AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

Section 2 of 11  

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Background

Concern about bowel function has been prevalent throughout history across many cultures. A normal bowel pattern is thought to be a sign of good health. Unfortunately, no uniform definition of childhood constipation is recognized. Moreover, health care providers have definitions of constipation that are very different than most parents' definitions. 

The North American Society of Gastroenterology and Nutrition defines constipation as "a delay or difficulty in defecation, present for 2 weeks or more, and sufficient to cause significant distress to the patient."¹ The Paris Consensus on Childhood Constipation Terminology defines constipation as "a period of 8 weeks with at least 2 of the following symptoms: defecation frequency less than 3 times per week, fecal incontinence frequency greater than once per week, passage of large stools that clog the toilet, palpable abdominal or rectal fecal mass, stool withholding behavior, or painful defecation."² For practical clinical purposes, constipation is generally defined as infrequent defecation, painful defecation, or both. In most cases, parents are worried that their child's stools are too large, too hard, not frequent enough, and/or painful to pass.

Constipation in children is an extremely common problem with reported prevalence rates between 4-37%. Constipation is the principal complaint in 3-5% of all visits to pediatric outpatient clinics and as many as 35% of all visits to pediatric gastroenterologists.³

Pathophysiology

Most children with constipation have no underlying medical condition. They are often labeled as having functional constipation or acquired megacolon. In most cases, childhood constipation develops when the child begins to associate pain with defecation. Once pain is associated with the passage of bowel movements, the child begins to withhold stools in an attempt to avoid discomfort. As stool withholding continues, the rectum gradually accommodates, and the normal urge to defecate gradually disappears. The infrequent passage of very large and hard stools reinforces the child's association of pain with defecation, resulting in worsening stool retention and progressively more abnormal defecation dynamics with anal sphincter spasm. Chronic rectal distension ultimately results in both loss of rectal sensitivity, and loss of the urge to defecate, which can lead to fecal incontinence (ie, encopresis).

The differential diagnosis of childhood constipation can be extensive and may include Hirschsprung disease (ie, congenital megacolon), spinal or neuromuscular abnormalities, hypothyroidism, anal stenosis, imperforate anus with fistula, anterior displacement of the anus (this is a controversial diagnosis), allergy or sensitivity to cow's milk, and celiac disease. Fortunately, in most cases in which an underlying condition causes constipation, other stigmata of the disorder point to diagnosis. For example, constipation is rarely the only symptom of hypothyroidism.

For practical purposes, in an otherwise healthy child, the differential diagnosis of chronic constipation is Hirschsprung disease and functional constipation (not Hirschsprung disease). Although this differentiation sometimes may be difficult, a number of clues in the history and physical examination are helpful (see Media file 1).

Frequency

United States

Constipation is extremely common among infants and young children. Issenman et al found that 16% of parents reported that their 2-year-old children had constipation.⁴ Loening-Baucke reported that the prevalence of constipation was 22.6% among 482 children aged 4-17 years.⁵ In a longitudinal study of children aged 9-11 years, Saps et al reported an 18% overall prevalence of constipation.⁶

International

Yong and Beattie found that 34% of parents in the United Kingdom reported their children aged 4-7 years had at least intermittent difficulties with constipation.⁷ de Araujo Sant'Anna and Calcado found that 28% of Brazilian children aged 8-10 years were constipated.⁸

Sex

Before puberty, constipation appears to be equally common among girls and boys. After puberty and into young adulthood, females are more likely to develop constipation.

Age

Constipation occurs in all pediatric age groups from infancy to young adulthood. Typically, childhood constipation develops during 3 stages of childhood: in infants during weaning, in toddlers during toilet training, and in school-aged children. In several published reports, approximately half of childhood constipation occurs during the first year of life.

CLINICAL

Section 3 of 11  

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History

• History is often helpful in discriminating functional constipation from Hirschsprung disease. Asking parents when their child passed his or her first bowel movement after birth is particularly important. Most children with Hirschsprung disease have difficulties with constipation dating to birth or shortly after birth. In most published series, more than one half of infants with Hirschsprung disease do not pass meconium during the first 36 hours of life and are diagnosed with constipation within the first 4-6 months of life.
• Asking the family about specific symptoms of their child's constipation is also important. Inquiring about the onset and duration of symptoms, whether the passage of bowel movements appears to be painful, and whether any bleeding has been associated with defecation is important. Obtaining history of fecal incontinence or soiling is also crucial because many parents confuse fecal soiling (ie, encopresis) with chronic or recurrent diarrhea.
• Most cases of chronic childhood constipation are precipitated by painful bowel movements with resultant voluntary withholding of stool.⁹ In young children, parents often confuse withholding of stool with pain or excessive straining (see Media file 5). In many cases of functional constipation, parents can identify a precipitating event.
• In young infants, functional constipation often develops at the time of a dietary transition (eg, from breast milk to formula, from formula to whole milk).
• In toddlers, functional constipation often develops near the time of toilet training.
• In toddlers and young children, constipation frequently develops following an illness associated with either a severe diaper dermatitis or dehydration.
• In older children, functional constipation often develops at the time of school entry because they refuse to defecate while they are at school.

Physical

• The most important part of the physical examination is the rectal examination. Perform a rectal examination in any child with chronic constipation, regardless of age. In young infants, the anus should be sufficiently large to permit the introduction of a pinkie finger.
• Carefully examine the perineum for any sacral dimples or pits that might indicate an abnormality of the distal spinal cord. Also note the location of the anus on the perineum.
• • In most children, the anus is approximately halfway between the posterior fourchette (base of the scrotum) and the tip of the coccyx.
  • Whether children with anterior displacement of the anus are at increased risk for constipation is not entirely clear. To date, no large prospective studies have been performed. In some cases, if the anus is sufficiently anterior, a posterior rectal shelf may develop, resulting in abnormal defecation dynamics. Some pediatric surgeons and pediatric gastroenterologists believe that this entity is at one end of the continuum of imperforate anus with a perineal fistula.
• Examine the anus for the presence of any fissures, fistulae, or hemorrhoids. Also, confirm the presence of an anal wink. To elicit an anal wink, stroke the perianal skin with a pin or probe. In response to the stroking, the subcutaneous portion of the external anal sphincter should contract and visibly pucker at the anal margin. Failure to elicit this reflex can indicate an abnormality with either peripheral sensory or motor nerves or central connections mediating the reflex.
• Upon digital examination, note the size of the anal canal, the size of the rectum, and whether any intrarectal masses are present. Also, note if the rectum is empty or filled with stool and note the consistency of the stool.
• Among children with Hirschsprung disease, the rectum is typically quite small and empty of stool. Following the digital examination, the infant may have a gush of liquid stool because the functional obstruction has transiently been relieved.
• Among children with functional constipation, the rectum is generally enlarged, and stool is present just beyond the anal verge.

DIFFERENTIALS

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Other Problems to be Considered

Anal stenosis
Anterior displacement of the anus
Celiac disease
Cerebral palsy (static encephalopathy)
Currarino's triad (rectal stenosis, hemi sacrum, presacral mass)
Cow's milk intolerance
Mitochondrial disorders
Neuronal intestinal dysplasia
Prune-belly syndrome
Spinal muscular atrophy
Tethered cord

WORKUP

Section 5 of 11  

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Imaging Studies

• Radiography
• • In most cases, the diagnosis is based on the history and physical examination; however, among children who are obese or who refuse a rectal examination, plain abdominal radiography can assess whether significant fecal retention is present (see Media file 3).
  • Plain abdominal radiography can also be useful in assessing efficacy of medical therapy when the history is unclear.
• Contrast enema
• • Radiography can be useful in excluding or diagnosing Hirschsprung disease. Although the diagnosis of Hirschsprung disease ultimately relies on a histologic demonstration of an absence of ganglion cells in the affected colon, the diagnosis is often suggested by single-contrast barium enema.
  • Do not use an air-contrast enema because radiographic evaluation for Hirschsprung disease depends on finding a change in colonic caliber between the normal and abnormal aganglionic segment. With an air-contrast study, the colon is evacuated to identify mucosal abnormalities. By evacuating the colon prior to study, any caliber change may be masked.
  • Moreover, do not perform any form of rectal manipulation on the child (eg, rectal examination, therapeutic enema, suppository) for 48 hours prior to the procedure. The radiologist is looking for a change in colonic diameter from the narrow aganglionic segment to more dilated ganglionic segment (see Media file 2). This transition zone is characteristic of Hirschsprung disease. Rectal manipulation with suppositories or therapeutic enemas may transiently dilate the narrowed distal segment, causing a false negative result.
  • Although an unprepared barium enema has reasonably good diagnostic sensitivity and specificity in older children, this procedure is substantially less reliable during the first several months of life. The proximal colon may require several months after birth to dilate sufficiently for a transition zone to be apparent.

Other Tests

• Anorectal manometry can be useful in discriminating between functional constipation and Hirschsprung disease. With anorectal manometry, a balloon catheter is inserted into the rectum. Normally, when the rectal balloon is inflated, the internal anal sphincter relaxes reflexively (see Media file 4).
• Among patients with Hirschsprung disease, the internal anal sphincter fails to relax in response to rectal distension. As many as 20% of healthy children may have a falsely absent reflex, especially if they were born prematurely or at low birth weight; however, a positive response is strong evidence against Hirschsprung disease.

Procedures

• Rectal biopsy is the definitive means of establishing or excluding Hirschsprung disease.¹⁰ The tissue is examined histologically for the presence or absence of ganglion cells in the submucosal plexus.

TREATMENT

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Medical Care

Although constipation is an extremely common problem among children, few studies have systematically evaluated different management strategies. Childhood constipation is treated in many ways, and virtually any therapeutic regime is likely to be effective as long as it is sufficiently aggressive and persistent.¹¹ Because of the medical profession's understanding of the pathophysiology of the problem, the basic tenets of therapy include evacuation of the colon, elimination of pain with defecation, and establishing regular bowel habits.

• Evacuate the colon.
• • With evidence of a fecal impaction, aim initial therapy at complete evacuation of the colon. Palpating a hard mass of stool upon physical examination, finding a large amount of stool in a dilated rectum during rectal examination, or finding excessive stool in the colon using abdominal radiography can identify a fecal impaction.
  • A series of enemas or the aggressive use of oral cathartics such as polyethylene glycol, sodium phosphate, magnesium citrate, or a balanced electrolyte solution with polyethylene glycol can accomplish disimpaction.¹² In uncontrolled trials, disimpaction by the oral route, the rectal route, or a combination of both have proven effective.
  • Convincing young children to ingest sufficient amounts of oral cathartics to evacuate their colons is difficult; therefore, enemas or suppositories may be necessary.
• Eliminate any pain associated with defecation.
• • Once the colon has been evacuated, chronic laxative therapy is generally required. Virtually any laxative can be used as long as it is used in sufficient quantity to produce 1-2 soft stools daily. In young children, eliminating any pain associated with the passage of bowel movements is extremely important. Using very large doses of laxatives to produce very soft stools may be necessary.
  • Continuing laxative therapy for a number of months is often necessary. As a result, reassuring caregivers of the safety of long-term laxative usage is very important. Address specific concerns regarding laxative dependency and the risk of colon cancer due to chronic laxative usage. Many popular misconceptions about laxative use and abuse exist.
  • If the child has anal fissures, using Xylocaine ointment or hydrocortisone suppositories for a short period of time to provide symptomatic relief may be appropriate.
• Establish regular bowel habits.
• • In many cases, long-term success depends on the child establishing regular and routine toilet times. Encouraging the child to attend the toilet once or twice daily for 5-10 minutes, preferably after breakfast and supper to take advantage of the gastrocolic reflex, is generally recommended. Not expecting the child to attend the toilet while at school is also preferable.
  • When the affected child has passed bowel movements regularly for weeks or months without apparent pain, fear, or excessive straining, attempting to discontinue laxative therapy is reasonable. Inform the family that relapses are common, particularly with changes in the child's daily routine (eg, vacations) and during times of stress. Also inform the family that requiring intermittent therapy with laxatives into adulthood is not unusual.

Consultations

• Consultation with a pediatric gastroenterologist or pediatric surgeon is appropriate if the history or examination findings suggests an underlying organic cause (eg, Hirschsprung disease). Seek consultation when the child fails routine therapy or when management is otherwise complex.

Diet

• Dietary changes, such as increasing the child's intake of fluids and carbohydrates, are commonly recommended as part of the treatment.¹³ Complex carbohydrates and unabsorbable sugars (eg, sorbitol) are found in many fruit juices (eg, prune, pear, apple). These carbohydrates increase stool frequency as a result of increased fecal water content. Although randomized controlled trials have not been conducted to examine the effects of increased fluids, nonabsorbable carbohydrates, or dietary fiber on childhood constipation, recommending a balanced diet that includes whole grains, fruits, vegetables, and lots of fluid seems appropriate. Because data are limited, forceful implementation of a particular diet does not seem warranted.
• In infants and young children, considering the removal of cow's milk protein from the diet for a period of time is appropriate because chronic constipation may be precipitated by ingestion of cow's milk proteins. Iacono and colleagues found that among 27 Italian children aged 5-36 months who had chronic constipation, the constipation resolved in 78% of the children when soy milk was substituted for cow's milk; in most cases, the constipation recurred when cow's milk was reintroduced.¹⁴
• Switching the patient to a low-iron formula is not necessary. Several studies have shown that ingestion of iron-supplemented formulas is not associated with an increased incidence of constipation.¹⁵

MEDICATION

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In several randomized trials, laxatives have been shown to be beneficial in the treatment of chronic childhood constipation.^{16, 17} Studies have shown that polyethylene glycol,¹⁸ mineral oil, magnesium hydroxide, and lactulose are effective and can be used for prolonged periods of time without risk. The key to therapy is to use a sufficient amount of laxative to produce the desired effect. The use of stimulant laxatives may be necessary intermittently in some children; however, routine usage of these agents in young children is not generally recommended. Continuous laxative therapy may be required for several months until the child extinguishes the association between pain and the passage of bowel movements.

Drug Category: Osmotic laxatives

These agents produce osmotic effect in colon that results in distention and promotes peristalsis.

Drug Category: Lubricants

These agents soften stools and decrease water absorption from the GI tract. They may also promote salt and water secretion by the colon.

Drug Category: Stimulant laxatives

These agents increase peristaltic activity in the GI tract. Most of these agents also stimulate salt and water secretion in the colon.

Drug Category: Stool softeners

These agents allow incorporation of water and fat into stool, causing stool to soften.

Drug Category: Stool softeners in combination with stimulants

Emollient stool softeners cause stool to soften. Most of these agents also promote salt and water secretion by the colon. Stimulants increase peristaltic activity in the GI tract. Most of these agents also promote salt and water secretion by the colon.

Drug Category: Osmotic enemas

These agents produce osmotic effect in colon that results in distention and promotes peristalsis.

FOLLOW-UP

Section 8 of 11  

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Further Outpatient Care

• Assessment after disimpaction assures that the prescribed therapy was effective. At that time, maintenance laxative therapy can be prescribed.
• When the patient has bowel movements regularly for weeks or months without apparent pain, fear, or excessive straining, attempting to discontinue laxative therapy is reasonable.

Patient Education

• Educating the family that using laxatives continuously for months may be necessary is important. This is particularly true among toddlers, because many months may pass before the association between fear and defecation is extinguished. Reassuring caregivers as to the safety of long-term laxative use and reinforcing the need for persistence is very important. Repeatedly address specific concerns regarding laxative dependency and the risk of colon cancer.
• Inform the family that relapses are common and are associated with changes in the child's daily routine (eg, vacations) and may occur during times of stress. Also, inform the family that the requirement of intermittent therapy with laxatives into adulthood is not unusual.
• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article, Constipation in Children.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Perform a digital rectal examination on every young child with chronic constipation to exclude underlying anatomic abnormalities that might account for the constipation, such as an imperforate anus with perineal fistula, intestinal obstruction (mass effect), or Hirschsprung disease.

MULTIMEDIA

Section 10 of 11  

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• Miscellaneous
• Multimedia
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Media file 1:  Differentiating functional constipation and Hirschsprung disease.
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Media file 2:  Unprepared single contrast barium enema demonstrating a transition zone consistent with Hirschsprung disease.
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Media type:  Radiograph

Media file 3:  Plain abdominal radiograph that demonstrates stool throughout the colon.
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Media type:  Radiograph

Media file 4:  Normal anorectal manometry that demonstrates relaxation of the internal anal sphincter in response to rectal distension.
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Media type:  Graph

Media file 5:  Common withholding behaviors in young children.
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Media type:  Graph

REFERENCES

Section 11 of 11

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18. Dupont C, Leluyer B, Amar F, et al. A dose determination study of polyethylene glycol 4000 in constipated children: factors influencing the maintenance dose. J Pediatr Gastroenterol Nutr. Feb 2006;42(2):178-85. [Medline].
19. Felt B, Wise CG, Olson A, et al. Guideline for the management of pediatric idiopathic constipation and soiling. Multidisciplinary team from the University of Michigan Medical Center in Ann Arbor. Arch Pediatr Adolesc Med. Apr 1999;153(4):380-5. [Medline].
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21. Khan S, Campo J, Bridge JA, et al. Long-term outcome of functional childhood constipation. Dig Dis Sci. Jan 2007;52(1):64-9. [Medline].
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Article Last Updated: Jul 15, 2008