Constipation is one of the most common reasons children see a pediatrician or pediatric gastroenterologist. The good news: most cases are functional, and most improve with a structured plan.

This post focuses on practical management and common pitfalls.

What constipation looks like (it’s not just “no stool”)

Children may have:

  • Infrequent stools
  • Painful stools
  • Large stools that clog the toilet
  • Stool withholding behaviors
  • Abdominal pain and bloating
  • Soiling (encopresis) from overflow leakage
  • Poor appetite

First: screen for red flags

Seek medical assessment urgently if constipation is associated with:

  • Delayed passage of meconium in infancy
  • Poor growth or weight loss
  • Bilious vomiting
  • Severe abdominal distension
  • Bloody stools without fissure
  • Fever, systemic illness
  • Abnormal neurologic exam or spine findings
  • Significant vomiting or dehydration
  • Onset in early infancy with persistent severe symptoms

Most children do not have these, but they matter.

The most common pattern: withholding → hard stool → pain → more withholding

Once painful stool occurs, children avoid stooling. Stool accumulates, becomes larger and harder, and the cycle continues. The goal is to:

  1. Empty the rectum
  2. Keep stools soft for months
  3. Rebuild normal toileting habits

Step 1: Decide if a cleanout is needed

Cleanout is often needed when there is:

  • Encopresis/soiling
  • Palpable stool burden
  • Large, infrequent stools
  • Chronic symptoms with abdominal pain

If symptoms are mild, you can sometimes start directly with maintenance therapy.

Step 2: Maintenance therapy (the key to long-term success)

The most common reason constipation “fails” is stopping therapy too early.

Maintenance aims for:

  • Soft, painless stool
  • Daily or near-daily stooling
  • No withholding

Many children need months of maintenance therapy before tapering.

Step 3: Toileting routine (as important as medication)

  • Sit after meals (gastrocolic reflex), 5–10 minutes
  • Feet supported (stool/box) for good posture
  • Calm, non-punitive approach
  • Reward effort, not “output”

Diet and fluids (helpful, but not usually sufficient alone)

  • Adequate fluid intake
  • Fiber from fruits/vegetables/whole grains
  • Prunes/pears can help
  • Avoid excessive cow’s milk if intake is very high and symptoms suggest it worsens constipation

Diet helps support the plan, but medication + routine usually drive success.

Encopresis is not “behavioral”

Soiling usually means the rectum is stretched and stool leaks around a large mass. The child often has reduced sensation. Blame and punishment make it worse.

Treat the constipation and the soiling resolves over time.

When to reassess

If constipation remains difficult despite a structured plan:

  • Confirm adherence and dosing strategy
  • Recheck for red flags
  • Consider secondary contributors:
    • Celiac disease
    • Hypothyroidism
    • Medication effects
    • Anatomic causes (selected cases)
  • Consider referral to pediatric gastroenterology if not improving

Parent-friendly summary

Constipation is common and treatable.

  • Many kids need a cleanout first
  • Then they need months of stool-softening therapy
  • A consistent toileting routine prevents relapse

Next post

Eosinophilic esophagitis (EoE) in children: symptoms by age, diagnosis, and modern treatment options.