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Constipation is a common problem in childhood and is one of the most frequent reasons for a referral to pediatricians. It is termed functional or idiopathic in the absence of any organic etiology. Almost 95% of childhood constipation is functional in nature and only a small minority is due to an identifiable etiology. The diagnosis of functional constipation can usually be made with a detailed history and physical examination. Constipation can often be a chronic problem in children lasting for several months to years. Almost 50% of the patients presenting with constipation during childhood can remain constipated on long-term follow-up. Long-standing constipation and withholding often result into fecal incontinence. Constipation and incontinence can lead to low self-esteem and behavior problems, causing significant stress and anxiety to the patient and the parents. The therapeutic approach involves patient education, disimpaction, laxative therapy, and behavioral modification. The treatment typically lasts for months to years and relapses are common. A successful treatment outcome requires a team approach involving the patient, family, nurses, pediatricians, and the specialists. In this chapter, we will review the diagnostic evaluation and therapeutic approach to functional constipation.


The term constipation is often defined differently by different parents. Constipation may mean infrequent bowel movements, hard stool consistency, large stool size, painful defecation, or voluntary withholding bowel movements. To most parents, constipation usually means infrequent bowel movements. It is important to remember that stool frequency varies in children with age.1 Normally, the initial bowel movement is within the first 24 hours of birth. Delayed passage of stool should raise the suspicion for Hirschsprung’s disease. Infants have approximately four stools per day during the first week of life. The frequency also differs between breast-fed and formula-fed infants. Some normal breast-fed infants can have only one stool per week. The stool frequency gradually changes to one to two stools per day by the age of 4 years. An adult defecation pattern is achieved after 4 years of age. The decrease in stool frequency is associated with an increase in stool size and prolonged gastrointestinal transit. The majority of children are toilet trained by 4 years of age. Girls tend to achieve toilet training slightly earlier than boys. Encopresis or fecal incontinence is defined as involuntary passage of stools after the developmental age of 4 years.


The North American Society for Pediatric Gastroenterology and Nutrition (NASPGHAN) defines constipation as a delay or difficulty in defecation, present for 2 or more weeks and sufficient to cause significant distress to the patient.1


The 2006 Rome III criteria for childhood functional gastrointestinal disorders describe the diagnostic criteria of functional constipation for neonate/toddler and for child/adolescent age groups as shown in Table 5–1.2,3

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Table 5–1. Diagnosis of Functional Constipation by Rome III Criteria 

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