Pediatric constipation: Recognizing red flags and symptoms

Constipation in children can involve more than infrequent bowel movements or hard stools, with symptoms varying substantially by age and sometimes presenting as abdominal pain, stool withholding, or fecal incontinence, according to Justin Wheeler, MD.

Wheeler, a pediatric gastroenterologist at Primary Children's Hospital in Salt Lake City, Utah, specializes in neurogastroenterology and motility at the University of Utah, with a focus on children with severe constipation. At the American Academy of Pediatrics (AAP) 2026 National Conference & Exhibition, he discussed recognizing constipation across pediatric age groups, identifying signs of underlying disease, and distinguishing overflow incontinence from diarrhea.

How does constipation present across different age groups?

In infants, stool frequency alone may not indicate constipation. Wheeler explained that breastfed infants may have bowel movements as frequently as 7 times daily or as infrequently as once every 7 days without having constipation, provided stools remain soft and comfortable to pass.

"So you can miss days, and as long as when the child stools, it's not hard or uncomfortable, it can be considered completely normal," Wheeler said.

Hard stools, poor feeding, and abdominal distension may be more concerning in infants. Delayed passage of meconium beyond 24 to 48 hours after birth is another important warning sign.

Among toddlers and school-aged children, constipation may manifest through withholding behaviors, including crossing the legs, standing rigidly, hiding, or refusing to use the toilet.

Wheeler noted that parents may misinterpret these behaviors as a child attempting unsuccessfully to pass stool when the child is actually trying to prevent a bowel movement.

Painful defecation can initiate a cycle of withholding, stool retention, and rectal dilation that perpetuates constipation.

In older children and adolescents, abdominal pain, nausea, and decreased appetite may be more prominent. These patients may also be reluctant to discuss their bowel habits or may not recognize abnormal stooling patterns.

Which red flags suggest an underlying medical condition?

Wheeler estimated that approximately 95% of pediatric constipation cases are functional, meaning they occur without an identifiable underlying organic disease.

Functional constipation may involve slow colonic transit, difficulty coordinating evacuation, or behavioral withholding.

However, pediatricians should remain alert for findings that suggest an anatomic, neurologic, or gastrointestinal disorder.

In infants, delayed meconium passage beyond 48 hours, the need for rectal stimulation to pass stool, and failure to thrive warrant additional attention. Weight loss in older children and unexplained blood in the stool are also concerning.

Neurologic findings, including lower-extremity weakness, toe walking, urinary symptoms, or certain sacral abnormalities, may raise concern for conditions such as tethered cord syndrome.

Wheeler also highlighted the importance of considering gastrointestinal diseases that may not typically be associated with constipation.

"Interestingly, some children who have celiac disease or Crohn's disease can present with constipation, and you wouldn't typically think about that," he said.

Poor growth, relevant family history, an abnormal-appearing anus, or a family history of Hirschsprung disease may further support additional evaluation.

Can fecal incontinence actually indicate constipation?

Fecal incontinence is frequently associated with underlying constipation rather than diarrhea, Wheeler explained.

Many affected children experience overflow incontinence, in which retained stool causes the rectum to stretch and gradually reduces the child's sensation of needing to defecate.

Softer stool may then leak around harder, impacted stool, resulting in repeated soiling episodes.

"Many many cases of pediatric fecal incontinence are actually overflow incontinence. It's soiling from underlying constipation," Wheeler said.

This distinction can be confusing for families, particularly when a child experiences leakage after beginning stool-softening medication without adequately evacuating retained stool.

"Parents often might jump to the conclusion, 'Oh, my child has diarrhea, but in reality, it's it's it's constipation with overflow incontinence,'" Wheeler said.

How can pediatricians distinguish overflow incontinence from diarrhea?

A detailed bowel history can help determine whether fecal accidents are related to stool retention or another gastrointestinal condition.

Wheeler recommended asking about bowel movement frequency, the frequency of substantial stools, painful defecation, and withholding behaviors.

Small amounts of stool leakage or smearing in underwear, particularly when accompanied by occasional very large bowel movements, may suggest overflow incontinence.

By contrast, watery diarrhea associated with urgency, tenesmus, or blood in the stool warrants consideration of other causes. Nocturnal stooling or waking from sleep to defecate may also signal a need for further investigation.

"In a child who's having fecal accidents, oftentimes constipation should be considered first rather than as the last resort," Wheeler said.

For pediatricians, recognizing these patterns can help identify children whose apparent diarrhea or behavioral toileting difficulties may instead reflect significant stool retention, while ensuring that concerning symptoms prompt further evaluation.

Reference

Wheeler J. Constipation and Encopresis: Evaluation and Management. Presented at: American Academy of Pediatrics 2026 National Conference & Exhibition; October 6, 2026; San Diego, CA.