Private constipation in children clinic in London, same-day paediatrics.

How it starts and why it persists

One hard or painful stool teaches a child that opening their bowels hurts. They then hold on. Holding on allows the stool sitting in the rectum to become harder and larger, which makes the next one more painful still. Over weeks the rectum stretches and the child stops feeling the normal urge at all.

This is not naughtiness, laziness or a behavioural problem, and it is not caused by bad parenting. It is a physical cycle, and it needs breaking physically.

Treatment

Laxatives — usually a macrogol powder mixed into a drink — are the mainstay. There are two phases, and both matter.

• During the clearing phase things often get temporarily messier, with more soiling and tummy ache, before they get better. This is expected and means it is working.
• The maintenance dose is adjusted to the child, not to the packet — aim for soft, easily passed stools, and tell us if you need to go up or down.
• Do not stop as soon as things are normal. The stretched bowel needs months of staying empty to recover its tone and sensation. Stopping early is the commonest cause of relapse.
• Reduce the dose gradually when the time comes, with our guidance, rather than stopping abruptly.

Toilet routine

Medicine alone often is not enough. A predictable routine retrains the reflex.

• Sit on the toilet for five to ten minutes after meals, particularly after breakfast and the evening meal, when the bowel is naturally most active.
• Feet must be supported on a step or stool, knees higher than hips. A child dangling their legs cannot use the right muscles.
• Make it unhurried and unpressured — a book or a timer works better than instruction.
• Reward the sitting, not the result. A sticker chart for going and trying removes the pressure that causes holding on.
• Never punish, criticise or show frustration about accidents.

Food and drink

Diet helps prevent constipation but rarely fixes it once established — do not rely on it instead of laxatives.

• Plenty of water through the day. Limit milk to around 400ml daily in toddlers, as large volumes fill children up and worsen constipation.
• Fruit, vegetables, wholegrain cereal and bread, beans and lentils.
• Fruits containing sorbitol — prunes, pears, apricots, peaches, plums — are particularly useful.
• Daily physical activity genuinely helps bowel movement.