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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 are met. Diagnostic studies should be performed if is suspected (e.g., constipation in infants aged < 6 months, presence of ) 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.
Primary or functional constipation (most common; 95%) 
- Typically due to stool-withholding behaviors, which may occur during:
- Other causes include:
- Secondary constipation (∼ 5%): causes include 
Clinical features 
- Infrequent bowel movements
- Painful bowel movements, which may lead to stool withholding behaviors
- Associated features include:
- Evidence of fecal impaction 
- In secondary constipation: features of the underlying disorder
Red flags in pediatric constipation 
- Delayed passage of meconium > 48 hours
- Symptom onset prior to 1 month of age
- 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 
- Review growth parameters.
- Lumbosacral examination and neurological examination of lower extremities
- Examination of perineum and anus
- Digital rectal examination; for the following indications (not routinely recommended) : 
General principles 
Diagnostics are not routinely required if the . are met
- Refer to pediatric gastroenterology for further evaluation of: 
- Considerations in infants
Rome IV diagnostic criteria for functional constipation in children 
- ≤ 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 ( )
- Additional criteria in children with a developmental age ≥ 4 years
Laboratory studies 
- Fecal occult blood test: Consider in the following groups to identify a potential underlying cause. 
- Diagnostics for secondary constipation as clinically indicated; examples include:
- Abdominal x-ray: not routinely recommended; consider for the following indications 
- Additional imaging as clinically indicated; examples include:
Additional studies 
Fecal disimpaction therapy 
- Preferred: oral laxative therapy with polyethylene glycol 
- Children: Consider once-daily enemas (e.g., saline enema , mineral oil enema ) for 3–6 days. 
- Infants: Consider glycerin suppositories. 
- Unsuccessful disimpaction at home: Consider hospitalization to administer polyethylene glycol via a nasogastric tube.
- Initiate maintenance therapy once disimpaction has been achieved.
Maintenance therapy for functional constipation 
Infants aged 1–5 months 
- 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
Infants aged ≥ 6 months, children, and adolescents 
- 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.) 
- Minimum daily fiber requirements (g/day) = (age in years + 5) 
- Healthy bowel habits
- Children who are toilet-trained: Recommend scheduled toileting. 
- Adolescents: Reinforce the importance of responding to urges to defecate. 
- Maintenance pharmacotherapy 
Supplementing fiber or fluid intake above daily requirements does not improve constipation in children. 
- Reassess patients in 2–4 weeks.
- Improvement in symptoms
- 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 “Diagnostics”) and/or refer to pediatric gastroenterology.
- adolescents with defecatory disorders.  may be beneficial in
- Manage relapses with maintenance therapy and, if needed, disimpaction therapy.