Constipation in children and adolescents

Last updated: November 8, 2022

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Constipation is characterized by the infrequent and sometimes painful passage of hard stools. Pediatric constipation is common, with a worldwide prevalence of approximately 10%. Functional constipation accounts for the majority of cases in children and adolescents. Secondary constipation, which is the result of an underlying pathological condition (e.g., Hirschsprung disease, spinal cord abnormalities, metabolic disorder) accounts for fewer than 5% of pediatric constipation. Diagnostics are not routinely recommended to confirm functional constipation; a clinical diagnosis can be established if the Rome IV diagnostic criteria for pediatric functional constipation are met. Diagnostic studies should be performed if secondary constipation is suspected (e.g., constipation in infants aged < 6 months, presence of red flags in pediatric constipation) or if symptoms persist despite treatment. Functional constipation in infants aged 1–5 months typically resolves with sorbitol juice supplementation (e.g., prune juice). Management in children and infants aged ≥ 6 months involves clearing fecal impaction and initiating maintenance therapy with behavior modification and oral laxatives. Oral polyethylene glycol is the preferred laxative for fecal disimpaction and maintenance therapy in infants, children, and adolescents. Secondary constipation is managed by addressing the underlying pathological cause.

The estimated worldwide prevalence of constipation in children and adolescents is approximately 9%. [1]

Epidemiological data refers to the US, unless otherwise specified.

A comprehensive history, physical examination, and assessment of red flag features should be conducted in all patients. [2][4][8]

Assess for risk factors for functional constipation (e.g., recent family stressors, moving home, starting school, change in diet) and features suggestive of secondary constipation.

Clinical features [2][4]

Red flags in pediatric constipation [2][3][4][8]

Red flag features should prompt referral to a specialist (e.g., pediatric gastroenterologist) for further evaluation. [2]

Physical examination [2][3][4][8]

Significant expulsion of stool upon removal of the finger following digital rectal examination suggests Hirschsprung disease. [8]

Assess for signs of possible sexual abuse (e.g., anal scars, hematomas, bruising; an intense fear of rectal examination).

General principles [2][8]

Diagnostics are not routinely required if the Rome IV diagnostic criteria for functional constipation in children are met.

Rome IV diagnostic criteria for functional constipation in children [2][3]

Functional constipation is a clinical diagnosis that is based on the presence of ≥ 2 of the following for ≥ 1 month.

  • ≤ 2 defecations per week
  • History of voluntary stool retention; and/or, in children with developmental age ≥ 4 years, stool-withholding behaviors
  • Painful or hard bowel movements
  • Large fecal mass in the rectum
  • Toilet-trained toddlers and children: history of large-diameter stools that can obstruct the toilet
  • Toilet-trained children and adolescents: ≥ 1 episode of fecal incontinence per week (retentive encopresis)
  • Additional criteria in children with a developmental age ≥ 4 years
    • Symptoms occur at least once per week
    • And other medical causes for constipation (e.g., IBS-C) have been ruled out

Children with functional constipation and no red flag features should not be routinely screened for cow's milk protein allergy, hypothyroidism, hypercalcemia, or celiac disease. [8]

Laboratory studies [2][4][8]

Imaging

Additional studies [2]

Referral to pediatric gastroenterology is recommended for advanced diagnostics if clinically indicated to evaluate for secondary constipation. Examples include:

Management of pediatric constipation involves clearing fecal impaction and initiating maintenance therapy.

Fecal disimpaction therapy [2]

Manual disimpaction is not recommended in infants and children because of the risk of colon perforation. [2]

Maintenance therapy for functional constipation [2][3][8][11]

Infants aged 1–5 months [2][4][8][12]

Functional constipation in infants aged 1–5 months typically resolves with sorbitol juice supplementation (e.g., prune juice). [2]

Infants aged ≥ 6 months, children, and adolescents [2][3][4][8][12]

  • Educate caregivers on
  • Consider referral to a child psychologist.
  • Age-appropriate fiber, fluid, physical activity, and scheduled toileting
    • Encourage minimum daily fluid intake. (See the consensus statement on “Healthy Beverage Consumption in Early Childhood” in “Tips and Links” for details.) [2][13][14]
    • Minimum daily fiber requirements (g/day) = (age in years + 5) [2][8]
    • Healthy bowel habits
      • Children who are toilet-trained: Recommend scheduled toileting. [4][8]
      • Adolescents: Reinforce the importance of responding to urges to defecate. [3]
  • Oral laxatives: Initiate maintenance therapy with polyethylene glycol (preferred) or lactulose. [2]

Supplementing fiber or fluid intake above daily requirements does not improve constipation in children. [2]

Follow-up [2][3][8]

Defecatory disorders are more common in adolescents than young children and should be evaluated for in individuals with constipation refractory to initial therapy. [3]

Management of secondary constipation [2]

  1. Koppen IJN, Vriesman MH, Saps M, et al. Prevalence of Functional Defecation Disorders in Children: A Systematic Review and Meta-Analysis. J Pediatr. 2018; 198 : p.121-130.e6. doi: 10.1016/j.jpeds.2018.02.029 . | Open in Read by QxMD
  2. Mulhem E, Khondoker F, Kandiah S. Constipation in Children and Adolescents: Evaluation and Treatment. American Family Physician. 2022 .
  3. Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol. 2019; 17 (1): p.21-39. doi: 10.1038/s41575-019-0222-y . | Open in Read by QxMD
  4. Nurko S, Zimmerman LA. Evaluation and treatment of constipation in children and adolescents. Am Fam Physician. 2014; 90 (2): p.82-90.
  5. Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013; 144 (1): p.218-38. doi: 10.1053/j.gastro.2012.10.028 . | Open in Read by QxMD
  6. Naguib M, Brull SJ. Sugammadex: a novel selective relaxant binding agent. Expert Rev Clin Pharmacol. 2009; 2 (1): p.37-53. doi: 10.1586/17512433.2.1.37 . | Open in Read by QxMD
  7. Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology. 2020; 158 (5): p.1232-1249.e3. doi: 10.1053/j.gastro.2019.12.034 . | Open in Read by QxMD
  8. Tabbers MM, DiLorenzo C, Berger MY et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014; 58 (2): p.258-274. doi: 10.1097/MPG.0000000000000266 . | Open in Read by QxMD
  9. Colletti BR. Evaluation and Treatment of Constipation in Infants and Children. Journal of Pediatric Gastroenterology & Nutrition. 2006; 43 (3): p.e1-e13. doi: 10.1097/01.mpg.0000233159.97667.c3 . | Open in Read by QxMD
  10. Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology. 2016; 150 (6): p.1456-1468.e2. doi: 10.1053/j.gastro.2016.02.015 . | Open in Read by QxMD
  11. Benninga MA, Nurko S, Faure C, Hyman PE, St. James Roberts I, Schechter NL. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology. 2016; 150 (6): p.1443-1455.e2. doi: 10.1053/j.gastro.2016.02.016 . | Open in Read by QxMD
  12. Choose Water for Healthy Hydration. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Choose-Water-for-Healthy-Hydration.aspx. Updated: January 27, 2020. Accessed: May 16, 2022.
  13. Consensus Statement. Healthy Beverage Consumption in Early Childhood: Recommendations from Key National Health and Nutrition Organizations. https://healthyeatingresearch.org/wp-content/uploads/2019/09/HER-HealthyBeverage-ConsensusStatement.pdf. Updated: September 1, 2019. Accessed: May 10, 2022.
  14. Hussain ZH, Whitehead DA, Lacy BE. Fecal Impaction. Curr Gastroenterol Rep. 2014; 16 (9). doi: 10.1007/s11894-014-0404-2 . | Open in Read by QxMD

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