Overview
Definition:
Constipation in children is defined as infrequent stools, hard stools, painful defecation, or fecal incontinence (encopresis) that occurs at least once a week for at least one month, in the absence of organic disease
Functional constipation is the most common type, accounting for over 90% of cases.
Epidemiology:
Affects 3-5% of children in primary care settings and up to 30% of those seen by pediatric gastroenterologists
It is more common in toddlers and preschoolers during toilet training
Boys and girls are affected equally.
Clinical Significance:
Chronic constipation can lead to significant distress for the child and family, impacting school attendance, social interactions, and self-esteem
Untreated, it can result in painful defecation, stool withholding, fecal impaction, overflow incontinence (encopresis), and urinary tract infections due to bladder compression by a fecal-loaded rectum.
Clinical Presentation
Symptoms:
Infrequent bowel movements, defined as fewer than 3 stools per week
Passage of hard, dry, or large stools
Straining or pain during defecation
Fecal soiling or leakage (encopresis), often misinterpreted as diarrhea
Abdominal pain, usually in the left lower quadrant
Decreased appetite
Nausea
Intermittent vomiting
Passing small amounts of liquid stool around a fecal impaction (overflow incontinence)
Stool withholding behaviors, such as posturing or tensing muscles.
Signs:
Palpable fecal mass in the abdomen, particularly the left lower quadrant
Dilated rectum filled with hard stool on digital rectal examination
Perianal fissures or skin irritation from soiling
Abdominal distension
Poor weight gain in some cases.
Diagnostic Criteria:
Rome IV criteria for functional constipation in children: At least two of the following, occurring at least once per week for at least one month: Two or fewer defecations per week
At least one episode of fecal incontinence per week
History of retentive posturing
History of painful or hard bowel movements
Large fecal mass in the rectum
History of large-volume stools that may obstruct the toilet
Diagnosis is typically made based on history and physical examination, excluding alarm symptoms suggestive of organic disease.
Diagnostic Approach
History Taking:
Detailed birth history, feeding history, and toilet training history
Onset and duration of constipation
Stool frequency, consistency (e.g., Bristol Stool Scale), and associated pain
Presence of abdominal pain, nausea, vomiting, or decreased appetite
Fecal incontinence (encopresis) – pattern, frequency, and relation to defecation
Stool withholding behaviors
Dietary assessment: fiber intake, fluid intake
Family history of gastrointestinal disorders or constipation
Review of systems to identify alarm symptoms (see red flags)
Red flags: Bilious vomiting, failure to thrive, bloody stools, fever, severe abdominal distension, anal stenosis, absent anal reflex, neurological deficits, or onset of constipation after 4-6 weeks of life.
Physical Examination:
General assessment: growth parameters (weight, height, BMI), signs of dehydration or chronic illness
Abdominal examination: inspection for distension, palpation for tenderness or fecal masses, auscultation for bowel sounds
Rectal examination: assessment of anal tone, presence of fissures, palpation of rectal vault for fecal impaction, and consistency of stool
Neurological examination: assessment of lower extremity reflexes, sensation, and sacral dimple/tuft of hair to rule out spinal dysraphism.
Investigations:
In most cases of suspected functional constipation, investigations are not required if alarm symptoms are absent
If alarm symptoms are present or if there is suspicion of organic causes: Abdominal X-ray: may show significant fecal loading but is not essential for diagnosis of functional constipation
Consider for suspected impaction or intussusception
Blood tests: Complete blood count (CBC) for anemia (e.g., iron deficiency), electrolytes, calcium, thyroid function tests if hypothyroidism is suspected
Urinalysis and urine culture: to rule out urinary tract infection, which can be associated with constipation
Swallowing study or gastrointestinal imaging: if dysphagia or other swallowing abnormalities are suspected
Spinal MRI: if neurological deficits or suspicion of spinal cord abnormalities (e.g., tethered cord).
Differential Diagnosis:
Hirschsprung disease: characterized by absence of ganglion cells in the distal colon, leading to functional obstruction
Symptoms include delayed meconium passage, abdominal distension, and failure to thrive
Celiac disease: can present with constipation or diarrhea, abdominal pain, and failure to thrive
Hypothyroidism: can cause generalized slowing of gut motility
Anal fissures: painful defecation can lead to stool withholding
Irritable bowel syndrome (IBS): diagnosis of exclusion in children over 4 years, with recurrent abdominal pain associated with changes in bowel habits
Neurological disorders: spinal cord abnormalities, cerebral palsy, autonomic neuropathy
Metabolic disorders: hypercalcemia, hypokalemia.
Management
Initial Management:
The cornerstone of management is a multi-faceted approach including education, disimpaction (if present), a regular bowel regimen, dietary modifications, and toilet training
Education for child and family is crucial, explaining that constipation is common, treatable, and not the child's fault
Reassurance is vital to reduce anxiety associated with defecation.
Medical Management:
Disimpaction: If fecal impaction is present, it must be cleared first
This can be achieved with oral osmotic laxatives (e.g., Polyethylene Glycol 3350 - PEG 3350, dosed higher, e.g., 1.5 g/kg/day divided doses for 3-4 days, or until impaction is cleared), or with rectal therapies (e.g., enemas or suppositories) under medical supervision
Maintenance therapy: Once disimpacted, a daily bowel regimen is initiated to prevent reaccumulation of stool
Osmotic laxatives are preferred for long-term use due to their safety and efficacy
Common options include PEG 3350 (e.g., 0.5-1 g/kg/day, max 17-34 g/day, titrated to soft stools 1-2 times/day) or Lactulose (0.5-1 mL/kg/day, max 10-20 mL/day)
Stimulant laxatives (e.g., Senna, Bisacodyl) should be used judiciously and for short durations due to risk of dependence
Stool softeners like Docusate sodium are less effective for functional constipation
Dietary modifications: Encourage increased intake of fiber-rich foods (fruits, vegetables, whole grains) and adequate fluid intake (water).
Toilet Training:
Once a regular bowel pattern is established with medication, toilet training can begin
Establish a regular time for sitting on the toilet (e.g., 10-15 minutes after meals), especially after breakfast, to take advantage of the gastrocolic reflex
Use a child-sized toilet seat or a potty chair
Ensure the child's feet are supported to allow for comfortable positioning and relaxation
Encourage a relaxed posture (e.g., leaning forward with elbows on knees)
Praise and reward efforts and success, avoiding punishment for accidents
Stool withholding behaviors should be addressed with positive reinforcement and patience.
Supportive Care:
Behavioral interventions are crucial
Regular toileting schedule
Positive reinforcement and sticker charts for successful toileting
Parental education and support to manage anxiety and frustration
Management of encopresis: Initially, disimpaction and a maintenance laxative regimen are essential
Once stools are soft and regular, focus on consistent toileting
Accidents should be managed calmly
Biofeedback therapy can be considered for older children with severe encopresis and dyssynergia of pelvic floor muscles, though it is less commonly used in routine pediatric practice in India.
Complications
Early Complications:
Fecal impaction: Failure to treat initial constipation can lead to severe fecal loading
Overflow incontinence (encopresis): Liquid stool leaks around the impacted mass, soiling underwear
Anal fissures: Painful tears in the anal mucosa from hard stools
Urinary tract infections: Due to rectal distension compressing the bladder and urinary tract
Abdominal pain and distension
Nausea and vomiting.
Late Complications:
Chronic functional constipation: If not managed appropriately, it can persist into adolescence and adulthood
Behavioral issues: Shame, anxiety, social isolation, school avoidance due to encopresis
Reduced quality of life for child and family
Potential for psychological distress.
Prevention Strategies:
Early recognition and management of constipation
Adequate fiber and fluid intake from infancy
Timely and positive toilet training experiences
Prompt treatment of any anal fissures or pain associated with defecation
Regular follow-up to ensure adherence to medication and behavioral strategies.
Prognosis
Factors Affecting Prognosis:
Early diagnosis and consistent management
Parental adherence to treatment recommendations
Child's cooperation and engagement
Absence of underlying organic disease or significant neurological impairment
Effective management of stool withholding behaviors.
Outcomes:
With appropriate and consistent management, the prognosis for functional constipation in children is generally excellent
Most children respond well to laxatives and behavioral interventions, achieving regular, soft stools and resolving encopresis
However, relapse can occur if treatment is discontinued prematurely or if lifestyle factors (diet, fluids) are not maintained.
Follow Up:
Regular follow-up with a pediatrician or pediatric gastroenterologist is important, especially in the initial months of treatment
The duration of treatment varies but often requires several months to a year or more, with gradual tapering of medication as bowel function normalizes and toileting habits are established
Long-term follow-up may be needed for children with complex cases or those at risk of relapse
Emphasis should be on empowering the child and family to manage bowel health independently.
Key Points
Exam Focus:
Remember the Rome IV criteria for functional constipation in children
Always rule out alarm symptoms before diagnosing functional constipation
Disimpaction is the first step in managing significant impaction
Osmotic laxatives (PEG 3350) are the first-line agents for maintenance therapy
Toilet training should commence after disimpaction and establishment of a regular bowel regimen
Encopresis is overflow incontinence, not true diarrhea.
Clinical Pearls:
Educate parents that constipation is not a willful act by the child
Use the Bristol Stool Scale for consistent communication about stool consistency
Encourage children to sit on the toilet for 10-15 minutes after meals, especially breakfast, to harness the gastrocolic reflex
Positive reinforcement is key for toilet training success
Gradual tapering of laxatives is crucial to prevent relapse.
Common Mistakes:
Starting stimulant laxatives as first-line treatment
Discontinuing laxatives too soon without establishing regular toileting habits
Punishing children for encopresis or accidents, which exacerbates stool withholding
Failing to adequately disimpact fecal masses before initiating maintenance therapy
Not thoroughly assessing for alarm symptoms, leading to delayed diagnosis of organic causes.