Gastroenterology Book

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Pediatric ConstipationAka: Constipation in Children

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  1. See Also
    1. Constipation in Adults
    2. Constipation in Infants
  2. Definition
    1. Decrease in stool frequency
      1. Fewer than 3 stools per week
    2. Decreased fluidity of Bowel Movements
      1. Most stools are hard, pebble-like or scybalous
  3. Physiology
    1. See Defecation
    2. Mean stool frequency varies by age
      1. Breastfed infants under age 3 months: 2.9 stools/day
      2. Formula-fed infants under age 3 months: 2 stools/day
      3. Age 6 to 12 months: 1.8 stools per day
      4. Age 1 to 3 years: 1.4 stools per day
      5. Age over 3 years: 1.0 stools per day
    3. References
      1. Baker (1999) J Pediatr Gastroenterol Nutr 29:612
  4. Etiologies
    1. See Constipation Causes in Children
    2. See Constipation Causes in Newborns
    3. Functional causes are most common
  5. History
    1. Stool characteristics
      1. Time of passage of first meconium
        1. Delayed >48 hours in Hirschsprung's Disease
      2. Age of onset of stool problems
        1. Neonatal onset suggests congenital cause
        2. Onset under age 1 year suggests dietary cause
        3. Onset after 18 months suggests behavioral cause
      3. Timing of stool problems
        1. Acute Constipation suggests organic cause
        2. Chronic Constipation suggests functional cause
      4. Frequency of stools
      5. Size of Bowel Movements
        1. Large caliber stools suggests functional cause
        2. Small caliber stools suggest Hirschsprung's Disease
    2. Associated symptoms and conditions
      1. Presence of pain with Defecation
      2. Presence of rectal prolapse
      3. Anal Fissures
    3. Bowel control
      1. Age of Toilet Training
      2. Presence of Encopresis or fecal soiling
      3. Presence of Enuresis
      4. Stool withholding
    4. Prior and current management (medications, diagnostics)
    5. Diet Diary (7 day history of foods and symptoms)
    6. Family History
      1. Constipation
      2. Hirschsprung's Disease
      3. Celiac Disease
      4. Cystic Fibrosis
      5. Thyroid disease
      6. Parathyroid disease
      7. Colon Cancer or Colonic Polyps
    7. Past medical and developmental history
    8. Psychosocial history (emotional stressors)
  6. History: Reassuring suggestive of functional cause
    1. Infrequent, hard, large-caliber stools
    2. Encopresis recurs after completing Toilet Training
    3. Pain on passing stool
    4. Perianal fissures (may causes blood on stool surface)
    5. Benign abdominal exam
    6. Stool witholding behaviors
      1. Avoiding toilet or hiding while stooling in diaper
      2. Crossing legs, rocking, or contracting buttocks
  7. History: Red flag symptoms suggestive of organic cause
    1. No meconium by 48 hours old (Hirschprung's Disease)
    2. Small-caliber stools
    3. Failure to Thrive
    4. Fever
    5. Bloody Diarrhea
    6. Bilious Vomiting
    7. Weight loss
    8. Abdominal Pain
    9. Nausea or Vomiting (especially Bilious Emesis)
  8. Exam
    1. Growth evaluation for growth delay
      1. Malabsorption (Cystic Fibrosis, Celiac Disease)
    2. Abdominal exam
      1. Abdominal distention
      2. Abdominal mass (Suprapubic fecal mass may be felt)
      3. Hepatomegaly or Splenomegaly
    3. Anal inspection
      1. Anterior anus
      2. Hemorrhoids
      3. Anal Fissures
    4. Rectal Examination
      1. Assessment of anal sphincter
      2. Retained stool
      3. Fecal Occult Blood testing
    5. Back Inspection (signs of Spinal Dysraphism)
      1. Sacral sinuses or sacral hair tufts
    6. Neurologic Exam
      1. Lower extremity reflexes
  9. Labs (consider if suggested by history)
    1. Thyroid Function Test
    2. Blood Urea Nitrogen
    3. Serum electrolytes
    4. Serum Calcium
    5. Serum Magnesium
    6. Blood lead level
    7. Celiac panel
  10. Imaging (indicated for red flags above)
    1. Abdominal XRay (KUB)
    2. Unprepped Barium Enema Indications
      1. Suspected anatomic abnormalities
      2. Hirschsprung's Disease
      3. Colonic strictures from necrotizing enterocolitis
    3. Rectal manometry
      1. Hirschsprung's Disease
      2. Anismus
        1. Paradoxical external anal sphincter contraction
    4. Rectal suction biopsy by surgery
      1. Assess for Hirschsprung's Disease
    5. Transit study
      1. Administer radiopaque marker rings over 3 days
      2. Perform Abdominal XRAy (KUB) on third day
    6. Consider Spinal Dysraphism evaluation (L-Spine MRI)
  11. Evaluation
    1. Initial evaluation in all patients
      1. Careful history and examination as above
      2. Consider Constipation in children causes
    2. Red flag symptoms or signs present
      1. Pediatric Gastroenterology referral
      2. Diagnostic testing as directed by history
    3. No red flag symptoms or signs
      1. Empiric management for functional causes (see below)
      2. If no improvement with empiric therapy
        1. Consider Lab testing above
        2. Consider pediatric gastroenterology
  12. Management
    1. Pediatric Constipation Management
    2. Pediatric Constipation Dietary Management
  13. References
    1. Bergeson (1996) Med J Allina 5(2):6-10
    2. Arce (2002) Am Fam Physician 65(11):2283
    3. Leung (1996) Am Fam Physician 54(2):611
    4. Rasquin-Weber (1999) Gut 45(suppl 2):1160

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