(We’re told this is German for constipation)
Diagnosis and Management of Functional Constipation in Infants & Children
author: David Rayburn, MD, MPH
Who gets constipated?
The short answer is everyone, at least at some point in their lives. Constipation is reported to affect 1-30% of children worldwide with an average prevalence of 3% for functional constipation (4). Pediatricians will see this problem in their offices, urgent cares, and emergency departments. To begin, we will focus on the difference in stooling patterns between infants and children and what constitutes constipation for these age groups. Knowing the “normal” can help you counsel your patients and parents. The good news for us as pediatricians is that constipation in childhood is almost always functional in nature and rarely is associated with an organic cause. We will not cover the organic causes of constipation in detail, but a key takeaway is that if there are concerning findings on the history or physical exam, an organic cause of constipation must be considered and worked up further.
Stooling patterns in infants
Parents really worry when their baby doesn’t poop. There is no required number of stools per day for infants and every infant will be different. The average infant will have 3-4 stools per day in the first week of life and decrease to 2 stools per day later in infancy (3). Remember to ask if they passed meconium within the first 48hrs of life as part of your history. The number of stools varies widely with some infants having a bowel movement with every feed. However, it is not uncommon, especially in breastfed infants, to go several days (up to 7) without having a bowel movement and this is completely normal. Formula fed infants can also go several days without a stool and this is still considered normal. Many parents believe their children are constipated because of grunting and pushing, but this is often actually infant dyschezia. Infant dyschezia is actually the baby’s way of learning how to poop correctly but trying out different pushing and valsalva like methods.
Stooling patterns in children
After infancy the average number of stools decreases to 2 per day in toddler years and then down to 1 per day or 1 every other day in preschool years and beyond (3). Again, everyone will be different but these are generally accepted stooling patterns.
First and foremost: stop with the KUBs already! Guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) recommend against routine use of abdominal xrays for the diagnosis of functional constipation. Constipation is a clinical diagnosis made in the majority of cases by history and physical alone. The ROME criteria (now in its 4th iteration) are the most accepted criteria for diagnosing constipation in childhood (1).
ROME IV Criteria
Infants up to 4 years of age:
Must include 1 month of at least 2 of the following and 2 or fewer defecations per week:
1. History of excessive stool retention
2. History of painful or hard bowel movements
3. History of large-diameter stools
4. Presence of a large fecal mass in the rectum
In toilet-trained children, the following additional criteria may be used:
1. At least 1 episode/week of incontinence after the acquisition of toileting skills
2. History of large-diameter stools that may obstruct the toilet
For children >4 years of age
Must include 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome:
1. 2 or fewer defecation in the toilet per week in a child of a developmental age of at least 4 years
2. At least 1 episode of fecal incontinence per week
3. History of retentive posturing or excessive volitional stool retention
4. History of painful or hard bowel movements
5. Presence of large fecal mass in the rectum
6. History of large diameter stools that can obstruct the toilet
When obtaining the history make sure to include information about the frequency and consistency of stools, associated symptoms, and the duration of symptoms. Parents may describe “small pebble” stools or large stools that fill the toilet. Both of these historical features could be consistent with the diagnosis of constipation. One of the tricky history points for constipation is when a parent describes “watery” bowel movements. This in the context of other history findings surrounding frequency, consistency, and associated symptoms could point towards encopresis and the liquid stools are actually the result of underlying constipation.
There are some life changes in the first several years of life that lead to constipation. These are things we should consider in our history to help us make the diagnosis. When infants transition to cow’s milk from breast milk this often leads to dry and hard stools. Another period of life that often precipitates constipation surrounds potty training time. Stool withholding behaviors often develop during this time period leading to functional constipation (2).
Red flags for organic cause of constipation
History of fever, severe abdominal pain, significant abdominal distention, weight loss, failure to thrive, weakness, urinary symptoms, vomiting, or ribbon like stools may suggest an organic cause of constipation. These findings plus concerning physical exam findings such as significant focal abdominal tenderness, exophthalmos or lid lag, sacral dimple or tuft of hair over lumbar spine, abnormal position of anus, absent anal reflex, abnormal lower extremity strength, reflexes, or sensory changes would warrant further evaluation for an organic cause of constipation (4).
Treating pediatric constipation
Once you have diagnosed functional constipation it is necessary to determine the degree of constipation and determine if there is impaction or not. Although the literature is conflicting on this topic, simply increasing free water intake and increasing fiber intake in child’s diet can relieve constipation symptoms, however this is easier said than done in our pediatric patients. If there is a suspected fecal impaction one approach is to use polyethylene glycol (PEG) at a high dose (1-1.5mg/kg) for clean out (1). If this does not work an enema or manual disimpaction may be required. NASPGHAN Guidelines also recommend against routine digital rectal exams in the diagnosis of constipation.
Once impaction has been relieved or ruled out a maintenance therapy will be necessary to prevent reoccurrence of hard stools and impaction. The data is limited, but the NSAPGHAN Guidelines recommend treatment for at least 2 months and constipation symptoms should be relieved for 1 month prior to discontinuing therapy. Polyethylene glycol (MiraLAX) (0.2-0.8 mg/kg/day) is an osmotic laxative and is the mainstay of treatment for constipation in the pediatric population. Lactulose(1-3ml/kg/day) and magnesium (0.5-3ml/kg/day) are other osmotic laxatives that can be used safely in pediatric patients. Stool softeners such as docusate (5mg/kg/day) may be used in conjunction with osmotic laxatives. A third medical therapy would be stimulant laxatives which consist of senna (2.5-7.5ml/kg/day) or bisacodyl (5-10mg/day).
GET THE POINT
√ H&P! History and Physical are KEY for diagnosing constipation.
√ NO KUB! Please do not order abdominal xrays to diagnose constipation unless you are concerned for an organic cause of the patient’s symptoms.
√ MOVE IT, MOVE IT! Once you get the stool moving, keep it moving! Most patients need ongoing therapy for at least 2 months (dealer’s choice, but PEG is well tolerated) to keep them from getting constipated again.
1. Allen P., Setya A., Lawrence V. Pediatric Functional Constipation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK537037/Accessed on October 15, 2020.
2. LeLeiko N., Mayer-Brown S., Cerezo C., Plante W. Constipation. Pediatrics in Review. 2020; 41(8): 379-392.
3. Nurko S., Zimmerman L. Evaluation and Treatment of Constipation in Children and Adolescents. American Family Physician. 2014; 90 (2): 82-90.
4. Tabbers M.M., DiLorenzo C., Berger M.Y., Faure C., Langendam M.W., Nurko S., Staiano A., Vandenplas Y., Benninga M.A. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations from ESPGHAN and NASPGHAN. JPGN. 2014; 58(2):258-274.