How to help children with constipation, through nutrition

Constipation is very common in kids. Most of the time, constipation in young children occurs without any underlying medical cause.

Bowel habits can vary quite a bit in young children, however by the age of two, a child typically has one-two formed bowel actions per day. - usually a “soft sausage” consistency.

Signs of constipation

Children who are constipated usually have very hard pellet like bowel actions which is often painful to pass. Their bowel actions may become less frequent as they become more constipated. Children may also become quite distressed when trying to have a bowel action.  

Constipated children may develop unusual habits when they feel the urge to have a bowel movement. They may show various “holding on” behaviours such as rocking back and forth while stiffening their lower body, crossing their legs, standing on their tiptoes and wriggling or fidgeting. They may also disappear off into a corner to squat.

Whilst these behaviours may appear as though the child is trying to have a bowel movement, often the child is actually trying to prevent a bowel movement (“holding on”) as they are fearful about the experience of having a bowel action.

What causes constipation?

Aside from medical causes (which are less than 5% of all children with constipation), there are a number of reasons why a child may develop constipation.

1.     Pain:

a.     A painful bowel action can cause young children to be scared of going again, and therefore begin to withhold to avoid more pain. In some instances, children may develop a tear in the anus which may also cause pain and lead to withholding. Treating pain early can help prevent withholding.

2.     Unfamiliar surroundings

a.     A child may delay their poo if they don’t have a place where they feel comfortable, or if they are busy and ignore the need to go.

b.    New environments such as starting preschool or school can be a time when constipation arises.

c.     It is helpful to reassure children that it’s important to go to the toilet for a bowel movement when their body tells them it is time to do so and that it is safe to do so in different places (such as school).

3.     Toilet training

a.     It is important that children are ready and interested in using the toilet (or potty), otherwise they may develop a fear of going to the toilet and consequently withhold to try to avoid a bowel action.

b.    Positioning is important – children need to have their feet supported with their knees bent above the height of their weight– ideally to less than 90 degrees (similar to quat position). This positioning enables the rectum and anus to be in an ideal position to facilitate a bowel movement.

c.     Timing and consistency are also important – to enable children to develop regular bowel habits.

Dietary management of children with constipation

Fluid:

Overall fluid intake needs to be checked to make sure it’s adequate for the child’s age and weight. Fluid requirements increase during hot and humid conditions.

Total fluid requirements (including food and fluid) for young children are approximately 1500ml per day. This equates to approximately 1100ml in fluids alone. Children should be offered water as their main fluid regularly throughout the day, and should be allowed to drink to thirst. There is no evidence to support increasing fluid intake above daily requirements.

Fibre:

For children who have a low fibre intake, increasing their fibre intake may be helpful. Fibre rich foods contain valuable prebiotics which support healthy bacterial communities and therefore a healthy gut microbiome.

 I always encourage parents to feed their children fibre rich foods such as fruit, vegetables, oats, grains, nut butters, seeds and legumes. Specifically, fruits such as apple, pear, kiwi or prune may support softer stools.

Where possible keep the skins on fruit and vegetables. Add extra fibre wherever possible - sprinkle psyllium/oat bran on cereals, use LSA (linseed/sunflower/almond meal) in baking, sprinkle chia into muffin or biscuit mixture, add nuts into butter chicken or stirfry, add lentils into bolognese or casseroles. Offer hommus or pesto on a platter with crackers and chopped vegies.

 Whilst ensuring a healthy fibre intake is recommended, there is no evidence for additional fibre supplements in the management of childhood constipation.

Dairy:

In a small number of cases, cows milk protein does contribute to constipation and for this reason needs to be considered if other possible causes have been ruled out and other treatments aren’t helpful. If dairy products do need to be avoided, consult with a paediatric dietitian to ensure adequate calcium and nutrient intake.

Pre and Probiotic Supplementation:

There is a link between an imbalance of gut bacteria (dybiosis) and gut disorders. Studies have shown that young children with constipation do have a different balance of microbes in the gasto intestinal tract, with a lower concentration of lactobacillus.

Pre and probiotics are safe to use in children and may offer benefit in maintaining healthy bacterial communities. Large-scale evidence, however is needed for the routine supplementation of probiotics to manage constipation in children.

I usually suggest a probiotic containing “LGG” probiotics ( Lactobacillus Rhamnosus LGG), as that strain has the most evidence behind it in children.

Other management options

This blog focuses on the dietary management of constipation; however, behaviour modification plays a large role in the management of constipation.

Setting up consistent daily toileting routines is important – I encourage parents to sit their child on the toilet after breakfast and after dinner – for 10 mins each time, with a book or something to relax them whilst they are sitting there. Reassure children that they don’t have to do anything, just sit there and see if something comes out.

Correct positioning on the toilet is also important to ensure the bowel is in an ideal position to pass a bowel action.

Further pharmaceutical management options (such as stool softeners) may be required If other changes aren’t effective. In this situation, talk further to your doctor about other treatment options, as it’s important that constipation is resolved as soon as possible.