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Spotting the early signs of constipation in under-fours


Key learning points:           

- Pooing less than four times a week, or pooing hard poos, could indicate that a child is constipated

- The National Institute for Health and Care Excellence produced a quality standard in 2014 to help healthcare professionals improve the care of children with idiopathic constipation           

- Many free materials about constipation for health professionals and parents are available

After a successful first phase of Education and Resources for Improving Childhood Continence (ERIC)'s 'Let's Talk About Poo' campaign in 2013, during which 6,000 GP surgeries received information about children's bowel problems, the campaign will re-launch in April 2015. This time with a focus on raising awareness of children's bowel problems among parents, health professionals and early years' education professionals.

The campaign aims to spread information about how to spot the early signs of a constipation problem in order to intervene early and the types of treatment available. It is important that children get appropriate treatment at the earliest possible stage in order to prevent conditions persisting for months or years.

The goal of the campaign is to ensure children get the support they need before they reach the age of four. It is acknowledged by continence professionals that this is a critical period for intervention, as avoiding and rectifying problems before a child reaches the age of four can reduce the incidence of problems in later childhood. Hospital episode statistics show that the highest number of admissions for childhood constipation are in children aged four years and younger. This equates to around 500 admissions per month in England alone.1

Constipation is responsible for 90-95% of all bowel problems and is a common problem affecting between 5-30% of children, but understanding of the signs and causes is often lacking.2

Constipation plays a key role in the development of bladder problems including daytime wetting and bedwetting, as the stretched bowel pushes against the bladder. Children with constipation may present to primary care nurses with problems such as bedwetting, daytime wetting, recurrent urine infections or behavioural problems (children can become irritable and lethargic when constipated as toxins in the poo become absorbed into the bloodstream). Hence, a holistic approach to treatment is needed and nurses in universal services are best-placed to offer the right advice and to signpost families to the correct place for diagnosis and treatment.3

The 'Let's Talk About Poo' website, which will be launched in April 2015, will contain information for parents and health professionals about the early signs of constipation, including how to spot them and what treatment is available for constipated children.

The website will feature ERIC's fun and colourful wee and poo characters and will have an interactive game aimed at small children. Nurses can encourage children to play the game with the aim of facilitating a conversation with the child about poo.

A child pooing less than four times a week could indicate they are constipated. Pooing more than three times a day could signal there is an overflow problem.

The problem involves poo building up in the large bowel and getting stuck, during which time more and more water is absorbed out of the poo and it becomes harder and more painful for the child to pass their stools. This can lead to withholding behaviour, as children become frightened to go to the toilet, which can exacerbate the condition. Appetite can also be affected as the child always feels full.

Parents may delay seeking help and advice for several reasons: they might not recognise the symptoms; they might not know where to go for help; they might fear a negative reaction from healthcare professionals; or they might be embarrassed to speak out. Providing parents with information about the prevalence of constipation in small children can ease the loneliness they often feel or the fear and anxiety that the constipation is a sign of a more serious illness. Parents can be signposted towards ERIC's message boards, where they can share their experiences with others going through the same thing, anonymously if they wish.


In most cases, children suffer from idiopathic constipation, which means that there are no underlying anatomical or physiological causes. The specific cause of constipation is not fully understood, but there are several known contributing factors, including pain, fever, dehydration, dietary and fluid intake, psychological issues, difficulties with toilet training, medicines, and a family history of constipation.4

Constipation is more likely to occur during weaning, potty training and when children start school and independent toilet use becomes important.4

Constipation is often aggravated by the passage of a large painful stool; the child associates the pain with the opening of their bowels and avoids going to the toilet as a result. Without treatment, acute constipation can thus develop into chronic constipation. Constipation becomes chronic when the symptoms persist for more than eight weeks.2

Signs and symptoms

Not all children will exhibit the signs and symptoms listed here but they may indicate a child is constipated.

- Defecating less than four times a week.

- Defecating small hard poos often.

- Large poos that may block the toilet.

- Painful defecation.

- Straining.

- Withholding.

- Small tears or fissures around the anus.

- Bright red blood or light red streaks on stools or in underwear.

- Foul smelling stools or foul smelling wind.

- Abdominal pains.

- Distended stomach.

- A feeling of the bowel movement not being finished.

- Unhappy or irritable mood.

- Lack of energy.

- Soiling.

Chronic constipation has been identified as the cause of soiling in 95% of children.1 The rectum is stretched by chronic constipation and if the rectum stays clogged up, overflow soiling can occur. This is when liquid faecal matter leaks around the solid stool. Soiling is often mistaken for diarrhoea. Soiling is frequently the first sign that parents are aware their child has a bowel problem, but a child can be constipated for months before soiling occurs.

The child cannot control the overflow and can lose the physical sensation that it is happening. It should be explained to parents that soiling is beyond the child's control and neither the child nor the parent should be blamed for it or feel any guilt.

Advice and treatment

To reach a positive diagnosis, a full assessment of the child should be carried out including history taking and an external physical examination. The National Institute for Health and Care Excellence (NICE) 2010 guidelines contain information on history taking and physical examination, and on recognising red flag symptoms that may indicate an underlying disorder and require the child to be referred to a specialist for further investigation. 

NICE (2010) recommends disimpaction (softening and clearing of faecal impaction) as the treatment for idiopathic constipation, via the use of an increasing dose of oral laxatives followed by a maintenance dose of laxatives until the child is cleared out (ie. the child is passing brown water) and the bowel has returned to normal size.2 The process can take up to a year and some children may require laxative therapy for several years.

Parents need to be made aware that disimpaction treatment can increase symptoms of soiling and abdominal pain at the start. Children undergoing disimpaction should be reviewed within one week of treatment commencing to assess progress and adjust the laxative dose if necessary. NICE (2010) only recommends the use of rectal medicines once all oral medication has been tried and failed. 

During the dismipaction process, the child should be supported to follow a toileting routine involving sitting on the toilet 20-30 minutes after meals. They should also be encouraged to relax on the toilet by playing with toys and books and should also be given lots of praise. The family should keep a record of stool frequency and consistency, which can indicate if medicines need adjusting and can be used for positive reinforcement.4

Children who are still in nappies or who have a fear of going to the toilet should not receive toilet training until constipation has been resolved and the child is passing regular stools with no associated unease.4

While a healthy diet and active lifestyle are important for long-term management of constipation, dietary changes alone will not address underlying constipation once it has become chronic and can in fact lead to acute constipation becoming chronic.3

The NICE guidelines state that health professionals should not suggest dietary changes as part of an initial treatment plan. Telling parents that their child's constipation can be solved by altering their diet should be avoided as it can fuel parents' feelings of guilt.3 However, adequate fluid and dietary fibre intake is important for long-term good bowel health.

A downloadable leaflet is available from the ERIC website called 'ERIC's Guide to Children's Bowel Problems.' ERIC has also created downloadable and printable leaflets for the parents of two-year-olds called 'Thinking about wee and poo now you've reached the age of two' and for parents of four-year-olds: 'Thinking about wee and poo now you're on your way to school.'

ERIC's website also has a 'poo diary' which health professionals can give out to parents, or parents can download, to keep track of what their child's poo looks like. Parents can bring this chart to their appointment with their GP.

The NICE quality standard published in May 2014 sets out six statements designed to help reduce emergency admissions and progression of symptoms and recurrence. It also emphasises the need to provide parents and carers with appropriate information about the condition.

Tips for clearing the bowel

- Feet should be firmly supported flat on a box or stool.

- Knees should be above hips with a secure seating position.

- The child should sit up straight so that the anal canal is straight.

- Children should sit on the toilet 20-30 minutes after meals and before bed for five to 10 minutes.

- The toilet area should be non-threatening and warm.

- Children need to relax on the toilet so distract them with books, toys or games.

- Parents should remain calm and relaxed as well during toilet times.

- Rock backwards and forwards on the toilet.

- Massage the abdomen, ideally in clockwise circles.

- Try blowing bubbles or an instrument to help push down the abdominal muscles.


1. Loening-Baucke. Constipation in children. The New England Journal of Medicine. 1998; 339:1155-1156 October 15

2. National Institute of Health and Care Excellence (NICE). Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. May 2010.

3. Dragh, A. Recognising and managing constipation in children. Nursing in Practice. March/April 2013;71:32-34

4. Rogers, J. Assessment, prevention and treatment of constipation in

children. Nursing Standard 2012;26(29):46-52