetics, temperament, and cultural forces play a larger role. Some children become constipated in infancy, when the shift to cow’s milk changes stool consistency. Suddenly, pooping feels different and uncomfortable, and the baby instinctively avoids it. A few painful pooping episodes can set off years of withholding.
More commonly, children develop constipation while potty training. Our culture treats potty training as a competitive sport, and preschool potty deadlines prompt parents to train their children too early. My clinic found children trained before age 2 have triple the risk of developing chronic constipation and daytime wetting.
Why? Because the ability to poop on the potty is different from the maturity to heed nature’s call — a maturity required by modern humans. It wouldn’t occur to a cat or to an Australopithecus to delay pooping when the urge strikes. Yet humans can delay pooping for hours, even days, and toddlers, with little grasp of the importance of daily pooping, are masters of delay.
The urge to poop is triggered when stool arrives in the rectum, signaling to the brain that it’s go time. But if we’re in a car or in preschool story circle or if we’ve had a painful pooping experience, we might override the signal by tensing our pooping muscles. Some kids clench their pooping muscles all day.
Treatment for Constipation in Kids
Resolving chronic constipation requires two things: cleaning out the rectum and establishing a daily pooping habit so the rectum remains empty. Both can be surprisingly difficult.
Fiber, prune juice, better hydration, probiotics, a few days of Miralax (PEG 3350) — these common measures won’t dislodge that hardened stool mass.
For children with mild symptoms, like stomachaches or urinary frequency, resolving constipation typically requires an osmotic laxative daily for months. PEG 3350, magnesium hydroxide, lactulose, and magnesium citrate all work well.
However, in my experience, kids with enuresis, encopresis, or chronic UTIs need more aggressive treatment.
Early in my career, I recommended a high-dose Miralax clean-out followed by a daily maintenance dose. But 15 years of research and experience have shown me oral “clean-outs” typically fail. Kids fill right back up, and symptoms return.
I prefer an enema-based regimen, sometimes in conjunction with osmotic and/or stimulant laxatives like Ex-Lax. (Nope, enemas are not “traumatic” and don’t cause “dependence.”) Some parents avoid laxatives and enemas, insisting they’re “not natural,” but you know what’s really not natural? Hauling around a belly load of poop! The sooner children get cleaned out, the sooner they’ll return to their natural state.
Whatever treatment you choose, assess monthly whether your child’s symptoms are improving. If they’re not, check back with your doctor and shift gears.
Nearly all my teen bedwetting patients showed symptoms of chronic constipation by age 3, but their symptoms were brushed off. The mom of one 14-year-old patient told me she was stunned to learn via X-ray that her son, who’d struggled with encopresis at age 5, was still constipated.
“I was like, ‘WHAT???’ We thought the constipation was under control because he wasn’t having poop accidents anymore.” Doctors had attributed her son’s bedwetting to “sleep issues.” An ordeal that began with the boy delaying kindergarten due to poop accidents concluded with him taking a gap year at age 18 due to bedwetting treatment — all because his constipation had been overlooked.
All that is to say: childhood constipation is a common issue, but one parents should address promptly. Watch for the telltale signs and visit your doctor to discuss treatment options. By taking action now, you can set your child up for a lifetime of healthy pooping.
Steve Hodges, M.D., is a professor of pediatric urology at Wake Forest University School of Medicine and the co-author of eight books, including The M.O.P Anthology: The Proven Way to STOP Bedwetting, Daytime Enuresis, Encopresis, and Chronic Constipation in Toddlers Through Teens and Bedwetting and Accidents Aren’t Your Fault. He blogs at bedwettingandaccidents.com.
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