59

Symposium : Gastroenterology & Hepatology

Constipation In Children
Joseph M. Croffie

Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA

ABSTRACT
Constipation is a common problem throughout the world. It occurs in about 10-20% of adults in Western Countries and 0.3%
to 28% of children worldwide. Most childhood constipation results from intentional withholding of stool following a painful
experience with defecation. Thus, an extensive evaluation is often not necessary in a child presenting with constipation.
Treatment should include education, evacuation of the rectum with oral or rectal laxatives if an impaction is present, laxatives
to ensure soft stools and behavior modification. [Indian J Pediatr 2006; 73(8) : 697-701] E-mail : jcroffie@iupui.edu

Key words : Constipation; Fecal retention; Encopresis

Constipation is a common problem throughout the world. less than 3 per week, more than 1 episode of fecal
It occurs in both adults and children. In the United States, incontinence per week, large stools in the rectum or
3 % of visits to a pediatrician and 25% of visits to a palpable on abdominal examination, passing of stools so
pediatric gastroenterologist are for problems related to large that they obstruct the toilet, retentive posturing and
constipation and 34% of British children aged 4 to 11 years withholding behavior, and painful defecation.4
have experienced constipation.1, 2
EPIDEMIOLOGY
DEFINITION
The exact worldwide prevalence of constipation in
Constipation is a symptom, not a disease or a sign. For children is not known. Population-based studies suggest
this reason, a precise definition has been elusive. that 10-20% of adults in Western Countries and in Asia
Constipation has a different meaning for different people have one or more symptoms of constipation. 5, 6 and it is
and often reflects an individual’s view of what the normal estimated that 0.3% to 28% of children worldwide are
pattern of defecation should be. Thus, its definition has constipated. 2 Constipation occurs in all social classes.
included terms such as difficult or infrequent bowel Contrary to adults where it is much more common in
movements, painful defecation, passage of hard stools females, childhood constipation probably occurs much
and a sensation of incomplete evacuation of stool. The more commonly in boys than in girls.7
practice guidelines of the North American Society for
Pediatric Gastroenterology Hepatology and Nutrition
PHYSIOLOGY OF DEFECATION
(NASPGHAN) defined constipation in children as a delay
or difficulty in defecation, present for 2 or more weeks
and sufficient to cause significant distress to the patient.3 The normal process of fecal evacuation begins with
Recently, a group of pediatric gastroenterologists and propulsion of the fecal matter through the colon. This is
pediatricians meeting in Paris to seek a consensus on accomplished by high amplitude propagated contractions
terminology for childhood constipation defined chronic (HAPCs) that occur several times during the day,
constipation as 2 or more of the following occurring over occurring more frequently in infants and decreasing to 2­
the preceding 8 weeks: Frequency of bowel movements 4 per day in adults. In addition to the high amplitude
contractions, an increase in motility of the colon following
a meal, the gastrocolic reflex, also helps to propel stool
along the colon to the rectum, where it is stored until
appropriate conditions are present for voluntary
Correspondence and Reprint requests : Dr. Joseph M. Croffie, MPH, evacuation. At the rectum, the mechanism for storage
MD, Indiana University School of Medicine, James Whitcomb Riley
Hospital for Children 702 Barnhill Drive – Room ROC 4210,
and evacuation of the fecal material is a complex process
Indianapolis, Indiana 46202-5225. Fax: (317) 274-8521.

Indian Journal of Pediatrics, Volume 73—August, 2006 697

In all cases. the anorectal angle. Borowitz and colleagues. straightening the anorectal angle. If defecation is not desired. found 698 Indian Journal of Pediatrics. psychotropics and symptoms in older children. Constipation may.8 A change from human systems. therefore. defecation. appropriate testing. Coercive or inappropriate canal. biochemical or physiologic abnormalities are • Asymmetry or flattening of the glutei muscles identified. is 85-105° and supports much of toilet training in a toddler not ready for toilet training the weight of the fecal mass in the rectum. In addition to infrequent bowel Defective/Impaired Propulsion movements. becomes a recurrent phenomenon that leads to a vicious cycle of withholding and evacuation of large. the puborectalis and levator ani may develop from situations that make defecation muscles are relaxed. Croffie involving the puborectalis muscle. result from The most common presentation of childhood constipation defective or impaired propulsion. hard and painful stools. at rest. 60 Joseph M. hard stools and display stool withholding behavior. hanging on to • Metabolic abnormalities such as hypo/hypercalcemia. Many of these children have functional • Nevi or sinus in the lumbosacral region constipation resulting from intentional withholding of • Multiple café-au-lait spots • Abnormal tone and strength stool. no obvious • Patulous anus anatomic. with the soy base formula may lead to firmer stools and hence internal and external anal sphincters surrounding the anal painful defecation in an infant. streptococcal anusitis or sexual abuse. furniture. Cystic fibrosis. Distension of the passage of dry hard stools with discomfort. celiac disease in older children. A careful history and physical examination will identify Outlet Obstruction red flags (Table 2) which may signal the probable • Mechanical as in anal stenosis. PATHOPHYSIOLOGY CLINICAL PRESENTATION Disruption of the normal physiology of defecation leads to constipation. • Diet deficient in bulk-producing fiber • Milk protein allergy characterized by stiffening of the whole body and • Neuropathy or myopathy of the gastrointestinal tract screaming in infants. presence of an organic cause for constipation and lead to imperforate anus. stool frequency decreases from 4 or more per day during infancy to about one per day at 4 years of age. tightening of the buttocks or hiding in corners hypothyroidism. Volume 73—August. In such children. the tendency to withhold If defecation is desired. defective or impaired is infrequent bowel movements. Hirschsprung’s disease. Studies have shown that sensation or outlet obstruction (Table 1).9 In the older child. Stool frequency of less than 3 times per week at any age is TABLE 1. The puborectalis muscle embraces the rectal milk to cow milk or from a cow milk base formula to a neck and forms an angle. pelvic or sacral mass. anal or colonic stricture. pelvic floor onset of symptoms. 2006 . • Functional as in intentional fecal retention. The history should include age of anteriorly displaced anus. Etiology of Constipation outside the norm. uncomfortable or inconvenient such as unpleasant toilet Straining increases the intraabdominal pressure and facilities at school or anal pain resulting from results in evacuation of feces. the infant who failed to pass dyssynergia meconium within the first 48 hours of life is more likely to TABLE 2. relieving the may lead to withholding of stool and eventual inevitable sphincters of the bulk of this pressure. Cow milk rectum causes a reflex relaxation of the internal anal allergy may lead to hard stools. Red Flags For Organic Disease • Poor weight gain/weight loss ETIOLOGY • Abdominal distention with or without vomiting • Anteriorly displaced anus • Tight anus In about 95% of children with constipation. to walking on tiptoes. This angle. the detrussor muscles that painful defecation was the primary precipitant of of the rectum and the autonomic and somatic nervous constipation in early childhood. anal fissures and painful sphincter and contraction of the rectal detrussor muscles. an unpleasant event may have • Abnormal lower extremity reflexes been the precipitating factor for the desire to withhold • Presence of gross or occult blood in stool stool. Abdominal pain and overflow fecal • Genetic predisposition incontinence (encopresis) may also be presenting • Medications such as narcotics. in a recent study. fecal contraction of the external anal sphincter prevents fecal withholding beginning as a reaction to an acute process loss until the rectal wall adapts to the increasing volume. many children with constipation pass large. anticholinergics Defective/Impaired Sensation • Primary sensory impairment such as from spinal cord EVALUATION abnormalities • Secondary sensory impairment as in case of megarectum resulting from chronic fecal retention.

The barium hyperplastic nerve trunks is diagnostic of Hirschsprung’s enema in an unprepared colon will demonstrate a disease. Normal values for children suggestive of Hirschsprung’s disease. Hirschsprung’s disease or cystic fibrosis. Other abnormalities. abnormalities of resting child who refuses a rectal examination and in the and squeeze pressures of the anus and pelvic floor markedly obese child in whom a good rectal examination dyssynergia (paradoxical contraction of the external anal is technically challenging. The neuronal intestinal dysplasia. Absence of the rectoanal inhibitory reflex is number of markers ingested. a studying colonic motility. Fecal masses are usually palpable in the suprapubic region and left lower quadrant of the abdomen in children with constipation. most do not need any diagnostic test. Anal examination may reveal perianal disease such as an anal fissure or anusitis. organic etiology for their symptoms. A plain radiograph of the abdomen is may be diagnosed at anorectal manometry include useful in determining if a fecal impaction is present in a abnormalities of rectal sensation. In the child with severe sphincter during attempts at defecation). which the catheter is placed in the colon during colonoscopy. abdominal distention. Distention of the transit times are determined by counting the number of rectum in a normal individual produces reflex relaxation markers in the entire colon or the segment of interest.11 In these patients. A water-perfused or solid-state rectal biopsy is normal despite a nonrelaxing internal anal catheter with pressure sensors placed at various lengths of sphincter. stool-filled normal or ganglionic are features of the controversial disorder referred to as bowel to an empty abnormal or aganglionic bowel. A digital rectal examination may reveal a tight anus suggesting the possibility of anal stenosis or Hirschsprung’s disease if the child also has a distended abdomen and no stool in the rectum. usual diet. Hyperganglionosis and/or ectopic ganglion cells transition from a dilated. A lax anus may be indicative of neurological disease. transition zone is better defined in an older child. of the internal anal sphincter (the rectoanal inhibitory multiplying that by 24 hours and dividing by the total reflex) (Fig 1). The physical examination should include all body systems so as to exclude any systemic illness complicated by constipation. presence of withholding behavior. An occasional child has a massive fecal mass palpable from the hypogastrium to the level of the umbilicus. fecal incontinence. Pancolonic or stool. Indian Journal of Pediatrics. weight loss. Anorectal manometry showing normal rectoanal inhibitory Since only about 5% of children with constipation have an reflex following rectal distention. A barium enema is also useful when other anatomic segmental colonic transit abnormalities can be detected abnormalities such as a colonic or rectal stricture is with this test. mostly functional. vomiting. even in such children. 2006 699 . Volume 73—August. INVESTIGATIONS Fig 1.10 Other pertinent historical data to obtain include duration of symptoms. an unprepared barium enema or Absence of submucosal ganglion cell in the presence of anorectal manometry are useful initial tests. constipation in whom Hirschsprung disease remains a A rectal biopsy provides histological information. Absence of the are available. 12 rectoanal inhibitory reflex is also seen in patients with Colonic manometry is a more sophisticated way of internal anal sphincter achalasia. The patient ingests radioopaque markers suspected. it may A colonic transit study using radioopaque markers is not be seen in an infant because there has not been useful in confirming constipation when there is no enough time to distend the normal portion of bowel with objective data to support the history. The total transit and segmental measure pressures in the anorectum. daily for 6 days and a plain abdominal radiograph is Anorectal manometry is a test which allows one to obtained on the 7th day. family history of constipation. frequency of bowel movements. abdominal distention is minimal if there is no anatomic obstruction because colonic gas is not retained with the feces. diagnostic possibility.61 Constipation in Children have Hirschsprung’s disease than the infant whose constipation began after being weaned from breast milk. celiac disease. abdominal pain. thyroid disease.

Rewarding success is absence of the gastrocolic response.13 helpful particularly in the difficult child. water is The patient is allowed to observe his/her abnormal reabsorbed.100 ml/kg over 6 hours. the laxative should be constipation should have the underlying cause gradually weaned and the patient transitioned to dietary appropriately treated medically or surgically. functional constipation who are found at anorectal This implies explaining to the child and parents why manometry to have pelvic floor dyssynergia anorectal withholding stool leads to a vicious cycle of constipation biofeedback training may be beneficial.5 ml/day (2 . In a selective number of patients with recalcitrant the treatment is 3-fold and should begin with education.3 ml/kg/day • Barley malt extract • 2 – 10 ml/240 ml of juice or milk • Sorbitol • 1 – 3 ml/kg/day • Magnesium Hydroxide • 1 – 3 ml/kg/day of 400 mg/5 ml • Polyethylene glycol 3350 • 1 – 2 gm/kg/day • Polyethylene glycol electrolyte solution • 25 . resolves the problem. Volume 73—August. 135 ml.3 mg/Kg/day.6 yrs old and 5-15 ml/day in 6 – 12 yrs old) • Bisacodyl • 0. The third and perhaps Normal colonic motility is characterized by the presence the most important aspect of the treatment is a behavior of HAPCs and increased colonic motility following a modification program. Avoid in infants 700 Indian Journal of Pediatrics.7. appendicocecostomy to provide access for daily Occasionally. 4 L – For oral disimpaction Stimulants: • Senna • 2. he or stool which is usually painful to evacuate. A myopathy is characterized by absence of colonic sit on the toilet and evacuate at specific times during the contractions or weak colonic contractions while a day so as to establish a regular pattern of defecation. 62 Joseph M. a child with a massive rectal impaction antegrade enemas. The process of establishing a regular bowel habit may take several months and laxatives may need to be continued for the TREATMENT length of time it takes to establish such a bowel habit. Recordings of requires manual disimpaction under anesthesia. leading to an accumulation of desiccated manometric tracing during simulated defecation.15 This therapy is with or without fecal incontinence. Laxatives Used in The Treatment of Constipation in Children Agent Dose Bulking Agent: • Psyllium • Age (yrs) + 5 gms Lubricant: • Mineral oil • 1 – 3 ml/kg/day Osmotic Agents: • Lactulose • 1 . 2006 . A colonic motility during fasting. There may be a role for increased dietary fiber if the diet is deficient. Max 10 mg Enemas: • Phosphate enemas • 6 ml/kg. postprandial and post­ laxative should then be prescribed at appropriate doses to colonic stimulation with a colon stimulant are obtained.5 .14 Normal intake should OTHER TREATMENTS be at least the patient’s age in year + 5 gm per day. anus loses resting tone resulting in incontinence of small Some difficult patients with or without abnormalities on amounts of fresh stool reaching the rectum. Max. the the dynamic manometric tracing for visual feedback. When stool is retained based on the principle of learning through reinforcement. dietary measures including includes an adequate amount of fiber and adequate an increase in fluid and carbohydrate intake often amount of fluid intake. neuropathy is characterized by disordered and Sitting after meals is recommended so as to take nonpropagating high amplitude contractions or an advantage of the gastro-colic reflex. for long periods of time in the rectum. TABLE 3. Max. For children management with emphasis on a balanced diet that with acute onset constipation. When a large she is then encouraged to correct the abnormality using amount of desiccated stool is retained in the rectum. After a colonic motility study may benefit from surgery 16 education. The child should be encouraged to meal. 3 After a regular bowel habit is established and the patient Patients with an identifiable organic cause for is no longer withholding stool. Croffie The study is performed over several hours. In the child with a clear history of intentional fecal withholding. any fecal impaction in the rectum should be including resection of an abnormal left colon and removed with oral or rectal laxatives (Table 3). ensure evacuation of soft stools.

Benninga MA. Philadelphia. The Paris 13. Group. Monai M. Iacono G. Neurogastroenterol Motility 2002. Childhood 10. Diagnosis of congenital constipation: is there new light in the tunnel? J Pediatr megacolon: an analysis of 501 patients. 44 : 63-71. Hillemeier C. Saunders. Sutphen JL. Is Anorectum”. Swenson O. J Pediatr Surg 1973.30(1):109]. 113 : e259-264. Chronic constipation in children. Melton LJ. constipation? J Pediatr Surg 2004. Talley NJ. Constipation in infants 11. 339 : 1100-1104. 2005. 8: Gastroenterol Nutr 2004. 14. anxiety and depression of patients with the effectiveness of biofeedback in children with dyssynergic idiopathic constipation: a population-based study. 2. 2004. Candy DC. 39 Nutr 1999. 5. Barksdale E. Taminiau JA. milk and chronic constipation in children. home biofeedback improve long-term outcomes. Montalto G et al. Aliment defecation and recalcitrant constipation/encopresis: does Pharmacol Ther 2003. 29 : 612-626. 40 : 273-275.B. 16 : 213-218. 9. 3. Pediatr Surg Internat 2001. 14 : 411-420. 39 : 73-77. Croffie JM. Ritterband LM. Baillie CT. Gastroenterology and Nutrition. Di Lorenzo C. and children: evaluation and treatment. 105 : 1557-1564. Turnock RR. Gastroenterology Clinics of North America “Disorders of the 16. Cox DJ. Loening-Baucke V. Fiber (glucomannan) is Functional constipation and outlet delay: a population-based beneficial in the treatment of childhood constipation. 1998. A medical position The treatment of internal anal sphincter achalasia with statement of the North American Society for Pediatric botulinum toxin. J Pediatr Gastroenterol Nutr 2005. 587-594. J Am Board Fam Pract 2003. Manometry Consensus on Childhood Constipation Terminology (PACCT) studies in children: minimum standards for procedures. Miele E. 6. J Pediatr Gastroenterol Colonic transit time—what is normal? J Pediatr Surg 2004. Gastroenterol Nutr 2000 Jan. 18 : 319-326. Ventura A. New Engl J Med Gastroenterology 1993. Cheng C. 2006 701 . In: Rao SSC ed. Gastroenterology 1993. Martellossi S. : 166-169. Youssef NN. Hui WM. 39 : 448-464. discussion 166-169. Lamont GL. 105 : 781-790. Assessment of illness perception. Messineo A. 4. Shankar KR. Jr. 17 : 521-523. Precipitants of constipation during early childhood. Benninga M. Staiano A. Borowitz SM. Di Lorenzo C. Lam SK. A. Intolerance of cow’s 1. Ammar MS. [erratum appears in J Pediatr 12. Sherman JO. Liptak GS. Clin Pediatr 7. Zinsmeister AR.. Colletti RB et al. Pensabene L. Pediatric anorectal disorders.63 Constipation in Children REFERENCES Penberthy JK. Pediatrics study. Hyman P et al. Chan AO. Di Lorenzo C. 15. Coping strategies. Cavataio F. Voskuijl WP. Weaver AL. W. Tam A. 3rd. 2001. Wagener S. Volume 73—August. PA. Fisher JH. Codrich D. Loening-Baucke V. Catto-Smith AG et al. Pfefferkorn MD et al. Indian Journal of Pediatrics. Baker SS. 30 : 269­ there a role for surgery beyond colonic aganglionosis and 287. anorectal malformations in children with intractable 8.

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