Leaky Stool? Hard Stool? No Stool? It Could Be Functional Constipation

Functional constipation occurs in children who have constipation that cannot be explained by a typical cause. The child will have two or more of the following:

• Two or fewer bowel movements in the toilet per week
• Stools that are painful or hard to pass
• Large stools that clog the toilet
• At least one episode of fecal incontinence/stool accident per week
• Stool withholding behaviors
• A large stool mass in the rectum on physical exam

What Causes Functional Constipation?

The colon’s main job is to absorb water. When a colon is longer, slower moving, or very efficient at absorbing water, stool becomes harder at the end and this results in constipation. We call this functional constipation.

Some children may withhold stool or try to not pass stool because of passing hard or painful stools in the past. This leads to increased water absorption and thus harder stools, which continues the cycle of withholding stool. As a result of withholding stools, over time the rectum can become distended or stretched leading to stool leakage from overflow, loss of rectal sensation, and most importantly, a decrease in the sensation for the urge to stool.

Many parents have questions regarding specific diets for the treatment of constipation. Children should eat a regular, healthy diet that contains a good amount of water, fiber and dairy. No specific foods need to be eliminated. Many children have a diet that does not contain a healthy amount of fiber and it is a fiber supplement may be recommended.

What Behavioral Issues Are Associated With Functional Constipation?

Resistance to Toilet Sitting

• Fear of the potty
• Not wanting to sit on the potty long enough to pass a bowel movement
• Going backward from being potty-trained

Stool Withholding Behaviors

• Stiffening, crossing legs, or clenching buttocks
• Hiding while stooling

Negative Associations With Stool Accidents

• Going back into disposable underwear or diapers
• Fear of discipline for accidents

We know that some children with certain behavioral health conditions may be more likely to struggle with constipation. Some examples of these are:

• Autism Spectrum Disorders
• Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder
• Anxiety Disorders
• Mood Disorders
• Learning Disorders
• Eating Disorders
• School Stress

It is important to note that in some cases, it can be difficult to determine if the behavioral health diagnosis is the cause or the effect of a child’s constipation. In either case, it is important to address behavioral health issues with your healthcare provider and get appropriate treatment, as these can impact a child’s quality of life.

What Are the Treatment Options for Functional Constipation?

• In children with a low fiber diet, supplementing with high fiber foods or water-soluble fiber may be helpful.
• Some children do well with a stool softening product to help prevent painful bowel movements.
• Your child’s care team may also recommend oral stimulant laxatives which can help the colon contract to move stool out.
• In some children, both kinds of medications (fiber or stool softeners and stimulants) can be used together.
• Pelvic floor physical therapy and biofeedback are additional therapies that can be used to help your child empty their colon. The main goal of pelvic floor physical therapy is to teach children to relax their pelvic floor muscles during straining efforts that can be caused by stool withholding behaviors.
• In children with behavioral concerns, positive reinforcement of toilet-sitting, and bowel movements should be used (rewards, sticker/star-charts, etc.).
• Children with stool accidents frequently are not aware that they have had an accident and do not intentionally have accidents. They should not be punished for having an accident, but they can help with clean-up. They can be rewarded for days with no accidents, appropriate medication usage and toilet-sits.

What Can I Do If My Child Is Soiling or Having Stool Accidents?

• Stool accidents typically occur when a child is not completely emptying their colon daily, leading to a build-up of stool in the rectum. While this mass of stool is hard to pass, smaller, softer stool is easily able to leak past this.
• First, kids need to start with a “clean slate” to make sure all the stool is cleaned out of the colon. Typically, this clean-out phase is done with a large volume of stool softener and/or an oral stimulant laxative.
• After the clean-out is complete, a maintenance medication will be started.
• If the stool moves well, it can prevent the rectum from becoming distended with stool and can often prevent overflow leaks of liquid stool from happening.
• Enemas to help the colon push out stool may be used as medical treatment in functional constipation in patients who are unable to stay clean on oral medications.
• Bowel management plans will often vary and can be unique for each child, and all plans should be started and monitored by your health care team.