Approach to Constipation in Children
Introduction to Constipation in Children
Constipation is a common pediatric problem, accounting for approximately 3% of general pediatric outpatient visits and 25% of pediatric gastroenterology consultations. It can significantly impact a child's quality of life and may lead to long-term complications if not properly managed.
Key points to remember:
- Constipation in children is defined differently than in adults.
- It can be functional (idiopathic) or organic in nature.
- Early recognition and treatment are crucial to prevent complications.
- Management often requires a multifaceted approach involving dietary changes, behavioral modifications, and sometimes medications.
Epidemiology of Pediatric Constipation
Understanding the epidemiology of constipation in children helps in recognizing its significance:
- Prevalence: Estimated to affect up to 30% of children worldwide.
- Age distribution:
- Can occur at any age, but peaks during toilet training (2-4 years)
- Another peak occurs in early adolescence
- Gender differences: Generally equal in boys and girls, though some studies suggest a slight male predominance.
- Geographic variations: Prevalence may vary by country and culture, influenced by dietary habits and toilet training practices.
- Socioeconomic factors: Lower socioeconomic status has been associated with higher rates of constipation in some studies.
Etiology of Constipation in Children
The causes of constipation in children can be broadly categorized as functional or organic:
- Functional (95% of cases):
- Withholding behavior (often due to painful defecation)
- Inadequate fluid or fiber intake
- Toilet training issues
- Psychosocial factors (e.g., school bathroom avoidance)
- Organic (5% of cases):
- Anatomic abnormalities: Anal stenosis, imperforate anus
- Neurological disorders: Spina bifida, cerebral palsy
- Endocrine disorders: Hypothyroidism, hypercalcemia
- Metabolic conditions: Cystic fibrosis, diabetes mellitus
- Medications: Opioids, anticholinergics, antacids
- Celiac disease
- Hirschsprung's disease
Clinical Presentation of Pediatric Constipation
The presentation of constipation in children can vary widely:
- Stool characteristics:
- Infrequent bowel movements (less than 3 per week)
- Hard, dry, or lumpy stools
- Large diameter stools that may clog the toilet
- Associated symptoms:
- Abdominal pain or distension
- Decreased appetite
- Irritability
- Soiling or encopresis (involuntary fecal soiling)
- Behavioral signs:
- Withholding postures (crossing legs, squeezing buttocks)
- Avoiding toileting
- Straining during defecation
- Physical findings:
- Palpable abdominal or rectal mass
- Anal fissures or skin tags
- Poor growth (in severe cases)
Diagnosis of Constipation in Children
Diagnosis is primarily clinical, based on history and physical examination:
- History:
- Bowel movement frequency, consistency, and size
- Age of onset and duration of symptoms
- Dietary habits
- Toilet training history
- Associated symptoms (pain, bleeding, soiling)
- Family history of gastrointestinal disorders
- Physical examination:
- Abdominal examination for distension or palpable masses
- Perineal inspection for fissures, skin tags, or anal position
- Digital rectal examination (when indicated) to assess for impaction or anatomic abnormalities
- Diagnostic criteria:
- Rome IV criteria for functional constipation in children
- Investigations (when organic causes are suspected):
- Abdominal X-ray: To assess fecal load
- Blood tests: Thyroid function, celiac screening, electrolytes
- Anorectal manometry: For suspected Hirschsprung's disease
- Colonoscopy: In cases of suspected inflammatory bowel disease
- MRI spine: If neurogenic causes are suspected
Management of Pediatric Constipation
Management of constipation in children involves a multifaceted approach:
- Education and reassurance:
- Explain the condition and its management to the child and family
- Address any misconceptions or fears
- Behavioral modifications:
- Regular toilet sitting schedule (typically after meals)
- Proper toileting posture
- Positive reinforcement for successful bowel movements
- Dietary changes:
- Increase fluid intake
- Add more fiber-rich foods to the diet
- Consider reducing excessive milk intake in young children
- Medications:
- Disimpaction (if needed): Oral or rectal laxatives
- Maintenance therapy:
- Osmotic laxatives (e.g., Polyethylene glycol, lactulose)
- Stimulant laxatives (e.g., senna, bisacodyl) for short-term use
- Stool softeners (e.g., docusate sodium)
- Follow-up:
- Regular monitoring to adjust treatment as needed
- Gradual weaning of medications once regular bowel habits are established
Complications of Pediatric Constipation
If left untreated, constipation can lead to several complications:
- Fecal impaction: Large, hard mass of stool in the rectum
- Encopresis: Involuntary passage of stool, often due to overflow around an impaction
- Rectal prolapse: Protrusion of rectal mucosa through the anus due to chronic straining
- Anal fissures: Tears in the anal mucosa causing pain and bleeding
- Urinary tract problems: Urinary retention or recurrent urinary tract infections
- Psychosocial issues: Embarrassment, social withdrawal, decreased quality of life
- Abdominal pain and distension
- Decreased appetite and failure to thrive (in severe cases)
Prevention of Constipation in Children
Preventive measures can significantly reduce the incidence of constipation:
- Dietary habits:
- Encourage a balanced diet rich in fruits, vegetables, and whole grains
- Ensure adequate fluid intake
- Limit excessive milk and dairy intake in young children
- Toilet training:
- Avoid forceful or punitive toilet training
- Encourage regular toilet habits
- Teach proper toileting posture
- Physical activity:
- Promote regular exercise and active play
- Awareness:
- Educate parents and children about normal bowel habits
- Encourage prompt attention to the urge to defecate
- Early intervention:
- Address constipation promptly when it occurs to prevent chronic issues
Constipation in Children
- What is the most common cause of constipation in children?
Answer: Functional constipation (withholding behavior) - Which of the following is NOT a typical symptom of constipation in children?
Answer: Fever - What is the term for involuntary leakage of liquid stool in a child with severe constipation?
Answer: Encopresis - Which of the following is considered a red flag symptom in a child with constipation?
Answer: Blood in stools - What is the most appropriate initial management for functional constipation in children?
Answer: Dietary changes and behavior modification - Which medication is commonly used as a stool softener in children with constipation?
Answer: Polyethylene glycol (PEG) - What is the term for hard, dry stools that are difficult to pass?
Answer: Scybalous stools - Which of the following is NOT a typical complication of chronic constipation in children?
Answer: Intussusception - What is the most common cause of organic constipation in infants?
Answer: Hirschsprung's disease - Which diagnostic test is most useful in evaluating for Hirschsprung's disease?
Answer: Rectal biopsy - What is the term for the enlargement of the colon seen in chronic constipation?
Answer: Megarectum - Which of the following dietary changes is most effective in managing constipation in children?
Answer: Increasing fiber intake - What is the most appropriate initial imaging study for a child with suspected constipation?
Answer: Abdominal X-ray - Which medication class should be used with caution in children with constipation due to its potential to worsen symptoms?
Answer: Anticholinergics - What is the term for painful bowel movements that may lead to withholding behavior in children?
Answer: Dyschemzia - Which of the following is NOT a typical behavioral intervention for constipation in children?
Answer: Prolonged toilet sitting - What is the most common cause of acute constipation in previously healthy children?
Answer: Dietary changes - Which endocrine disorder can present with constipation as a symptom in children?
Answer: Hypothyroidism - What is the term for the reflexive withholding of stool due to fear of painful defecation?
Answer: Retentive posturing - Which of the following is NOT a typical physical examination finding in a child with severe constipation?
Answer: Abdominal distension - What is the most appropriate long-term management strategy for children with functional constipation?
Answer: Combination of dietary modification, behavior therapy, and laxatives as needed - Which medication is commonly used as a stimulant laxative in children with severe constipation?
Answer: Senna - What is the term for the inability to completely empty the rectum during defecation?
Answer: Incomplete evacuation - Which of the following is NOT a typical risk factor for developing constipation in children?
Answer: Excessive physical activity - What is the most appropriate initial management for fecal impaction in children?
Answer: Disimpaction with oral or rectal medications - Which neurological condition is associated with an increased risk of constipation in children?
Answer: Spina bifida - What is the term for the involuntary contraction of the external anal sphincter during attempted defecation?
Answer: Anismus - Which of the following is NOT a typical complication of chronic encopresis in children?
Answer: Malnutrition - What is the most appropriate follow-up interval for children with well-controlled functional constipation?
Answer: 3-6 months - Which medication is used as a lubricant laxative in children with constipation?
Answer: Mineral oil
Further Reading
- Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN
- Childhood Functional Gastrointestinal Disorders: Child/Adolescent
- Evaluation and Treatment of Constipation in Children and Adolescents
- Constipation in infants and children: Beyond the basics (UpToDate, patient information)
