Pediatric Chronic Constipation

Infants with chronic constipation may have trouble passing stool because their digestive system is not fully developed, or they are transitioning to solid foods. Other potential causes of chronic constipation in infants include:

• Low fiber diet (if eating solids)
• Milk protein allergy
• Formula intolerance
• Medications such as iron supplements

Babies born prematurely or with developmental disorders like cerebral palsy are at higher risk for chronic constipation and may require specialized care.

As children transition from infancy to toddlerhood and start potty training, they can experience chronic constipation for various reasons. This period sets the foundation for good bowel habits. It's essential to work closely with your pediatrician during this time if you notice any issues with your child's bowel movements.

There is not any one reason children develop chronic constipation — there could be several different factors that contribute to the condition. Causes may include:

• When a child decides to hold their bowel movement for a prolonged period, which could be due to anxiety, not wanting to interrupt play or not wanting to use a restroom outside of the house
• A diet low in fluids and fiber-rich foods
• Other underlying medical conditions, such as anorectal malformations or Hirschsprung’s disease
• Certain medications, such as antidepressants or opioids
• Side effects of certain medications or treatments

When children ignore bodily cues to go to the bathroom, their stool becomes hard and backs up into the rectum. Over time, the rectum fills with stool and begins to stretch. At this point, the hard stool can be difficult and painful to pass, and many children will avoid going to the bathroom. This exacerbates the problem, with waste continuing to back up and the rectum and colon continuing to stretch. The condition can become so severe that it interferes with the ability to feel the urge to go. As a result, many children experience overflow incontinence, which is when soiling and accidents occur.

Symptoms among infants and toddlers can vary. Infants may experience:

• Straining in the diaper area
• Small, hard stool passed infrequently
• Blood on the surface of the stool, in the diaper or on toilet paper/wet wipes after a bowel movement

Toddlers and older children may experience:

• Painful bowel movements
• Less frequent stools (less than three per week)
• Large, painful stools that are difficult to pass
• Stool accidents or soiling between bowel movements (encopresis)
• Abdominal pain or discomfort
• Inability to pass stool without assistance
• Loss of appetite

If you have noticed any of these symptoms in your child, it’s essential to seek medical attention from a pediatric specialist. Early diagnosis and treatment can prevent complications and help restore normal bowel function.

An accurate diagnosis to figure out what could be causing idiopathic constipation is very important to develop the best possible treatment plan. Our gastrointestinal (GI) specialists conduct motility studies and use the latest diagnostic tests and tools to accurately pinpoint the problem. Motility studies are done to track how a child’s digestive system is functioning as well as identify any issues with potty training or toileting behavior.

Motility testing may include:

• Anorectal manometry. This study measures the ability of the rectum to store and evacuate stool. It also looks at the strength and coordination of muscles in the anus.
• Colonic manometry. This study measures the movement, pressure and coordination of muscles in the colon.

While not all children with chronic constipation will need motility testing, it can provide vital information about your child’s condition and guide treatment decisions. 

If it is determined that there are no underlying serious medical or anatomical problems associated with the cause of constipation, your child will likely begin pediatric chronic constipation treatment in our Bowel Management Program. Our Bowel Management Program is a comprehensive program that addresses all of the behavioral and/or medical issues that are contributing to the problem. Children are seen daily for an intensive week of outpatient therapy and then at about three and 12 months after the initial visit. Enemas or laxatives may be given to ensure your child has a clean bowel before treatment begins.

Treatment for chronic constipation through the Bowel Management Program includes:

• Establishing a bathroom schedule (based around the gastrocolic reflex) to train your child to recognize their body cues.
• Setting up a reward system to encourage your child to go.
• Working with nutritionists who help create recipes and diet plans rich in fiber. Our nutritionists understand how to work with picky eaters and can offer helpful tips for increasing daily fiber intake.
• Administering medications, if needed, such as laxatives. These may be given to soften stool or help to relax the rectal muscles. For children who have sensory problems or have difficulty swallowing pills, alternatives are suggested to assist parents with administering medications successfully.
• Utilizing enemas, which are sometimes chosen to help empty the bowels regularly.

A nurse practitioner and child psychologist work closely with families to monitor your child’s progress and adjust to the treatment plan when needed. Depending on your child’s age and the severity of their condition, their time in the program will vary. In general, children who are potty training will see positive results within four months; in school-aged children, success may require six months to a year. It is very important to closely follow the treatment plan in order to get the best possible outcome and improve the quality of your child’s life.

In some cases, surgery may be necessary to address underlying issues contributing to chronic constipation. Surgery is typically considered when other treatment options have been exhausted or are not effective.

Children with certain medical problems that are causing their chronic constipation, such as anorectal malformations, Hirschsprung's disease, colonic dysmotility or spinal disorders, may require surgery. Our colorectal surgeons are highly experienced, having performed over 10,000 surgeries for pediatric colorectal disorders.

Surgeries performed for chronic constipation include:

• Malone appendicostomy 
• Colon resection

A Malone appendicostomy (MACE) is a procedure where a surgeon connects the appendix to the abdomen, making a pathway from the belly button to the colon using laparoscopic techniques. This pathway works as a valve where a catheter is inserted. A special solution is administered through the catheter to clean out your child’s colon each day. No artificial implants or devices are used because the valve has been created with your child’s own tissue. Following a MACE, your child will spend about two days in the hospital and require follow-up visits with your surgeon at one month to ensure they are healing properly.

A colon resection may be performed to remove diseased areas of the bowel that may be causing your child’s chronic constipation. This is only necessary in very rare cases unresponsive to medical treatments. This may include any area of the large intestine or rectum. The type of resection your child may need will depend on the severity of their specific condition. The surgery is performed using non-invasive techniques and is guided by the motility evaluation which maps which parts of the colon are working. Your child will typically spend one week in the hospital following a bowel resection and require a follow-up visit at one month to ensure that your child has healed properly and to check for any complications.

After completing treatment, it's important to continue monitoring your child's bowel movements and make any lifestyle changes recommended by their medical team. Maintaining a regular bathroom schedule for your child can also help prevent future episodes of chronic constipation.

If you notice any recurring symptoms or concerns, do not hesitate to reach out to your pediatrician or specialist for further guidance. With proper care and support, children with chronic constipation can lead healthy, active lives.

If your child has had a MACE procedure, a catheter will remain in place for one month. To keep the opening from closing once the catheter is removed, a type of plug called an ACE stopper will be put in its place for six months. The plug will be removed once daily to irrigate and flush the colon with a special solution.

View our videos featuring MACE recovery tips.

Your child’s medical team will give you detailed instructions on how to care for your child’s Malone surgery site once you are home. Keep in mind that drainage is normal and may resemble a clear to light yellow color. You will need to administer enema fluid daily through the catheter to keep the colon flushed and clean. For the first month, you should keep the Malone tube secured to your child’s abdomen (with clear tape dressing) without completely covering the opening. It is safe to shower and bathe after surgery. Make sure to clean around the tube insertion with soap and water and then pat dry.

You should call your child’s provider if you notice the following:

• Abdominal swelling or pain during or after flushing the colon
• Fever
• If the area or stitches holding the catheter in place become red and irritated
• The tube falls out prior to your child’s follow-up visit

After a colon resection, your child will be encouraged to get out of bed and walk as soon as possible. Doing so helps speed up recovery time. Your child may also receive medication for pain management.

Once you return home, make sure to follow your doctor's instructions regarding bathing and dressing changes. Keep an eye on the incision site for signs of infection, such as redness, swelling or drainage. It's normal to see some blood in the stool or diaper following surgery, but contact your doctor if you notice any excessive bleeding.

It will take some time for your child’s bowel movements to return to normal after surgery, and it's important to follow a healthy diet with enough fluids and fiber. Your doctor can provide specific guidance on your child's dietary needs during recovery.