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.
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
Other diagnostic factors
- abdominal pain
- abdominal distention
- anal fissure
- associated bladder problems
- abnormal anal appearance
- low-fiber diet
- poor-nutrient diet
- genetic predisposition
- low birth weight
- psychiatric history
- physical disability
- poor toilet training
- immune dysregulation
- low fluid intake
1st investigations to order
- no initial test
Investigations to consider
- abdominal radiograph
- radiopaque marker colonic transit study
- abdominal ultrasound
- contrast enema
- rectal suction biopsy
- psychological assessment
- anorectal manometry
- colonic manometry
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
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
JB-G declares that he has no competing interests.
Claire Zar-Kessler, MD
Instructor in Pediatric Gastroenterology
Massachusetts General Hospital for Children
CZ-K has received support from Takeda for a clinical trial on prucalopride.
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.
CB, WE-M, SR, and MM declare that they have no competing interests.
David C.A. Candy, MBBS, MSc, MD, FRCP, FRCPCH, FCU
Consultant Paediatric Gastroenterologist
Royal West Sussex NHS Trust
DCAC has served as a consultant to, and spoken at symposia sponsored by, Norgine Ltd.
Vikram Boolchand, MD
University of Arizona
VB declares that he has no competing interests.
David J. Hackam, MD, PhD
Associate Professor of Pediatric Surgery
University of Pittsburgh School of Medicine
DJH declares that he has no competing interests.
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