No one has likely gone through life without experiencing bowel movement issues. Sometimes we face diarrhea, other times constipation. When a child is young and still in diapers, every mother monitors his stools. However, as the child grows and begins to use the toilet independently, this aspect gradually fades, and we no longer ask how often he has bowel movements, which means defecations. Especially when the child learns to flush the toilet and no longer calls out: "Mom, I'm done! Come and help me!" If there were no problems with bowel movements before, it is often assumed there won't be any in the future. Therefore, when I ask the mother of an older child about his bowel movements, she is surprised that this might be important.

I'm not a pediatric gastroenterologist, but early in my career as a pediatrician, I realized that the digestive system is crucial for the immune system. Thus began my long journey of studying microbiota, bowel movement disorders, and their connections to respiratory illnesses.

This time, I want to talk about constipation, which is closely related to common childhood illnesses. So, why do children get constipated?

First, it’s essential to understand that a child's body is not a perfectly functioning machine and requires time, experience, and sometimes mistakes to function properly. The digestive process is very complex: food needs to be broken down, digested, absorbed, and waste products eliminated. Simply putting food in the mouth is not enough. Our body performs this process without our conscious influence. Although we might wish to command it not to absorb toxic or harmful substances from inappropriate food. The intestines is a long, more than 7-meter tube consisting of muscles contracting in various directions and mucous membrane, under which about 70% of the immune system components accumulate.

Digested and undigested food is pushed by intestinal muscles without our will. So it would be naive to expect that a small child’s muscles will function perfectly and harmoniously from birth. I think that’s why nature made newborns and exclusively breastfed infants have loose stools. It’s easier for them to defecate since their abdominal muscles are very weak, making straining ineffective. Therefore, very young children rarely have constipation, more commonly experiencing colic. Sometimes infants start defecating only once a week or less. This is not constipation but infrequent bowel movements, and if the child feels fairly well, there is no need to rush to treat it. Such a condition passes quickly. However, if a few-month-old baby is really constipated (passing hard stools, pellets), more serious illnesses should be looked into.

When the intestine, accustomed only to breast milk, suddenly receives potatoes, cauliflower, or other foods when complementary feeding starts, stools change, become harder, and the smell less pleasant. Obviously, the sensitive child’s intestines are under stress. What has entered here? The immune system must also react, as new food is like a foreign body to the child, and it must be determined whether it is good or bad.

We know well how the body reacts to stress—freeze, flight, or fight. Therefore, some children immediately vomit the food they received, some have diarrhea, while others freeze. More precisely, their intestinal peristalsis (rhythmic smooth muscle contractions pushing intestinal contents toward the anus) slows down because it needs to determine what has entered and how to react to it. The slower the contents move through the intestines, the more water is reabsorbed into the body, and stools harden. If this happens once, it can be predicted that such stress-induced "freezing," i.e., constipation, may accompany the child in the future when they feel tension and anxiety.

It should not be forgotten that the defecation process itself is not easy. The coordinated work of muscles during straining and defecating is very important. The external sphincter must be relaxed in time, and the straining coordinated, i.e., muscle involvement. For some children, it’s quite hard just to strain. They sit on the potty or toilet and wait for defecation to happen on its own. Attention should be paid to strengthening the abdominal muscles, as this is very important. There are many videos online with exercises that help with constipation. Active physical activity is necessary, as prolonged sitting in cars, buses, or at the computer or TV often leads to constipation. It is necessary to take breaks and move a bit during them. By the way, good muscle tone requires vitamin D, so it’s worth assessing whether the body has enough of it.

It is important to respect your body and its signals. If the child does not listen to the body’s impulses when the urge to defecate arises, the body may later stop sending any signals—why ask to remove stools if no one pays attention to the request? For example, a child starts going to kindergarten. If the child was used to defecating at the time when they are in kindergarten, and the urge to defecate arises while they are outside with other children, playing, or learning, a more sensitive child will not dare to ask to go to the toilet. They will hold it in, suppress the urge, and won’t feel the urge anymore when they get home.

Let’s not forget the so-called "aesthetes"—if such children don’t like the toilet in another house, kindergarten, or school, if the potties or toilets are uncomfortable or dirty, the child will also not defecate. I think it’s not right to blame the child for this. How many of us defecate in public toilets, especially knowing there are people waiting outside the door? The defecation process is quite intimate. Not surprisingly, many people go to the toilet (with or without a phone) to defecate and spend much longer there than the process itself takes. Time is needed to relax to defecate. So, some children need peace to relax the external anal sphincter and defecate. We can’t rush this.

A common situation is that the child holds their stools at kindergarten and only defecates at home, and not every day. When asked what the child does before the urge to defecate arises, I often hear—they come home from kindergarten, start drawing, dancing, singing, and after a few minutes, the mother hears, "Mom, I need to poop." It’s clear—the child relaxes in a safe place, the tension in the belly disappears, and the urge to defecate arises. Do you think constant demands for the child to go and defecate help reduce tension? I doubt it. It would be more effective to help the child relax with running water, quiet music, or just a calm game and addressing the child's feelings.

Another anatomical reason why some children constantly have constipation is a relatively large rectum. The larger the reservoir, the more intestinal contents are needed to fill it and create the urge to defecate. However, the longer the stools stay in the rectum, the harder they become because water is reabsorbed into the body. Such children could benefit from appropriate foods or medications that increase stool volume. As the child grows, this problem usually disappears.

Finally, one of the most important causes of constipation is improper nutrition. Simply saying, "follow a diet" doesn't explain much. It’s important not only what the child eats but also when. Changing established eating habits is quite difficult but possible. Proper eating habits should be for the whole family, not just the child, as they see the example and will want to eat as their parents do. If it's okay for the parents, why not for the child? Therefore, regular, always at the same time, and quite frequent meals—about five times a day—are crucial. Eating irregularly, for example, not eating all day and then overeating, especially in the evenings, can lead to not only constipation but also other digestive disorders.

Children should eat as varied a diet as possible, with lots of dietary fiber, such as various fruits, dried plums, apricots, peaches, whole grains like rye or oats. Milk should be replaced with yogurt or sour milk. Rice, corn, bananas, and dishes containing them should be avoided. Of course, it’s important that the child gets enough fluids, preferably water. The most important thing is to monitor the child's diet and evaluate which foods suits him and which don’t. For some, especially infants, constipation can occur from frequent consumption of potatoes or bananas; for others, it’s too much milk or wheat products. So, everything is very individual.

Besides considering the child's habits and emotions, physical activity, and diet correction, how else can we help the child? Medications can come to the rescue. Unfortunately, medications are often the first choice for constipation because few take the time to delve into and search for causes. If we’re already late, if we’ve waited too long, and the child can’t defecate by themselves, enemas might help. But if enemas help the child defecate, don’t expect the problem to be solved—you haven’t removed the cause. While you try to help the child, understand why they have constipation, adjust their diet and fluid intake, time can be saved by using laxatives—lactulose, which softens stools and facilitates the movement of intestinal contents by drawing water into the intestines, or macrogol, which belongs to the group of osmotic laxatives and increases the water content in stools, helping with problems associated with very slow bowel movements. Much debate exists about the role of probiotics in correcting constipation. Unfortunately, there is not enough evidence of their effectiveness. Therefore, I would recommend stool tests and, only if dysbiosis is found, try them.

There is much more to write about this problem. But if your child is prone to constipation, please pay attention to the children themselves and try to find the main cause of the disorder. Just medication, scolding, or constant visits to doctors and numerous tests will only further traumatize the child.