Constipation in children is a common and often distressing problem characterized by infrequent, difficult, or painful passage of stools. Causes may include inadequate fiber or fluid intake, changes in routine or diet, stress, or underlying medical conditions.

  • <5% children with constipation have a definitive organic etiology (e.g., congenital, surgical, neurological, and endocrine conditions)
  • Majority of children have no proven cause and are labeled as functional constipation.

Functional Constipation Diagnostic Criteria ( two or more)

  • Stool frequency ≤2 per week
  • History of hard and painful bowel movements
  • History of retention of stools
  • Large diameter stool obstructing
  • Fecal incontinence
  • Per abdomen or per rectum examination reveals fecal mass

History and examination

  • Ask about stool frequency, stool consistency/associated pain or struggle during defecation/associated fissure/soiling of underwear, duration of symptoms, bowel movement pattern, diet, fluid intake, history of toilet training, family history of constipation, growth and developmental milestones, and history of withholding.
  • Age of Onset: Surgical causes are more common in infantile onset
  • Passage of meconium after birth: Delayed passage of meconium is observed with Hirschsprung’s disease
  • Urinary symptoms: Increased frequency, burning micturition, and urinary incontinence may suggest coexisting urinary tract infection or voiding dysfunction.
SymptomsSigns
Infrequent bowel movements, hard or large stools, straining, pain during defecation, fecal soiling, abdominal painPalpable fecal mass in the abdomen
Anal fissures
Rectal prolapse (rare)
  • Presence of fecal impaction (inability to pass/evacuate hard and large diameter stools) which often causes abdominal pain or fecal soiling.
  • Perianal examination (for the presence of fissure/sentinel skin tags) and examination of the spinal area for any possible underlying spinal/neurological conditions is recommended.
bristol stool chart

Differential diagnosis (D/D) & Complication

D/D

  • Hirschsprung’s disease (delayed passage of meconium, chronic constipation, failure to thrive, abdominal distension)
  • Hypothyroidism (constipation, cold intolerance, fatigue, weight gain, lethargic, short stature, delayed development)
  • Spinal cord abnormalities: Tuft of hair at back of the spine
  • Cerebral palsy and neurodegenerative disorder: Significant perinatal history, delayed developement, feeding abnormalities, regression of acquired milestones)
  • Cystic fibrosis: Recurrent respiratory infections, meconium ileus and failure to thrive

Complications: Fecal impaction, rectal prolapse, anal fissures, psychosocial issues

Investigation

  • Abdominal X-ray (if fecal impaction is suspected)
  • Thyroid function tests to rule of hypothyroidism if suspected

Admission criteria

  • Admission may be necessary for severe cases with fecal impaction or complications requiring further evaluation and management

Management

Medical
Detecting fecal impaction and disimpaction with laxatives is an important first step toward effective maintenance laxative therapy. Very hard and impacted stool may not be cleared with regular/maintenance dose laxatives.

Ezevac enema Stat if there is fecal impaction then give Syp Lactulose for maintenance phase.

  • Syp Lactulose PO BD x 2-3 weeks then tapper gradually (It can be used for 2-3 months and then gradually tapered and stop)

Treatment success is defined as regular painless defecation, toilet training, and the absence of fecal soiling or blood in stools.

Dose:

  • <1 year: 2.5 mL BD
  • 1–<5 years: 2.5–10 mL BD
  • 5–20 years: 5–20 mL BD

Parental counseling and education

  • Explain pathophysiology of functional constipation
  • Longer the stool is retained in the colon, the drier/harder and bulkier it becomes and this causes painful evacuation leading to withholding behavior establishing a vicious cycle.
  • Osmotic laxative cause bloating, nausea, vomiting,and diarrhea.
  • High fiber and increase intake of water. Daily diet should include cereals, pulses, vegetables, and fruits.
  • Discourage sedentary life style and encourage physical activity.
  • Toilet training, encourage child to defecate within 30 minutes of the major meal in order to utilize gastrocolic reflex.

Referral

  • Refer to a pediatric gastroenterologist for further evaluation and management if constipation persists despite conservative measures or if an underlying medical condition is suspected

Follow up

  • Follow up within 2-4 weeks to assess the response to treatment and monitor for complications

References:

  1. Tabbers, M. M., DiLorenzo, C., Berger, M. Y., Faure, C., Langendam, M. W., Nurko, S., … & Benninga, M. A. (2014). Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of Pediatric Gastroenterology and Nutrition, 58(2), 258-274.