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If your child is constipated, they don't pass a stool often enough. And when your child does go, it hurts because the stools are hard and dry. Many children get constipated from time to time. But if your child has this problem a lot, it can get worse if it isn't treated.

Constipation isn't normal, but most children with constipation don't have anything physically wrong with them. Usually they've just gotten into the habit of not going very often. Treatment can help your child break this habit, but it may take some time, so you'll need to be patient.

• Many children get constipation from time to time, and usually it goes away on its own after a few days. But in some children, it turns into an ongoing problem.
• Having even one experience of pushing out hard, dry stools can make your child afraid of going again.
• So your child may form a habit of holding in stools to avoid the pain.
• This can lead to the kind of constipation that lasts and that isn't likely to go away on its own (called chronic constipation).
• If your child typically has small, hard stools (like pellets) or passes stools less than two times a week or says that it hurts, they could have this kind of constipation.^{1 2}
• Chronic constipation is most likely to happen between ages 2 and 4, when your child is potty training.
• Treatment may help your child break the habit, get back to normal, and keep constipation from coming back.

To understand what goes wrong in constipation and how it's treated, it helps to know a little about what happens in your child's body during a normal bowel movement. Here's how a bowel movement works.³

• After you eat, food goes down to your stomach and bowels. Your bowels (also called your small and large intestines) are a long tube that runs from your stomach to your anus. The bowels remove nutrients and water from food.
• Whatever's left over is waste that your body doesn't need. The waste forms solid lumps (stools) that are pushed into your rectum.
• When a lot of stool builds up there, the walls of your rectum stretch a bit. This feeling tells you that you need to go to the bathroom.
• A ring of muscle around the end of your rectum (called the internal sphincter) relaxes and opens. This lets the stool pass into a small tube just before your anus, called the anal canal.
• To push the stool out of your body, you must relax another ring of muscle around your anus (called the external sphincter). You also have to tighten your stomach muscles, so that they press on your rectum and help push the stool out.
• You shouldn't have to try too hard to pass a stool. The stool should be soft and wet.
• Most children need to empty their bowels just after they've eaten, when they wake up or both. It's at these times that their bowels are most active.
• You can take certain steps to help your child stay regular. To learn more, see Keeping your child's bowels healthy.

There aren't any rules about how many times your child should pass a stool in a day or a week. Every child is different. What's normal for one child may not be normal for another.

Here's what we know from studies on children.

• In the first four months of life, a baby may pass a stool as often as four times a day or as little as once every two days.⁴ Both these patterns are normal
• As babies get older, they go less often and their stools get bigger and more solid.
• By the time they're 1 year old, children usually go about twice a day.⁵
• When they're 3 or 4 years old, children may go as often as three times a day or as little as three times a week.⁴

Remember that these are only averages. If your child goes less or more often than this, it doesn't mean there's definitely something wrong. But if your child usually has small, hard stools (like pellets), passes a stool less than two times a week or says that it hurts, they could be constipated.^{1 2}

Most of the steps your child goes through to pass a stool happen automatically. Your child doesn't have any control over them. The only part they can control is the very last step, when the ring of muscle around the anus (the external sphincter) needs to relax to let stools out. If your child tightens these muscles instead of relaxing them, the anus stays closed. This is the most common reason why your child gets constipation. Children usually tighten the muscles because they have found passing a stool painful in the past.

• Tightening the muscles may put off the urge to go.
• Then stool builds up, and the next time your child gets the urge, it's even harder and more painful to push the stool out.
• So your child may tighten the muscles more and put off the urge to go to the bathroom for longer.
• As this cycle goes on, more and more stool builds up in your child's bowels.
• The longer the stool stays there, the more water is removed, making the stool harder and dryer.
• Hard and dry stools are more difficult to push out, so your child will need to strain. Children soon learn that this hurts.
• To stop the pain, they tense up more, making it even harder and more painful to go.

If your child keeps holding in stools, the constipation gets worse. Here's why.^{6 7 8}

• Stool builds up and stretches your child's rectum more than usual.
• A stretched-out rectum makes it harder for your child to sense the need to pass a stool. Your child may not feel the urge until their bowels are very full.
• If your child doesn't use the muscles for pushing very often, they may get weaker and out of practice. This makes it harder to push stools out.
• The longer the stool stays in your child's bowels, the bigger and harder it gets, and the more painful it can be to push it out.
• After a while, your child may find it very hard to relax enough when they need to pass a stool. Tensing up when trying just becomes a habit.
• This keeps your child's constipation going. Doctors call this chronic constipation.

Most children who have ongoing constipation don't have anything physically wrong with them. More than half of children with bad constipation just start holding in stools because they've had one experience when it was painful.⁹ Or there may be something else that makes them avoid passing stools.

For example, some hold on too long because they're embarrassed to use a public bathroom. Others hold on because they don't want to stop what they're doing. These problems often happen when your child's first learning to control bowel movements.

Very few children with ongoing constipation have a medical condition that's causing the problem. These children tend to have more severe constipation as well as other problems. The condition is usually diagnosed during infancy because the symptoms are so bad. To learn more, see Medical conditions linked to constipation.

Your doctor probably won't be able to say exactly why your child is constipated. Most children with constipation (90 percent to 95 percent) aren't ill. There isn't anything wrong with their bowels.

Certain things increase your child's chances of getting constipated. Things that increase your chances of getting a condition are called risk factors. The most common risk factor for getting constipation in childhood is having a painful time passing a stool. To learn more, see Risk factors for constipation in children.

This information is for educational use only, and is not a substitute for prompt professional medical advice. Readers should always consult a physician or other professional for advice and treatment. ©BMJ Publishing Group Limited 2008. All rights reserved.