Constipation in children

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 21 Oct 2024

Last updated: 09 Feb 2023

Childhood constipation is typically characterized by infrequent bowel evacuations, large stools, and difficult or painful defecation.

Symptoms often result from low fiber, poor nutrient, poor stooling technique, and/or insufficient water intake, which leads to excessive hardening of the stool. This often starts as an acute problem but can progress to fecal impaction and chronic constipation.

Particularly in young children, any cause of painful defecation may provoke active withholding. Withholding may worsen the constipation and lead to a vicious cycle.

Duration of constipation and amount of stool burden may depend on capacity of the child's rectum, the degree of rectal dilation (if excessive, often called megarectum), and other factors including rectal sensory function.

After fecal disimpaction, maintenance stool softeners are essential and are often required for many months or years to reduce relapse risk.

Definition

Constipation in childhood is the infrequent passage of stools leading to 1 or more of the following: painful defecation; overflow fecal incontinence; rectal fecal impaction; or active defecation avoidance behavior.

History and exam

Key diagnostic factors

difficult or painful defecation
long interval between stools
fecal incontinence
small-volume, soft, incontinent stool
palpable fecal mass per abdomen
otherwise healthy child

Full details

Other diagnostic factors

abdominal pain
abdominal distention
anal fissure
associated bladder problems
abnormal anal appearance

Full details

Risk factors

low-fiber diet
poor-nutrient diet
genetic predisposition
infection
stress
obesity
low birth weight
psychiatric history
physical disability
poor toilet training
immune dysregulation
low fluid intake
trauma

Full details

Diagnostic tests

1st tests to order

no initial test

Full details

Tests to consider

abdominal radiograph
radiopaque marker colonic transit study
abdominal ultrasound
contrast enema
rectal suction biopsy
psychological assessment

Full details

Emerging tests

anorectal manometry
colonic manometry

Treatment algorithm

ACUTE

no impaction: <1 year of age

no impaction: ≥1 year of age

with impaction: <1 year of age

with impaction: 1-3 years of age

with impaction: ≥4 years of age

Contributors

Authors

Jaime Belkind-Gerson, MD, MSc

Director Neurogastroenterology and Motility Program

Digestive Health Institute

Children's Hospital Colorado

Associate Professor of Pediatrics

University of Colorado School of Medicine

Colorado

Disclosures

JB-G declares that he has no competing interests.

Claire Zar-Kessler, MD

Instructor in Pediatric Gastroenterology

Massachusetts General Hospital for Children

Boston

Disclosures

CZ-K has received support from Takeda for a clinical trial on prucalopride.

Acknowledgements

Dr Jaime Belkind-Gerson and Dr Claire Zar-Kessler would like to gratefully acknowledge Dr Corey Baker, Dr Wael El-Matary, Dr Steffen Reinsch, and Dr Meghan McPherson, the previous contributors to this topic.

Disclosures

CB, WE-M, SR, and MM declare that they have no competing interests.

Peer reviewers

David C.A. Candy, MBBS, MSc, MD, FRCP, FRCPCH, FCU

Consultant Paediatric Gastroenterologist

Royal West Sussex NHS Trust

Chichester

Disclosures

DCAC has served as a consultant to, and spoken at symposia sponsored by, Norgine Ltd.

Vikram Boolchand, MD

Gastroenterology Fellow

University of Arizona

Tucson

Disclosures

VB declares that he has no competing interests.

David J. Hackam, MD, PhD

Associate Professor of Pediatric Surgery

University of Pittsburgh School of Medicine

Pittsburgh

Disclosures

DJH declares that he has no competing interests.

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Constipation in children

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

no impaction: <1 year of age

no impaction: ≥1 year of age

with impaction: <1 year of age

with impaction: 1-3 years of age

with impaction: ≥4 years of age

Contributors

Authors

Jaime Belkind-Gerson, MD, MSc

Disclosures

Claire Zar-Kessler, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

David C.A. Candy, MBBS, MSc, MD, FRCP, FRCPCH, FCU

Disclosures

Vikram Boolchand, MD

Disclosures

David J. Hackam, MD, PhD

Disclosures

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice