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