Beyond laxatives: Modern dietary approaches for managing childhood constipation

Colleen Sloan, PA-C, RDN

"She's so constipated. I give her a laxative, and she eats fruit. What else can I do?" This familiar concern echoes through pediatric offices daily. While medications can be important in managing constipation, dietary interventions are equally critical and can significantly improve treatment success. This article explores practical strategies using the "3 Fs" of constipation management: Fiber, fluid, and fitness.

Confirming functional constipation

Before diving into dietary strategies, it is crucial to confirm whether the child is truly constipated. Key indicators include infrequent defecation, painful or hard bowel movements, large-diameter stools, or fecal incontinence. Refer to the ROME IV Criteria and use the Bristol Stool Chart to help parents describe stool consistency, with Types 1 and 2 suggesting constipation.¹ Organic causes such as Hirschsprung disease, anorectal malformations, cow's milk protein allergy, or cystic fibrosis should be ruled out, especially if signs like failure to thrive, bilious vomiting, severe abdominal distension, fatigue, or rash are present.^2,3 Once functional constipation is confirmed, a comprehensive approach that includes dietary modifications can be implemented.

Fiber: Understanding the types

Dietary fiber plays a well-established role in managing constipation, but understanding its types can lead to more effective recommendations. Soluble fiber dissolves in water, forming a gel that slows digestion and softens stool. Common sources include oats, apples, citrus, and legumes. Insoluble fiber, on the other hand, does not dissolve in water and adds bulk to stool, helping it pass more easily. This type is found in foods like wheat bran, nuts, and vegetable skins.

Despite its importance, many children consume insufficient fiber. Young children in the United States average only 7g-9g per day for toddlers and 10g-11.5g for preschoolers.⁴ The American Academy of Pediatrics (AAP) recommends an easy-to-remember guideline of "age + 5g" for daily fiber intake in children aged three years and older.⁵ This approach is simpler than body weight or calorie-based recommendations. Another approach is the IOM’s DRI for dietary fiber, which is 14g fiber/1000 kcal:⁶

• Ages 1-3: 19g/day
• Ages 4-8: 25g/day
• Ages 9-13: 31g/day for boys, 26g/day for girls
• Ages 14-18: 38g/day for boys, 26g/day for girls

Fiber is found in a wide variety of foods. Here are a few child-friendly, fiber-rich foods to suggest:

Fruits: Not only are fruits a great source of fiber, but their sweetness and soft texture make them an excellent food for constipated kids.

• Pears (6g fiber): Serve sliced with nut butter or yogurt dip.
• Apples (3g fiber): For added fiber and a fun crunch, allow children to sprinkle toppings like chia seeds, flax seeds, or hemp seeds.
• Berries (4-8g fiber per cup): Great for mashing and spreading on toast or pancakes.
• Kiwi (2g fiber): Serve sliced or scooped with breakfast. Kiwis also contain actinidin, an enzyme thought to help promote bowel regularity.⁷

Vegetables: Vegetables are not as popular amongst kids due to their bitter taste, however, you can encourage families to be creative. Mix pureed vegetables into soups or pasta sauces or chop them into small pieces for salsa or chili.

• Sweet potato (3g fiber): Serve as wedges or mashed.
• Broccoli (5g fiber/cup): Serve as "trees" with hummus or mixed into mac and cheese.
• Carrots (3g fiber/cup): Serve with ranch or hummus.
• Green peas (4g fiber/½ cup): Add to pasta or rice dishes.
• Spinach (4g fiber/cup cooked): Blend into smoothies or sauces.

Beans and legumes: Excellent sources of fiber and highly versatile. Chickpeas, containing 9g fiber per 1/3 cup, can be roasted as a crunchy snack, blended into hummus with vegetables or pretzels, or added to pasta dishes. Black beans, with 8g fiber per ½ cup, work well in bean and cheese quesadillas, added to tacos or burritos, or even mixed into brownie batter.

Whole grains: Choose whole grains that retain the bran, germ, and endosperm.

• Breakfast cereals: Aim for >5g fiber/serving.
• Mix high-fiber cereal with a favorite cereal.
• Add berries and seeds for extra fiber.
• Breads and wraps: Choose whole grain with ≥3g fiber/slice.
• Pasta alternatives:
• Whole wheat pasta (7g fiber/cup).
• Chickpea pasta (8g fiber/cup).
• Red lentil pasta (6g fiber/cup).

Implementation tip: When increasing fiber intake, start low and go slow to prevent bloating and discomfort. Gradual increases paired with sufficient fluid intake are key to avoiding adverse effects.

Fluid: Keeping stool soft

Adequate hydration is critical in constipation management, as water keeps stool soft and easier to pass. Children should aim for daily water intake roughly equivalent to their age in 8-ounce cups, with a minimum of 64 ounces for children over the age of eight.⁸ A general rule of thumb is to consume approximately half an ounce of water per pound of body weight daily. To encourage hydration, suggest strategies like using colorful water bottles, offering fruit-infused water, or serving hydrating foods such as watermelon, cucumber, and fruit popsicles. Other effective fluid sources include broth-based soups, prune juice, pear nectar, and caffeine-free herbal teas.

Fitness: The often forgotten “F”

Physical activity is often overlooked in constipation management but is vital in supporting healthy bowel function. Movement helps stimulate the natural contractions of the intestines, aiding stool passage.⁹ Age-appropriate activity recommendations include encouraging preschool-aged children (3-5 years) to stay active throughout the day and school-aged children (6-17 years) to engage in at least 60 minutes of physical activity daily.¹⁰ Activities can be as simple as outdoor play, dance, or family walks.

Managing pediatric constipation requires a comprehensive approach that extends beyond medications. Dietary modifications centered around the "3 Fs"—Fiber, Fluid, and Fitness—can significantly improve bowel regularity and reduce the need for long-term laxative use. By guiding families to gradually increase fiber intake, prioritize hydration, and encourage physical activity, pediatric providers can empower caregivers with practical, effective tools for long-term success. To learn more about effective nutrition strategies for pediatric constipation, listen to Episode 19 of the Exam Room Nutrition podcast titled The Scoop on Poop: https://www.examroomnutritionpodcast.com/19-the-scoop-on-poop-managing-constipation-in-kids/ .

References:

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2. Madani S, Tsang L, Kamat D. Constipation in Children: A Practical Review. Pediatr Ann. 2016;45(5):e189-e196. doi:10.3928/00904481-20160323-01

3. Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. doi:10.1097/MPG.0000000000000266

4. Finn K, Jacquier E, Kineman B, Storm H, Carvalho R. Nutrient intakes and sources of fiber among children with low and high dietary fiber intake: the 2016 feeding infants and toddlers study (FITS), a cross-sectional survey. BMC Pediatr. 2019;19(1):446. Published 2019 Nov 18. doi:10.1186/s12887-019-1822-y

5. Kranz S, Brauchla M, Slavin JL, Miller KB. What do we know about dietary fiber intake in children and health? The effects of fiber intake on constipation, obesity, and diabetes in children. Adv Nutr. 2012;3(1):47-53. doi:10.3945/an.111.001362

6. Trumbo P, Schlicker S, Yates AA, Poos M; Food and Nutrition Board of the Institute of Medicine, The National Academies. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids [published correction appears in J Am Diet Assoc. 2003 May;103(5):563]. J Am Diet Assoc. 2002;102(11):1621-1630. doi:10.1016/s0002-8223(02)90346-9

7. Eltorki M, Leong R, Ratcliffe EM. Kiwifruit and Kiwifruit Extracts for Treatment of Constipation: A Systematic Review and Meta-Analysis. Can J Gastroenterol Hepatol. 2022;2022:7596920. Published 2022 Oct 6. doi:10.1155/2022/7596920

8. CHOC. How Much Water Should Kids Drink? Children’s Hospital of Orange County. 2024. Accessed January 10, 2025 https://choc.org/programs-services/urology/how-much-water-should-my-child-drink/

9. Gao R, Tao Y, Zhou C, et al. Exercise therapy in patients with constipation: a systematic review and meta-analysis of randomized controlled trials. Scand J Gastroenterol. 2019;54(2):169-177. doi:10.1080/00365521.2019.1568544

10. CDC. Physical Activity for Children: An Overview. Physical Activity Basics. CDC. January 8, 2024. Accessed January 10, 2025. https://www.cdc.gov/physical-activity-basics/guidelines/children.html