Constipation in children

Last reviewed: 28 Dec 2022

Last updated: 08 Feb 2019

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

Symptoms may result from low fibre, poor nutrient, and/or insufficient water intake, which leads to excessive hardening of the stool. This often starts as an acute problem but can progress to faecal 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 megarectum, and other factors including rectal sensory function.

After faecal 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 faecal incontinence; rectal faecal impaction; or active defecation avoidance behaviour.

History and exam

Key diagnostic factors

presence of risk factors
difficult or painful defecation
long interval between stools
faecal incontinence
small-volume, soft, incontinent stool
palpable faecal mass per abdomen
otherwise healthy child

More key diagnostic factors

Other diagnostic factors

abdominal pain
anal fissure
associated bladder problems
abnormal anal appearance
abnormal neurological examination

Other diagnostic factors

Risk factors

low-fibre diet
poor-nutrient diet
genetic predisposition
infection
stress
obesity
low birth weight
psychiatric history
immune dysregulation
low fluid intake
trauma

More risk factors

Diagnostic investigations

1st investigations to order

no initial test

More 1st investigations to order

Investigations to consider

abdominal x-ray
radiopaque marker colonic transit study
abdominal ultrasound
pelvic ultrasound
rectal mucosal biopsy
psychological assessment

More investigations to consider

Emerging tests

endoanal sonography
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 to 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 been reimbursed by Genzyme for speaking at several conferences.

Corey Baker, MD

Fellow in Pediatric Gastroenterology

Massachusetts General Hospital for Children

Boston

Disclosures

CB declares that he has no competing interests.

Acknowledgements

Dr Jaime Belkind-Gerson, Dr Claire Zar-Kessler, and Dr Corey Baker would like to gratefully acknowledge Dr Wael El-Matary, Dr Steffen Reinsch, and Dr Meghan McPherson, the previous contributors to this topic. WE-M, SR, and MM declare that they have no competing interests.

Peer reviewers

David C.A. Candy, MB.BS, 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.

Differentials
- Hirschsprung's disease
- Anorectal anomaly
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Guidelines
- Constipation in children and young people: diagnosis and management
- Evaluation and treatment of functional constipation in infants and children
More Guidelines
Patient leaflets
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Constipation in children

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations 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 to 3 years of age

with impaction: ≥4 years of age

Contributors

Authors

Jaime Belkind-Gerson, MD, MSc

Disclosures

Claire Zar-Kessler, MD

Disclosures

Corey Baker, MD

Disclosures

Acknowledgements

Peer reviewers

David C.A. Candy, MB.BS, MSc, MD, FRCP, FRCPCH, FCU

Disclosures

Vikram Boolchand, MD

Disclosures

David J. Hackam, MD, PhD

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

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