Overview
Definition:
Constipation in children is defined as infrequent stools, hard stools, painful defecation, or the presence of fecal incontinence (soiling)
The Rome IV criteria provide standardized diagnostic guidelines for functional gastrointestinal disorders in children, including functional constipation.
Epidemiology:
Functional constipation is a common pediatric problem, affecting 3-10% of children worldwide
It is more prevalent in toddlers and preschool-aged children, with a slight female predominance in older children
Recurrence is common, impacting quality of life and healthcare utilization.
Clinical Significance:
Untreated or inadequately managed constipation can lead to significant morbidity, including abdominal pain, fecal impaction, encopresis, urinary tract infections, and psychological distress
Early and accurate diagnosis is crucial for effective management and prevention of long-term complications, making it a high-yield topic for DNB and NEET SS preparation.
Clinical Presentation
Symptoms:
Infrequent bowel movements (less than 3 per week)
Passage of hard, dry, or large stools
Straining or pain during defecation
Fecal soiling or soiling accidents (encopresis)
Avoidance of defecation (e.g., withholding posture, hiding)
Abdominal pain, bloating, or nausea
Decreased appetite.
Signs:
Abdominal distension
Palpable fecal impaction in the abdomen or rectum on physical examination
Rectal examination may reveal hard stool in the rectal vault or anal fissures
Soiling may be evident on underwear or in the perianal area
Poor weight gain in some cases.
Diagnostic Criteria:
Rome IV Criteria for Functional Constipation in Children (aged 4 years and older): At least two of the following present at least once per week for at least 1 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 diameter stools that may obstruct the toilet
Diagnosis requires exclusion of organic causes
For children younger than 4 years, criteria are similar but the duration is at least 1 month, and include at least 2 of the following: Two or fewer defecations per week
At least one episode of fecal incontinence per week
History of retentive posturing or excessive volitional stool retention
History of painful or hard bowel movements
Large fecal mass in the rectum
History of large diameter stools that may obstruct the toilet.
Diagnostic Approach
History Taking:
Detailed history of bowel habits (frequency, consistency, pain, straining, soiling)
Age of onset and duration
Toilet training history
Dietary history (fluid and fiber intake)
Medications and supplements
Family history of constipation or bowel disorders
Presence of red flag symptoms: failure to thrive, bilious vomiting, abdominal distension, blood in stool (without anal fissure), neurological deficits, delayed passage of meconium (first stool within 48 hours).
Physical Examination:
General assessment: growth parameters (weight, height, BMI)
Abdominal examination: inspection for distension, palpation for tenderness and masses (fecal impaction)
Rectal examination: inspection of perianal area for fissures or soiling, palpation for tone, presence and consistency of stool in the rectal vault
Neurological examination: to rule out spinal cord anomalies or neurological deficits.
Investigations:
Generally, investigations are not required for diagnosis of functional constipation if red flags are absent
Red flags may prompt: Abdominal X-ray: to assess fecal loading and impaction (though not routinely recommended for diagnosis)
Blood tests: Complete blood count (to rule out anemia of chronic disease), electrolytes, calcium, phosphate, thyroid function tests (TSH), celiac serology (tissue transglutaminase antibodies) if malabsorption is suspected
Urine analysis and culture: to rule out urinary tract infection, especially in girls with encopresis
Contrast enema or anorectal manometry: rarely indicated, reserved for severe or refractory cases to rule out Hirschsprung disease or other structural anomalies.
Differential Diagnosis:
Hirschsprung disease: delayed meconium passage, absent anal reflex, dilated proximal bowel
Metabolic disorders: hypothyroidism, hypercalcemia, hypokalemia
Celiac disease: associated with malabsorption and constipation
Neurological conditions: spinal dysraphism, cerebral palsy
Medications: anticholinergics, opioids
Anatomic abnormalities: anal stenosis, rectovaginal fistula
Inflammatory bowel disease (rare cause of isolated constipation)
Lead poisoning.
Management
Initial Management:
Education and reassurance for the child and family
Establish a regular toilet routine, encouraging sitting on the toilet for 5-10 minutes after meals
Address any behavioral issues related to toilet training
Dietary modifications: increase fluid and fiber intake (fruits, vegetables, whole grains).
Medical Management:
Pharmacological therapy aims to soften stools and facilitate easier passage
Options include: Osmotic laxatives: Polyethylene glycol (PEG) 3350 (e.g., Macrogol) is the first-line agent
Dose typically 0.5-1.5 g/kg/day, divided doses, titrated to effect
Lactulose (0.5-1 ml/kg/day, max 20 ml/day, divided doses)
Sorbitol
Stimulant laxatives (e.g., senna, bisacodyl): generally used for short-term relief or as an adjunct if osmotic laxatives are insufficient, due to potential for cramping and dependence
Doses vary by age and preparation
Stool softeners (e.g., docusate sodium): less effective for chronic constipation management than osmotic agents.
Clean Out Regimens:
For fecal impaction, a clean-out regimen is necessary to evacuate the accumulated stool
Options include: High-dose oral PEG 3350: e.g., 1.5-2.0 g/kg/day (max 100 g/day) divided into 2-3 doses for 3-7 days, usually mixed with juice
Rectal administration: Glycerin suppositories or small volume enemas (e.g., saline, mineral oil) may be used for younger children or in acute impaction, under medical supervision
Following the clean-out, maintenance therapy with osmotic laxatives is crucial to prevent reaccumulation
Success of clean-out is evidenced by passage of large, watery stools
Monitor for electrolyte imbalances and dehydration.
Supportive Care:
Regular follow-up is essential to monitor treatment adherence, stool consistency, and recurrence
Psychological support for the child and family to address anxiety and behavioral issues
Encourage physical activity
Nutritional counseling to ensure adequate intake of fluids and fiber.
Complications
Early Complications:
Anal fissures: painful tears in the anal mucosa due to passage of hard stools
Fecal impaction: a large mass of hardened stool in the rectum or colon, leading to overflow incontinence (encopresis)
Abdominal distension and pain.
Late Complications:
Encopresis and social embarrassment
Urinary tract infections (UTIs) due to rectal compression of the bladder
Bladder dysfunction
Rectal prolapse (rare)
Psychological distress, low self-esteem, and behavioral problems
Development of fear and avoidance of defecation.
Prevention Strategies:
Early recognition and management of constipation
Consistent adherence to maintenance laxative therapy
Education on regular toilet habits and adequate fluid/fiber intake
Addressing underlying behavioral or psychological factors
Regular follow-up to prevent recurrence.
Prognosis
Factors Affecting Prognosis:
Severity and duration of constipation
Adherence to treatment
Family support and understanding
Presence of comorbidities or red flags
Effective management of encopresis and behavioral issues.
Outcomes:
With appropriate management, including education, dietary changes, pharmacological therapy, and behavioral strategies, the prognosis for functional constipation in children is generally good
Most children achieve regular bowel movements and resolution of symptoms
However, recurrence is common, requiring ongoing management.
Follow Up:
Regular follow-up appointments are recommended, initially every few months, then annually or as needed
The goal is to gradually taper laxative therapy once regular bowel habits are established, but to maintain it long-term if necessary
Education on recognizing early signs of recurrence is vital.
Key Points
Exam Focus:
Differentiate functional constipation from organic causes using red flags
Understand Rome IV criteria for diagnosis
Key agents for clean-out (high-dose PEG) and maintenance therapy (osmotic laxatives)
Management of encopresis is crucial.
Clinical Pearls:
Educate parents that constipation is common and treatable
reassure them that laxatives are safe for long-term use
Toilet sitting routine post-meals is as important as medication
Address withholding behavior proactively
For encopresis, clean-out followed by sustained maintenance therapy is key.
Common Mistakes:
Underestimating the severity of constipation or fecal impaction
Inadequate clean-out regimens leading to persistent encopresis
Discontinuing maintenance therapy too soon
Focusing solely on medication without addressing diet, behavior, and toilet habits
Missing red flag symptoms that indicate organic disease.