Practice Essentials
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, healthcare providers have definitions of constipation that are very different from most parents' definitions.
Constipation in children has reported prevalence rates between 1% and 30%. [1] It 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. [2]
Definitions
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.
The North American Society of Gastroenterology, Hepatology, and Nutrition (NASPGHAN) defines constipation as "a delay or difficulty in defecation, present for 2 weeks or more, and sufficient to cause significant distress to the patient." [3]
The Paris Consensus on Childhood Constipation Terminology (PACCT) 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." [4]
The following image is an abdominal radiograph of a child with constipation.
See also Constipation and Surgery for Pediatric Constipation and Bowel Management.
Anatomy
Bowel motility is one of the most complex and sophisticated functions in the human body. The colon absorbs water and functions as a reservoir. Liquid waste delivered by the small bowel into the cecum becomes solid stool in the descending and sigmoid colon. The colon has a slow motility; its peristalsis seems to be less active in the distal portions of the colon. Every 24-48 hours, the rectosigmoid develops active peristaltic waves that indicate that it must be emptied. This is perceived by the individual, who then has the capacity to voluntarily retain the stool or to empty it, depending on social circumstances.
Pathophysiology
Most children suffering from constipation have no underlying medical condition. They are often labeled as having functional constipation or acquired or functional 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 distention ultimately results in both loss of rectal sensitivity, and loss of the urge to defecate, which can lead to fecal incontinence (ie, encopresis).
Epidemiology
In the United States, constipation is extremely common among infants and young children. In a 1987 report, Issenman et al found that 16% of parents reported that their 2-year-old children had constipation [5] ; 2 decades later, Loening-Baucke reported that the prevalence of constipation was 22.6% among 482 children aged 4-17 years. [6] In a longitudinal study of children aged 9-11 years, Saps et al reported an 18% overall prevalence of constipation. [7]
In a European study, 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, [8] and a South American study by de Araujo Sant'Anna and Calcado found that 28% of Brazilian children aged 8-10 years were constipated. [9]
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.
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 than males.
Patient Education
It is very important to educate the family that using laxatives continuously for months may be necessary. This is particularly true in toddlers, because many months may pass before their association between the fear of pain and defecation is extinguished.
Caregivers should be reassured as to the safety of long-term laxative use, and the importance of persistent treatment should be strongly reinforced. Address the common misconceptions about laxative dependency and the increased risk of colon cancer due to long-term laxative usage.
Inform the family that relapses are common and are often associated with changes in the child's daily routine (eg, vacations) or during times of stress. Also, inform the family that the requirement of intermittent therapy with laxatives into adulthood is not unusual.
For patient education information, see Constipation in Children.
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Plain abdominal radiograph that demonstrates stool throughout the colon.
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This table differentiates functional constipation from Hirschsprung disease.
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This unprepared single-contrast barium enema demonstrates a transition zone consistent with Hirschsprung disease.
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The images illustrate normal anorectal manometry with relaxation of the internal anal sphincter in response to rectal distention.
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This image delineates common withholding behaviors in young children.
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Contrast enema of a patient with megasigmoid and impacted stool.
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Contrast enema in a patient in whom the rectosigmoid was resected.
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Position for enema administration in an infant.
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Another position for enema administration.
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Administration of an enema.
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Incorrect enema administration. The enema is administered against stool impaction and cannot be successful.
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Enema administration with a tube.
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Enema with inflated Foley balloon catheter.
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Administration of an enema against impacted stool.
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Administration of an enema against fecal impaction.
