For adults, see separate article Constipation in Adults.
Constipation in children is a common problem affecting between 5% and 30% of children. It is often accompanied by parental anxiety. It is typically characterised by infrequent bowel evacuations, large stools and difficult or painful evacuation. About a third of patients develop chronic symptoms and referral to secondary care is common. It accounts for some 25% of paediatric gastroenterologists' work and is also one of the 10 most common problems seen by general paediatricians. On a practical note, when faced with the casual request of a laxative for a child, think carefully. It is recommended that the child be seen for a proper assessment and diagnosis.
Definitions of constipationAttempts have been made to define terms more precisely. There is something of a lack of consensus on the meaning of words used for common defecation problems. It is important to distinguish the normal from the abnormal. Constipation is usually defined as infrequent defecation, painful defecation, or both. The following terms were recommended by the Paris Consensus on Childhood Constipation Terminology (PACCT) Group in 2005 and they inform the diagnostic criteria. In practice, there are still children who have symptoms not adequately described by these terms.
- Chronic constipation- two or more of the following in the preceding eight weeks:
- Fewer than three bowel movements per week.
- More than one episode of faecal incontinence per week.
- Either palpable stools in the abdomen, or large stools palpable rectally.
- Passing stools so large they block the toilet.
- Retentive posturing and withholding behaviours.
- Painful defecation.
- Faecal incontinence- passage of stool in inappropriate places:
- Organic faecal incontinence - faecal incontinence resulting from organic disease.
- Functional faecal incontinence- faecal incontinence without organic disease:
- Constipation-associated faecal incontinence.
- Non-retentive faecal incontinence - (no constipation associated). This is the passage of stools in inappropriate places in children over 4 years old with no evidence of constipation.
- Faecal impaction - large faecal mass (abdominal or rectal and assessed by abdominal, rectal or other methods of examination) unlikely to be passed on demand.
- Pelvic floor dyssynergia - the inability to relax the pelvic floor when attempting to defecate.
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- Constipation in children, from whatever cause, is very common worldwide. A systematic review in 2006 found:
- Prevalence ranged from 0.7% to 29.6%.
- 90-95% of constipation was functional.
- Prevalence rates were similar in boys and girls.
- Age of highest prevalence could not be identified.
- Socio-economic factors were not found to be associated.
- Further studies using newer diagnostic criteria were called for.
- Most children with constipation are developmentally normal. It is seen commonly in:
- Infants at weaning.
- Toddlers acquiring toilet skills.
- School age.
- Constipation in children may also be associated with problems with toilet training, psychological problems, major life events (eg, parental divorce, bullying, sexual abuse), neurodevelopmental disorders and autism.
- History. In addition to general history (past medical history, school and social history and family history), the parent and child should be specifically questioned about the constipation. Parents can mistake incontinence for diarrhoea. In infants aged under 6 months, straining and crying for 10 minutes before passage of stools is caused by dyschezia (painful or difficult defecation which resolves spontaneously) and may be mistaken for constipation. Specific questions should cover:
- The frequency of defecation.
- Consistency of stools - this may include use of the Bristol Stool Chart.
- Episodes of faecal incontinence.
- Pain on defecation.
- Whether stools block the toilet.
- Any associated behaviour.
- Examination. This should include:
- Palpation of the abdomen for faecal mass.
- Inspection for anal stenosis or ectopia.
- Looking for sacral abnormalities.
- Rectal examination is not routinely necessary or required.
- Routine radiography is not recommended.
Organic causes of constipation
It is important to distinguish these organic causes from the much more common functional causes. Many of the organic causes will present in the first few weeks of life.
- Anorectal malformations:
- Physical examination. Careful inspection of the perineum in any baby with constipation:
- Is the anus in the correct position relative to the vulva or scrotum?
- Careful digital rectal examination with the well-lubricated fifth finger is advocated by some (detect stricture, assess volume and hardness of rectal stool). However, this should only be undertaken by healthcare professionals competent to interpret features of anatomical abnormalities or Hirschsprung's disease.
- Physical examination. Careful inspection of the perineum in any baby with constipation:
- Anal fissure is common and associated with painful defecation. Passage of blood and sentinel pile on the anterior anus are characteristic.
- Rectal prolapse may be caused, for example, by chronic straining and constipation, disorders of sacral nerve innervation and chronic diarrhoea.
- Hirschsprung's disease usually presents early (as delay in passing meconium, failure to thrive, etc) well inside the first month. However, rarely it can present late. Diagnosis is by:
- Rectal biopsy - the test of choice.
- Anorectal manometry, which is NOT recommended.
- Barium enema.
- Neurenteric problems:
- Colonic motility - the test of choice.
- Colonic transit.
- Possibly rectal biopsy.
- Spinal cord problems:
- Physical examination.
- Magnetic resonance imaging - the investigation of choice.
- Possible anorectal manometry.
- Pelvic floor dyssynergia:
- Anorectal manometry - the test of choice.
- Metabolic or systemic disorders:
- Lead levels, toxicology screen.
- Cow's milk allergy:
- Elimination diet.
- Allergy testing.
Functional causes of constipation
Chronic constipation and other types of functional constipation:
- History and physical examination are most important in the assessment and further tests are rarely necessary.
- Further investigations are recommended occasionally in chronic constipation and always in non-retentive faecal incontinence. Specifically:
- Radiology (kidneys, ureter, bladder).
- Colonic transit.
Confirm that constipation is present:
In a child <1 year, at least two of the following:
- Less than three complete stools per week (unless exclusively breast-fed when infrequent stools can be normal).
- Large hard stool or 'rabbit droppings'.
- Symptoms associated with defecation: distress on passing stool, bleeding with hard stool or straining.
- Past history of constipation.
- Previous or current anal fissure.
An older child may have the above, plus:
- Overflow soiling (the child may be unaware of passing loose, smelly stools, which may be thick and sticky, or dry and flaky).
- Large stools, big enough to block the toilet!
- Poor appetite that improves with passage of a large stool.
- Abdominal pain which waxes and wanes with passage of stool.
- Retentive posturing - eg, on tiptoes, straight-legged, and with an arched back.
- Straining, painful bowel movements, and/or anal pain.
Management (including any investigations)
History and examination are most important to make a diagnosis and should determine whether further investigations are required.
A useful flow chart to guide overall management is incorporated in the National Institute for Health and Clinical Excellence (NICE) guidance, emphasising the importance of identifying any amber or red-flag symptoms or signs:
|A summary of NICE guidance on constipation in children and young people|
|Constipation||Red flags||Amber flags|
Management of functional or idiopathic constipation
This section is aimed at the management of functional or idiopathic constipation. The aims are to remove faecal impaction, restore bowel habit (with soft stools passed without pain), self-toileting and passing of stools in appropriate places. Children and parents should be offered support through the treatment process.
- Anxiety of the parent and child.
- Attitudes of guilt or blame.
- Inappropriately coercive toilet training.
- Social consequences (for example, faecal incontinence in older children).
- Disimpaction. Retained faeces should be cleared from the rectum:
- Initially, use an osmotic laxative - eg, polyethylene glycol (PEG) 3350 plus electrolytes (Movicol® Paediatric Plain). This may increase symptoms (eg, soiling) at first. Gradually increase the dose if ineffective. If not tolerated, substitute a stimulant laxative (see below) either on its own or with lactulose (osmotic laxative) or faecal softener (docusate) if stools are hard.
- If ineffective after two weeks, add a stimulant laxative - eg, sodium picosulfate or senna in children over one month of age, docusate (softener and weak stimulant laxative) from 6 months of age or bisacodyl suppositories from 2 years of age. If success is not forthcoming, discuss with a paediatrician.
- Rectal treatments should be avoided in children (suppositories, enemas, manual evacuation), although they may be recommended by specialists, and in hospital.
- Review the child at least weekly until successful.
- Maintenance therapy. This may incorporate:
- Dietary advice, including intake of fluids and fibre.
- Use of bowel charts and a diary for objective record.
- Regular laxatives over months or even years, preferably osmotic (PEG 3350 or lactulose), titrated to maintain soft formed stool.
- Avoiding stopping and starting treatment causing intermittent impaction.
- Avoiding prolonged use of stimulant laxatives (causes atonic colon and hypokalaemia).
- Using stimulant laxatives intermittently only to avoid impaction.
- Modification of behaviour. Behavioural principles are useful in management. Specific behavioural modification techniques can be employed in specialist clinics. In general:
- Encourage regular, unhurried toileting.
- Encourage use of reward systems for successful use of the toilet.
- Encourage linkage of diary to reward system.
- Incontinence. Dealing with this requires:
- Explanation to the parent and child of the involuntary nature of this.
- Encouragement of regular toileting.
- Involvement of the school nurse if possible to help with toileting and teacher education.
- Infrequent defecation increases the likelihood of pain on passage of hard stools, anal fissures, anal spasm and ultimately a learned response to withhold defecation.
- Chronic obstruction may cause the rectum to enlarge to form a megarectum, which has impaired sensation and decreased contractility, resulting in soiling.
- Regular bowel actions must then be established using dietary advice (fibre and fluid intake), regular laxatives and encouragement of a toileting pattern.
- Laxatives must be continued for many months and then gradually withdrawn. Relapses are common and should be treated early with increased doses of laxatives.
- However, evidence for the benefit of laxatives is weak but a Cochrane review found that polyethylene glycols (macrogols) may be more effective than placebo, lactulose or milk of magnesia for constipation in children.
- A systemic review found no significant benefits from increased fluid intake, exercise, prebiotics, probiotics, behavioural therapy, biofeedback, multidisciplinary treatment or forms of alternative medicine.
- NICE advises against routinely referring children with idiopathic constipation to a psychologist or any other mental health services unless they have been identified as being likely to benefit specifically from a psychological intervention.
- Very rarely, children may require enemas under sedation and even surgery to modify the anal sphincter.
Indications for referral
Specialist assessment is indicated if:
- An organic cause is suspected or there are any red flags (see NICE guidance table, above).
- Treatment is unsuccessful (ie no response in four weeks for a child aged under 1 year); refer (to exclude Hirschsprung's disease), or no improvement after three months in an older child.
- Management is complex.
- Child abuse is suspected.
When an organic cause is suspected, the GP can arrange for initial tests (such as inflammatory markers, thyroid function, calcium, tests for coeliac disease). Some specialists measure colonic transit time to differentiate:
- Soiling with normal transit time.
- Constipation and delayed transit time (worse outcomes).
Surgery is required rarely for the most severe cases of chronic constipation and overflow soiling. It can be important in intractable cases. Botulinum toxin has been used for short aganglionic segments of bowel and to provide temporary weakening of the sphincter.
Failure to correct functional constipation may lead to problems. For example, the following may arise:
- Faecal impaction.
- Chronic constipation.
- Megacolon (may predispose to, or result from, constipation).
- Rectal prolapse.
- Anal fissure.
- Faecal soiling.
- Psychological effects.
Two large outcome studies reported:
- Multiple relapses after the initial treatment, especially in boys, in children under 4 years of age, in those with a background of psychosocial or behavioural problems, or when constipation was associated with encopresis.
- Resolution of constipation occurred in 50% of children after one year and 65-70% after two years.
- A third of children followed up beyond puberty continued to have severe problems.
Further reading & references
- British National Formulary for Children; British Medical Association and Royal Pharmaceutical Society of Great Britain. London
- Constipation in children and young people, NICE Clinical Guideline (May 2010)
- Borowitz S; Pediatric Constipation, Medscape, Feb 2012
- Benninga M, Candy DC, Catto-Smith AG, et al; The Paris Consensus on Childhood Constipation Terminology (PACCT) Group. J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):273-5.
- G S Clayden, A S Keshtgar, I Carcani-Rathwell, A Abhyankar; The Management of Chronic Constipation and Related Faecal Incontinence in Childhood, Archives of Disease in Childhood Education and Practice Edition 2005
- van den Berg MM, Benninga MA, Di Lorenzo C; Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol. 2006 Oct;101(10):2401-9.
- Auth MK, Vora R, Farrelly P, et al; Childhood constipation. BMJ. 2012 Nov 13;345:e7309. doi: 10.1136/bmj.e7309.
- Bristol Stool Chart
- Nurko S; What's the value of diagnostic tools in defecation disorders? J Pediatr Gastroenterol Nutr. 2005 Sep;41 Suppl 1:S53-5.
- Constipation in children, Prodigy (September 2010)
- Rubin G, Dale A; Chronic constipation in children. BMJ. 2006 Nov 18;333(7577):1051-5.
- Gordon M, Naidoo K, Akobeng AK, et al; Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database Syst Rev. 2012 Jul 11;7:CD009118. doi: 10.1002/14651858.CD009118.pub2.
|Original Author: Dr Richard Draper||Current Version: Dr Colin Tidy||Peer Reviewer: Dr John Cox|
|Last Checked: 28/02/2013||Document ID: 3091 Version: 5||© EMIS|
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