Beyond a restroom pass: ‘silent crisis’ of childhood constipation in schools

In the daily bustle of classrooms, playgrounds and lunchrooms, one of the most common chronic health problems in children is one that is not typically discussed: constipation, and its consequence, encopresis.

Imagine a third grader, quietly fretting at her desk because she can’t concentrate on what her teacher is saying. She’s worried about the painful urge she feels in her belly to use the restroom and the dilemma of whether to ask to be excused. Will her teacher say no? Is the restroom clean? And what will her classmates think? Overcome by these worries, she decides to wait to use the restroom at home, silently suffering the rest of the day.

For millions of schoolchildren, this scenario is a daily reality that turns a basic bodily function into a source of stress and anxiety that can have lasting consequences for physical and mental health.

Constipation is one of the most common issues seen by pediatricians, affecting up to 30% of children worldwide and leading to $3.9 billion in estimated additional U.S. healthcare costs.

While often dismissed as a simple problem and overlooked in favor of other digestive disorders, chronic constipation can lead to painful complications including stool accidents and soiling of underwear and clothing (encopresis), social withdrawal and a lower quality of life. Since children spend most of their day at school, the school environment plays a critical role in managing this condition. However, many schools are not prepared to handle the issue.

To answer this, we recently published a study in the Journal of School Health surveying 125 school nurses that revealed a significant and under-supported challenge:

• A frequent problem: Nearly all surveyed nurses (95%) encountered students with constipation at least monthly, and more than half saw six or more cases every month. For nurses in elementary schools, 74% dealt with stool accidents at least once a month.
• Significant barriers: Nurses identified major obstacles that lead students to avoid the restroom. The most common were unclean restrooms (48%), bullying (42%) and drug use (23%).
• A policy vacuum: Restroom access policies are often inconsistent. Half of the school nurses said they rely on individual teacher discretion, and only 37% were aware of any formal school-wide policy on restroom use.
• A critical training gap: Despite being on the front lines of childhood constipation, the majority of school nurses (62%) reported having no formal training or education on managing constipation and its complications.

The policy implications of these findings are not just about plumbing and bathroom passes. When children must choose between health and education due to policies or facilities they view as unclean or unsecure, this problem spotlights the responsibility of schools to provide a safe and supportive learning environment for all.

The path to overcoming the issue will require a collaborative approach.

• Develop clear, supportive policies: Schools and districts must create standardized, evidence-based policies that ensure students have timely and unrestricted access to restrooms. This removes the burden of discretion from teachers and protects students’ health.
• Invest in safe and clean facilities: Addressing challenging barriers like uncleanliness, bullying and drug use is crucial. Well-maintained and monitored restrooms can reduce student anxiety and restroom avoidance.
• Empower school nurses: We must provide nurses with targeted training and resources on pediatric constipation. As the primary health contact in schools, their expertise is invaluable, but it must be cultivated and supported.

Effectively managing childhood constipation is a multidisciplinary challenge that requires pediatricians, school administrators, nurses and parents to work together. By addressing the systemic barriers within schools, an environment will be created that actively promotes education, health and well-being.

By Dr. Andrew Chu and Dr. Eric Chiou, associate professors in the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics