Constipation in Children

Background

• Constipation in children is generally defined as a decreased frequency of defecation, occurrence of fecal incontinence (soiling, encopresis), stool retention (fecal impaction), painful or hard bowel movements, or large stools; but, the definition varies based on the criteria used.
• Constipation in children can be divided into 2 types: organic (due to an underlying physical disorder) or functional (no evidence of a pathologic condition).
• Functional constipation is usually due to voluntary withholding of feces to avoid painful bowel movements and is the most common cause of constipation in children.
• Most children with functional constipation require long-term therapy and have frequent relapses.
• Some common complications include abdominal pain, encopresis, rectal bleeding, enuresis, recurrent urinary tract infections, anal fissures, rectal prolapse and hemorrhoids.

Evaluation

• Obtain a complete history including diet, stool description and medications as well as birth, past medical, family, and social histories.
• Perform a thorough physical exam including vital signs and charting growth parameters as well as back, neurologic, genital, and external rectal examinations.
• Obtain diagnostic testing only if organic constipation is suspected or if constipation persists after adequate treatment.
• Blood testing for hypothyroidism, celiac disease, and electrolyte abnormalities is not routinely recommended.
• Imaging studies such as x-rays, barium enema, colonic transit time study, magnetic resonance imaging (MRI), ultrasound, or colonic scintigraphy are not routinely recommended.
• Consider other diagnostic testing such as a rectal biopsy, manometry, or allergy testing as clinically indicated.

Management

• If fecal impaction is present, consider disimpaction with oral or rectal medication as initial treatment prior to initiation of maintenance therapy.
• For maintenance therapy of constipation in children (Weak recommendation),
  • continue treatment for at least 2 months,
  • all symptoms should be resolved for at least 1 month before discontinuing treatment,
  • decrease treatment gradually,
  • if child is in developmental stage of toilet training, discontinue medication only after toilet training is achieved.
• For maintenance medications in infants, consider polyethylene glycol (PEG), osmotic laxatives such as juices containing sorbitol, lactulose, or polyethylene glycol (PEG) as first line treatment and magnesium laxatives as additional or second-line therapy (Weak recommendation).
• For maintenance medications in children > 1 year, consider PEG as first line treatment and/or stimulant laxatives as additional or second-line treatment (Weak recommendation).
• Consider normal fiber and fluid intake as well as physical activity in children with constipation (Weak recommendation).
• Consider negotiated and non-punitive behavioral intervention in accordance with the child's stage of development such as scheduled toileting, supporting regular bowel habits, maintaining and discussing a bowel diary, providing information on constipation, and encouragement.
• Perform surgical interventions only for specific organic causes of constipation such as Hirschsprung disease or anorectal malformations and not routinely for functional constipation.
• Refer to a pediatric gastroenterologist for concerning signs or symptoms, or if there is continued therapeutic failure.