Introduction 

Constipation is a common issue in children, with up to 28% of all children affected (Auth et al, 2012). The incidence increases to over 50% among children with Down syndrome and other learning disabilities (Bermudez et al, 2019; Maslen et al, 2022). A study by Sullivan et al (2000), involving 270 children with neurological impairment, reported a constipation rate of 59%, and Del Giudice et al (1999) estimated that the prevalence of chronic constipation was 74% among children with cerebral palsy from an outpatient neurology cohort.
 
About 95% of children with constipation have no identifiable organic cause; these cases are classified as functional constipation (Loening-Baucke, 2005). The pathophysiology of functional chronic constipation is multifactoral, including physiological and genetic influences, physical activity, diet, and psychological considerations. The primary mechanism underlying functional constipation, particularly in children, is withholding behaviour, which frequently begins after a painful or distressing bowel movement. Retained stools accumulate in the rectum, and the rectal mucosa absorbs additional water from these stools, making them harder and therefore evacuation increasingly difficult. This perpetuating cycle can result in faecal impaction, occasionally progressing to overflow faecal incontinence, diminished rectal sensation, and ultimately, loss of the normal urge to defecate (Rajindrajith and Devanarayana, 2011).
 
If this cycle is not addressed with appropriate treatment, the accumulation of stool in the rectum may cause gradual dilation, which can lead to megarectum and reduce rectal sensation and urge. This usually occurs when constipation remains untreated or insufficiently treated over an extended period. It is commonly associated with significant colonic faecal loading and abdominal distension, often resulting in reduced appetite. Distress and painful defecation are less frequently seen in these cases. This group tends to be more challenging to manage, and approaches to treatment may differ depending on local services (Elawad and Sullivan, 2001).
 
One main issue is often the delay in recognition and appropriate treatment of constipation in children – symptoms can present for months or years before appropriate treatment is provided (Bardisa-Ezcurra et al, 2010). Such delay is a particular problem in children with disabilities, either because it is often accepted as an inevitable consequence of the neurological impairment or because a higher priority is given to other aspects of medical management such as treatment of convulsions or postural deformity. Many children develop chronic constipation with faecal overloading which causes soiling and this is often attributed to the child’s disability rather than any underlying constipation. It is believed that 80% of cases of faecal incontinence in children with disabilities are caused by overflow from chronic constipation (Heron et al, 2018).
 
Communication impairments often exacerbate delays in identifying constipation, as children with disabilities may be unable to articulate the discomfort they experience. Among those able to describe their symptoms, abdominal pain is a common manifestation of chronic constipation and significantly contributes to its negative impact on quality of life (Elawad and Sullivan, 2001).
 

When does constipation develop? 

Although constipation can develop at any time, clinical experience has shown that there are certain times in a child’s life that the risk of developing constipation is at its highest.
 

Weaning

Constipation can occur when transitioning from breast or formula milk to whole cow’s milk. This may be related to the higher protein-to-carbohydrate ratio in whole cow’s milk which can result in firmer stools (Inan et al, 2007; Leung and Hon, 2021). Additionally, some children may have an intolerance to cow’s milk protein. Consuming large amounts of whole cow’s milk may also lower the intake of other foods and fluids, such as vegetables, fruits, and water, that support regular bowel movements. Inadequate fluid intake or excessive loss of fluids, for instance as a result of vomiting, diarrhoea, or fever, can lead to harder stools and is a significant cause of constipation, particularly in infants (Sood, 2025).
 
A study by Aguirre et al (2002), involving 275 infants, looked at the prevalence of constipation in breast-fed vs formula-fed infants. They found that, in the first 6 months of life, the rate of constipation was much lower in exclusively breast-fed compared to formula-fed infants (4.5% vs 27.3%). However, when breastfeeding was reduced as the infant was weaned the rate of constipation started to rise. They concluded that in the first 6 months of life breastfeeding has a protective role against constipation.
 

Diet

Intake of low levels of dietary fibre has been identified as a potential risk factor for constipation. Undigested fibres in the colon may help to increase colonic transit and stool output. Lee et al (2008) reported that kindergarten-aged children with constipation had a significantly lower intake of dietary fibre than non-constipated children. Additionally, fruit and total plant food consumption were lower in the constipated group.
 
The composition of gut bacteria, collectively known as the microbiota, is influenced by dietary intake. Variations in the composition of the gut microbiota are associated with the development of various gastrointestinal functional disorders, including constipation. Research indicates that individuals with constipation have different gastrointestinal microbiota compared to those without this condition (Avelar Rodriguez et al, 2021). Changes in the microbiota may affect peristalsis by slowing gut transit, which is a factor in constipation (Kwiatkowska and Krogulska, 2021). Encouraging a balanced diet that includes a ‘rainbow’ mix of fruit and vegetables is important.
 

Potty training

Behavioural issues, such as stool withholding resulting in constipation, often begin during the toddler years, particularly around the time of toilet training (Pawasarat and Biank, 2021). In an early study by Taubman (1997), 22% (106 of 482) of children refused to open their bowels on the potty or toilet. Only 29 parents sought medical advice about the issue; the rest did not view it as a problem, focusing instead on their child wearing underpants and not soiling them. Most children who were toilet refusers wore underpants and either asked for a nappy to open their bowels or waited for one to be put on at naptime or bedtime. Some children would only soil their underpants at home or other ‘acceptable’ times and never at nursery or on outings. Parents often considered their child toilet-trained until asked specifically about bowel movements in the toilet. Lack of parental awareness around ‘normal’ bowel habits contributed to the development of constipation.
 

Starting nursery or school

Starting nursery and primary school can often lead to faecal retention and constipation triggered by unpleasant experiences associated with defecation. Lack of privacy, a change in routine or the unacceptable condition of toilets all may play a role (Classen et al, 2022).
 
ALMadi et al (2025) conducted a study looking at the effect of school toileting behaviour on the development of bladder and bowel dysfunction, such as dysfunctional voiding and constipation. The study population consisted of 290 fully toilet‑trained children between the ages of 5–10 years attending school regularly. Although they cited no direct link to the quality of the toilet facilities, they concluded that the availability of safe clean toilets with readily available soap and towels will help to improve both the incidence and management of bladder and bowel problems.
 
A larger study conducted by Jørgensen et al (2021) found a direct link between dissatisfaction with toilet facilities and the occurrence of bladder and bowel dysfunction related to toilet avoidance. In this research, students from Danish schools completed online surveys about their toilet behaviours, perceptions of school toilet standards and quality, and symptoms associated with bladder and bowel dysfunction. The study involved 19 577 children from 252 schools; their exact age range was not stated in the study. More than half of the participants (50% of boys and 60% of girls) reported dissatisfaction with school toilets, while approximately one quarter (28% of girls and 23% of boys) indicated that they avoided using them. The findings showed a strong correlation between dissatisfaction with school toilets, toilet avoidance, and the presence of bladder and bowel dysfunction symptoms.
 

Management of constipation

The management of constipation involves both non-pharmacological and pharmacological interventions. Non-pharmacological strategies include dietary modifications to increase fibre and fluid intake, behavioural interventions, biofeedback, and pelvic floor physiotherapy and education to demystify the condition (Pawasarat and Biank, 2021; Rajindrajith et al, 2022). Pharmacological treatments often involve the use of laxatives, with macrogols recommended as a first-line therapy (Richardson and Rogers, 2017). Overall, a comprehensive approach that addresses dietary, behavioural, and emotional factors is crucial for effectively managing constipation in young children.
 
Early intervention with dietary modifications and behavioural strategies, such as regular toileting and reward systems, can prevent the condition from becoming chronic (Richardson and Rogers, 2017; Rajindrajith et al, 2022). 
 
Additionally, parental education on these aspects is crucial, as it empowers them to implement effective preventive measures and recognise when medical intervention may be necessary. From experience parents will often report that their child with constipation is really trying to have their bowels opened. However, when they describe the typical postures their child presents with, including hyperextension with standing on tiptoes and contracting gluteal muscles, these positions impede relaxation of the pelvic floor. The child in this position is in fact ‘holding on’ and stopping their bowels opening rather than them straining to pass a stool.
 

Conclusions

Functional constipation is a very common childhood problem with a higher incidence noted in children with disabilities. If untreated or undertreated, constipation can have a huge negative impact on the child’s overall health and wellbeing, so it is important to provide an individualised holistic approach to treatment and management. There are certain times in a child’s life that the risk of constipation is increased. Healthcare professionals need to be mindful of the triggers that can make the development of constipation more likely and proactively advise parents accordingly. Early identification of children at risk of constipation and soiling could lead to timely interventions to reduce the adverse impacts on quality of life and psychosocial development.