1. Constipation in children
By Phil Byass, 4th Year, HYMS

2. Definition
• “Infrequent passage of stool associated with
pain and difficulty, or delay in defecation”
• Normal: Frequency of defecation reduces
from >4 times per day in early childhood to
about once per day by age 4.

3. Epidemiology
• Approx. 5% of schoolchildren suffer from
constipation
• 90-95% of constipation is functional
• Often psychosocial factors involved. Painful
defecation causes fear of defecation
• Most children with constipation are
developmentally normal. It is seen commonly in:
a) Infants at weaning.
b) Toddlers acquiring toilet skills.
c) School age.

4. History
• The frequency of defecation. Infrequent but normal stools
are not indicators of constipation
• Consistency of stools - this may include use of the Bristol
Stool Chart.
• Episodes of faecal incontinence (overflow) – typically
spotting of faeces on underwear. Not diarrhoea!
• Pain on defecation.
• Blood on stool or toilet paper
• History of anal fissure in PMH
• Whether stools block the toilet.
• Any associated behaviour.
• Onset in infancy may signify Hirschprung’s disease – ask
about meconium!
• Diet – ask as a basis for giving advice!

6. Examination
• Review growth as Hirschprung’s can cause FTT
• Abdominal exam – hard indentable faeces
often felt in LLQ
• Anorectal examination – anal exam may reveal
hard faeces. Look for anal fissure.

7. Functional Constipation
• Low fibre diet
• Lack of exercise
• Poor colonic history (55% +ve FH)
• Stems from painful passage of a hard stool,
causing anal fissure
• Child withholds to avoid further pain
• Water reabsorbed making stool harder and more
painful to pass
• Cycle perpetuates
• Colon becomes stretched and less efficient at
moving stool (cannot ‘grasp’ during peristalsis)

8. Organic Causes of Constipation
• Only 5% of causes are organic
• GI organic causes:
1) Hirschprung’s disease (delay in passing
meconium)
2) Anal disease (stenosis, ectopic, fissure)
3) Partial intestinal obstruction
4) Food hypersensitivity esp cow’s milk
5) Celiac disease

9. • Non-GI organic causes:
1) Hypothyroidism
2) Hypercalcemia
3) Neurological (spinal disease)
4) Cystic fibrosis
5) Sexual abuse
6) Chronic dehydration – check diabetes
insipidus
7) Drugs e.g. opiates, anticholinergics

10. Management of functional constipation
• Aims of treatment to soften stool and promote gut motility
and address psychosocial factors:
1) Treat anal fissure with topical anaesthetic (2% lignocaine
ointment) to reduce pain
2) Diet: increase oral fluid and fibre e.g. fruit juice
3) Behavioural measures: encourage parents not to show
concern, star charts, regular 5 min toilet time after meals
4) Softeners: lactulose (also osmotic laxative) or sodium
docusate
5) Stimulant laxatives: senna, sodium picosulphate
6) Macrogels: e.g. Movicol – osmotic laxative.
7) Enemas if no response to treatment. Often use air to
inflate colon
8) Hospital admission for manual evacuation under
sedation/GA if appropriate

11. Complications
• Faecal impaction.
• Chronic constipation.
• Mega-colon (may predispose to, or result
from, constipation).
• Rectal prolapse.
• Anal fissure.
• Faecal soiling.
• Psychological effects.