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Constipation is a common problem in children and is often associated with maladaptive behavior triggered by a painful or otherwise unpleasant defecation. There is no universally accepted definition of constipation, although the term is generally describes infrequent or painful bowel movement due to stool that is too large or hard to pass.1,2 The Rome Committee, consisting of a group of pediatric gastroenterologist from Europe and North America, defined constipation as 2 or more of the following symptoms in a child with a developmental age of at least 4 years: 2 or fewer defecations in the toilet per week, at least 1 episode of fecal incontinence per week, history of retentive posturing or excessive volitional stool retention, history of painful or hard bowel movements, presence of a large fecal mass in the rectum, and history of large-diameter stools that may obstruct the toilet.3,4

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Epidemiology

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The incidence of constipation in 5 to 21 year olds is estimated to be 3.9 per 1000 person-years. The prevalence of constipation in children ranges from 0.7% to 29.6% (median 8.9%).5,6 About 3% of children experience constipation in the first year of life and about 10% in the second year of life.7 Constipation accounts for almost 3% of general pediatric outpatient clinic visits and 10% to 25% of visits to a pediatric gastroenterology clinic. Most cases of functional constipation present between ages 2 and 4 years. The incidence of constipation in children younger than 13 years is similar between genders, but in older children, girls seek medical help more often than boys. In school-aged children, fecal soiling is 3 times more common in boys than in girls. The incidence increases when a parent, sibling, or twin has constipation. Monozygotic twins are 4 times more likely than dizygotic twins to have constipation.

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Pathophysiology

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A normal pattern of defecation requires the removal of water from the liquid chyme that enters the cecum and propulsion of soft, formed colonic contents through the colon to the rectum, which stores stool until defecation. Sensation of the need to pass stool by rectal smooth muscle contraction and reflexive partial inhibition of the internal anal sphincter allows stool to impinge on the sensory area of the mucosa of the upper anal canal. To achieve continence, the child must be able to perceive this urge to defecate, and then, if in the appropriate setting, the child must plan to find a lavatory depending on the urgency. This is not an innate ability but requires learning in a supportive environment. If the child has learned that stooling is painful, or if appropriate access to a socially acceptable location for passing stool is unavailable, the child withholds the stool by external anal sphincter and pelvic floor contraction. Once the child decides to defecate, the puborectalis muscle is relaxed, allowing the pelvic floor to descend and straighten the anorectal angle from ...

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