Constipation in children and adolescents

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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%. ^[2]

Epidemiological data refers to the US, unless otherwise specified.

• Primary or functional constipation (most common; 95%) ^[3][4][5]
  • Typically due to stool-withholding behaviors, which may occur during:
    • New school attendance (avoidance of school toilets) ^[4]
    • Toilet training (pressure to control bowels)
    • Breastfeeding weaning
    • Sexual abuse and/or trauma
  • Other causes include:
    • Lifestyle: poor diet, insufficient physical activity (in older children and adolescents) ^[6]
    • Psychological and behavioral disorders
    • Eating disorders (especially in adolescents) ^[7]
    • Genetic disposition
    • Alterations in normal gut flora, colonic dysmotility ^[8]
• Secondary constipation (∼ 5%): causes include ^[3][4][5]
  • Cow's milk protein allergy
  • Hirschsprung disease
  • Congenital anorectal malformation
  • Cystic fibrosis
  • Spina bifida
  • Celiac disease
  • Hypothyroidism
  • Neuromuscular disorders

A comprehensive history, physical examination, and assessment of red flag features should be conducted in all patients. ^[3][5][9]

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 ^[3][5]

• Infrequent bowel movements
• Painful bowel movements, which may lead to stool withholding behaviors
• Associated features include:
  • Abdominal distention, pain, nausea, anorexia
  • Hematochezia (due to anal fissures)
  • Urinary tract infection (due to urinary stasis)
• Evidence of fecal impaction ^[10]
  • Fecal incontinence (overflow soiling)
  • Palpable mass in the left lower abdominal quadrant
  • Dilated rectum containing a large amount of hard stool on rectal examination
• In secondary constipation: features of the underlying disorder

Red flags in pediatric constipation ^[3][4][5][9]

Red flag features should prompt referral to a specialist (e.g., pediatric gastroenterologist) for further evaluation. ^[3]

• Delayed passage of meconium > 48 hours
• Symptom onset prior to 1 month of age
• Constitutional symptoms, fever
• Failure to thrive
• Bilious vomiting, severe abdominal distention
• Stool changes: bloody stools in the absence of anal fissures or tears , change in stool caliber
• Features suggestive of Hirschsprung disease
• Family history of Hirschsprung disease or other GI conditions
• Features suggestive of spina bifida
• Anal abnormalities
• Fecal occult blood

Physical examination ^[3][4][5][9]

• Review growth parameters.
• Abdominal examination
• Lumbosacral examination and neurological examination of lower extremities
• Thyroid examination
• Examination of perineum and anus
• Digital rectal examination; for the following indications (not routinely recommended) : ^[3][9]
  • Infants < 6 months of age ^[5]
  • Red flags in pediatric constipation
  • Uncertain diagnosis of functional constipation ^[9]
  • Persistent constipation despite 3 months of adequate treatment ^[9]

Significant expulsion of stool upon removal of the finger following digital rectal examination suggests Hirschsprung disease. ^[9]

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

General principles ^[3][9]

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

• Refer to pediatric gastroenterology for further evaluation of: ^[3][5][9]
  • Red flags in pediatric constipation (i.e., concern for secondary constipation)
  • Lack of improvement despite treatment
  • Children with no red flag features who do not meet the diagnostic criteria for functional constipation ^[3]
• Considerations in infants
  • Immediate workup for constipation is not required if all of the following are present: ^[9]
    • Exclusively breastfed, otherwise healthy infants aged > 2 weeks
    • Normal physical examination
    • No red flag features
  • Reevaluate after 2–4 weeks of conservative management.

Rome IV diagnostic criteria for functional constipation in children ^[3][4]

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. ^[9]

Laboratory studies ^[3][5][9]

• Fecal occult blood test: Consider in the following groups to identify a potential underlying cause. ^[11]
  • Infants ^[3]
  • Children with pain, diarrhea, or failure to thrive
  • Children with a family history of colon cancer or polyps
• Diagnostics for secondary constipation as clinically indicated; examples include:
  • Diagnostics for cystic fibrosis
  • Thyroid function tests
  • Fasting glucose levels
  • Celiac disease panel
  • Serum calcium and potassium levels
  • Evaluation for lead toxicity

Imaging

• Abdominal x-ray: not routinely recommended; consider for the following indications ^[3]
  • Suspected fecal impaction that cannot be confirmed on physical examination. ^[9]
  • Diagnostic uncertainty
• Additional imaging as clinically indicated; examples include:
  • MRI spine: for suspected spinal cord abnormalities
  • Barium enema: for suspected colorectal malformation

Additional studies ^[3]

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

• Anorectal manometry, balloon expulsion test: for suspected defecatory disorders
• Rectal biopsy: for suspected Hirschsprung disease

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

Fecal disimpaction therapy ^[3]

• Preferred: oral laxative therapy with polyethylene glycol ^[3]
• Second-line options
  • Children: Consider once-daily enemas (e.g., saline enema , mineral oil enema ) for 3–6 days. ^[3]
  • Infants: Consider glycerin suppositories. ^[3]
• Unsuccessful disimpaction at home: Consider hospitalization to administer polyethylene glycol via a nasogastric tube.
• Initiate maintenance therapy once disimpaction has been achieved.

Manual disimpaction is not recommended in infants and children because of the risk of colon perforation. ^[3]

Maintenance therapy for functional constipation ^{[3][4][9][12]}

Infants aged 1–5 months ^{[3][5][9][13]}

• Exclusively breastfed infants with no red flag features: may only require reassurance
• Dietary intervention : Consider 2 ounces/day (1–3 mL/kg once or twice daily) of apple, pear, or prune juice.
• Oral laxative therapy
  • Consider if constipation persists despite dietary interventions.
  • Preferred agent: polyethylene glycol
    ^[3]

Functional constipation in infants aged 1–5 months typically resolves with sorbitol juice supplementation (e.g., prune juice). ^[3]

Infants aged ≥ 6 months, children, and adolescents ^{[3][4][5][9][13]}

• Educate caregivers on
  • The causes of functional constipation
  • How to recognize and prevent stool withholding behaviors
• 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.) ^[3][14][15]
  • Minimum daily fiber requirements (g/day) = (age in years + 5) ^[3][9]
  • Healthy bowel habits
    • Children who are toilet-trained: Recommend scheduled toileting. ^[5][9]
    • Adolescents: Reinforce the importance of responding to urges to defecate. ^[4]
• Maintenance pharmacotherapy ^[3][9][16]
  • First-line: polyethylene glycol ^[3]
  • Second-line: lactulose ^[3]
  • Newer alternative for children ≥ 6 years of age: linaclotide ^[3]

Supplementing fiber or fluid intake above daily requirements does not improve constipation in children. ^[3]

Follow-up ^[3][4][9]

• Reassess patients in 2–4 weeks.
• Improvement in symptoms
  • Continue maintenance therapy for 2 months. ^[3][9]
  • Gradually taper laxatives based on clinical response.
• Persistent symptoms
  • Confirm treatment adherence.
  • Offer reeducation of caregivers.
  • Consider possible untreated fecal impaction and/or a change in medication or dosage.
  • If refractory to the above measures, consider additional testing (see “Diagnosis”) and/or refer to pediatric gastroenterology.
  • Biofeedback training may be beneficial in adolescents with defecatory disorders. ^[4]
• Manage relapses with maintenance therapy and, if needed, disimpaction therapy.

Defecatory disorders are more common in adolescents than young children and should be evaluated for in individuals with constipation refractory to initial therapy. ^[4]

Management of secondary constipation ^[3]

• Evaluate and treat the underlying cause.
• Laxative therapy: the same as that for functional constipation