59

Symposium : Gastroenterology & Hepatology

Constipation In Children
Joseph M. Croffie

Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA

ABSTRACT
Constipation is a common problem throughout the world. It occurs in about 10-20% of adults in Western Countries and 0.3%
to 28% of children worldwide. Most childhood constipation results from intentional withholding of stool following a painful
experience with defecation. Thus, an extensive evaluation is often not necessary in a child presenting with constipation.
Treatment should include education, evacuation of the rectum with oral or rectal laxatives if an impaction is present, laxatives
to ensure soft stools and behavior modification. [Indian J Pediatr 2006; 73(8) : 697-701] E-mail : jcroffie@iupui.edu

Key words : Constipation; Fecal retention; Encopresis

Constipation is a common problem throughout the world.
It occurs in both adults and children. In the United States,
3 % of visits to a pediatrician and 25% of visits to a
pediatric gastroenterologist are for problems related to
constipation and 34% of British children aged 4 to 11 years
have experienced constipation.1, 2
DEFINITION
Constipation is a symptom, not a disease or a sign. For
this reason, a precise definition has been elusive.
Constipation has a different meaning for different people
and often reflects an individuals view of what the normal
pattern of defecation should be. Thus, its definition has
included terms such as difficult or infrequent bowel
movements, painful defecation, passage of hard stools
and a sensation of incomplete evacuation of stool. The
practice guidelines of the North American Society for
Pediatric Gastroenterology Hepatology and Nutrition
(NASPGHAN) defined constipation in children as a delay
or difficulty in defecation, present for 2 or more weeks
and sufficient to cause significant distress to the patient.3
Recently, a group of pediatric gastroenterologists and
pediatricians meeting in Paris to seek a consensus on
terminology for childhood constipation defined chronic
constipation as 2 or more of the following occurring over
the preceding 8 weeks: Frequency of bowel movements
Correspondence and Reprint requests : Dr. Joseph M. Croffie, MPH,
MD, Indiana University School of Medicine, James Whitcomb Riley
Hospital for Children 702 Barnhill Drive Room ROC 4210,
Indianapolis, Indiana 46202-5225. Fax: (317) 274-8521.
less than 3 per week, more than 1 episode of fecal
incontinence per week, large stools in the rectum or
palpable on abdominal examination, passing of stools so
large that they obstruct the toilet, retentive posturing and
withholding behavior, and painful defecation.4
EPIDEMIOLOGY
The exact worldwide prevalence of constipation in
children is not known. Population-based studies suggest
that 10-20% of adults in Western Countries and in Asia
have one or more symptoms of constipation. 5, 6 and it is
estimated that 0.3% to 28% of children worldwide are
constipated. 2 Constipation occurs in all social classes.
Contrary to adults where it is much more common in
females, childhood constipation probably occurs much
more commonly in boys than in girls.7
PHYSIOLOGY OF DEFECATION
The normal process of fecal evacuation begins with
propulsion of the fecal matter through the colon. This is
accomplished by high amplitude propagated contractions
(HAPCs) that occur several times during the day,
occurring more frequently in infants and decreasing to 2
4 per day in adults. In addition to the high amplitude
contractions, an increase in motility of the colon following
a meal, the gastrocolic reflex, also helps to propel stool
along the colon to the rectum, where it is stored until
appropriate conditions are present for voluntary
evacuation. At the rectum, the mechanism for storage
and evacuation of the fecal material is a complex process

Indian Journal of Pediatrics, Volume 73August, 2006 697


Joseph M. Croffie
involving the puborectalis muscle, the detrussor muscles
of the rectum and the autonomic and somatic nervous
systems. The puborectalis muscle embraces the rectal
neck and forms an angle, the anorectal angle, with the
internal and external anal sphincters surrounding the anal
canal. This angle, at rest, is 85-105 and supports much of
the weight of the fecal mass in the rectum, relieving the
sphincters of the bulk of this pressure. Distension of the
rectum causes a reflex relaxation of the internal anal
sphincter and contraction of the rectal detrussor muscles.
If defecation is desired, the puborectalis and levator ani
muscles are relaxed, straightening the anorectal angle.
Straining increases the intraabdominal pressure and
results in evacuation of feces. If defecation is not desired,
contraction of the external anal sphincter prevents fecal
loss until the rectal wall adapts to the increasing volume.
PATHOPHYSIOLOGY
Disruption of the normal physiology of defecation leads
to constipation. Constipation may, therefore, result from
defective or impaired propulsion, defective or impaired
sensation or outlet obstruction (Table 1).
TABLE 1. Etiology of Constipation
Defective/Impaired Propulsion
Diet deficient in bulk-producing fiber
Milk protein allergy
Neuropathy or myopathy of the gastrointestinal tract
Metabolic abnormalities such as hypo/hypercalcemia,
hypothyroidism, Cystic fibrosis, celiac disease
Genetic predisposition
Medications such as narcotics, psychotropics and
anticholinergics
Defective/Impaired Sensation
Primary sensory impairment such as from spinal cord
abnormalities
Secondary sensory impairment as in case of megarectum
resulting from chronic fecal retention.
Outlet Obstruction
Mechanical as in anal stenosis, Hirschsprungs disease,
imperforate anus, pelvic or sacral mass, anal or colonic stricture,
anteriorly displaced anus.
Functional as in intentional fecal retention, pelvic floor
dyssynergia
ETIOLOGY
In about 95% of children with constipation, no obvious
anatomic, biochemical or physiologic abnormalities are
identified. Many of these children have functional
constipation resulting from intentional withholding of
stool. In such children, an unpleasant event may have
been the precipitating factor for the desire to withhold
stool. Borowitz and colleagues, in a recent study, found
698
60
that painful defecation was the primary precipitant of
constipation in early childhood.8 A change from human
milk to cow milk or from a cow milk base formula to a
soy base formula may lead to firmer stools and hence
painful defecation in an infant. Coercive or inappropriate
toilet training in a toddler not ready for toilet training
may lead to withholding of stool and eventual inevitable
passage of dry hard stools with discomfort. Cow milk
allergy may lead to hard stools, anal fissures and painful
defecation.9 In the older child, the tendency to withhold
may develop from situations that make defecation
uncomfortable or inconvenient such as unpleasant toilet
facilities at school or anal pain resulting from
streptococcal anusitis or sexual abuse. In all cases, fecal
withholding beginning as a reaction to an acute process
becomes a recurrent phenomenon that leads to a vicious
cycle of withholding and evacuation of large, hard and
painful stools.
CLINICAL PRESENTATION
The most common presentation of childhood constipation
is infrequent bowel movements. Studies have shown that
stool frequency decreases from 4 or more per day during
infancy to about one per day at 4 years of age. Stool
frequency of less than 3 times per week at any age is
outside the norm. In addition to infrequent bowel
movements, many children with constipation pass large,
hard stools and display stool withholding behavior,
characterized by stiffening of the whole body and
screaming in infants, to walking on tiptoes, hanging on to
furniture, tightening of the buttocks or hiding in corners
in older children. Abdominal pain and overflow fecal
incontinence (encopresis) may also be presenting
symptoms in older children.
EVALUATION
A careful history and physical examination will identify
red flags (Table 2) which may signal the probable
presence of an organic cause for constipation and lead to
appropriate testing. The history should include age of
onset of symptoms; the infant who failed to pass
meconium within the first 48 hours of life is more likely to
TABLE 2. Red Flags For Organic Disease
Poor weight gain/weight loss
Abdominal distention with or without vomiting
Anteriorly displaced anus
Tight anus
Patulous anus
Asymmetry or flattening of the glutei muscles
Nevi or sinus in the lumbosacral region
Multiple caf-au-lait spots
Abnormal tone and strength
Abnormal lower extremity reflexes
Presence of gross or occult blood in stool
Indian Journal of Pediatrics, Volume 73August, 2006
61

Constipation in Children

have Hirschsprungs disease than the infant whose

constipation began after being weaned from breast milk.10
Other pertinent historical data to obtain include duration
of symptoms; frequency of bowel movements; usual diet;
presence of withholding behavior, fecal incontinence,
abdominal pain, abdominal distention, vomiting, weight
loss; family history of constipation, thyroid disease, celiac
disease, Hirschsprungs disease or cystic fibrosis.
The physical examination should include all body
systems so as to exclude any systemic illness complicated
by constipation. Fecal masses are usually palpable in the
suprapubic region and left lower quadrant of the
abdomen in children with constipation. An occasional
child has a massive fecal mass palpable from the
hypogastrium to the level of the umbilicus; even in such
children, abdominal distention is minimal if there is no
anatomic obstruction because colonic gas is not retained
with the feces. Anal examination may reveal perianal
disease such as an anal fissure or anusitis. A digital rectal
examination may reveal a tight anus suggesting the
possibility of anal stenosis or Hirschsprungs disease if the
child also has a distended abdomen and no stool in the
rectum. A lax anus may be indicative of neurological
disease.

INVESTIGATIONS
Since only about 5% of children with constipation have an
organic etiology for their symptoms, most do not need
any diagnostic test. A plain radiograph of the abdomen is
useful in determining if a fecal impaction is present in a
child who refuses a rectal examination and in the
markedly obese child in whom a good rectal examination
is technically challenging. In the child with severe
constipation in whom Hirschsprung disease remains a
diagnostic possibility, an unprepared barium enema or
anorectal manometry are useful initial tests. The barium
enema in an unprepared colon will demonstrate a
transition from a dilated, stool-filled normal or ganglionic
bowel to an empty abnormal or aganglionic bowel. The
transition zone is better defined in an older child; it may
not be seen in an infant because there has not been
enough time to distend the normal portion of bowel with
stool. A barium enema is also useful when other anatomic
abnormalities such as a colonic or rectal stricture is
suspected.
Anorectal manometry is a test which allows one to
measure pressures in the anorectum. Distention of the
rectum in a normal individual produces reflex relaxation
of the internal anal sphincter (the rectoanal inhibitory
reflex) (Fig 1). Absence of the rectoanal inhibitory reflex is
suggestive of Hirschsprungs disease. Absence of the
rectoanal inhibitory reflex is also seen in patients with
internal anal sphincter achalasia.11 In these patients, a
rectal biopsy is normal despite a nonrelaxing internal anal
sphincter. Other abnormalities, mostly functional, which
Fig 1. Anorectal manometry showing normal rectoanal inhibitory
reflex following rectal distention.
may be diagnosed at anorectal manometry include
abnormalities of rectal sensation, abnormalities of resting
and squeeze pressures of the anus and pelvic floor
dyssynergia (paradoxical contraction of the external anal
sphincter during attempts at defecation).
A rectal biopsy provides histological information.
Absence of submucosal ganglion cell in the presence of
hyperplastic nerve trunks is diagnostic of Hirschsprungs
disease. Hyperganglionosis and/or ectopic ganglion cells
are features of the controversial disorder referred to as
neuronal intestinal dysplasia.
A colonic transit study using radioopaque markers is
useful in confirming constipation when there is no
objective data to support the history. Pancolonic or
segmental colonic transit abnormalities can be detected
with this test. The patient ingests radioopaque markers
daily for 6 days and a plain abdominal radiograph is
obtained on the 7th day. The total transit and segmental
transit times are determined by counting the number of
markers in the entire colon or the segment of interest,
multiplying that by 24 hours and dividing by the total
number of markers ingested. Normal values for children
are available. 12
Colonic manometry is a more sophisticated way of
studying colonic motility. A water-perfused or solid-state
catheter with pressure sensors placed at various lengths of
the catheter is placed in the colon during colonoscopy.

Indian Journal of Pediatrics, Volume 73August, 2006 699


Joseph M. Croffie
The study is performed over several hours. Recordings of
colonic motility during fasting, postprandial and post
colonic stimulation with a colon stimulant are obtained.
Normal colonic motility is characterized by the presence
of HAPCs and increased colonic motility following a
meal. A myopathy is characterized by absence of colonic
contractions or weak colonic contractions while a
neuropathy is characterized by disordered and
nonpropagating high amplitude contractions or an
absence of the gastrocolic response.13
TREATMENT
Patients with an identifiable organic cause for
constipation should have the underlying cause
appropriately treated medically or surgically. For children
with acute onset constipation, dietary measures including
an increase in fluid and carbohydrate intake often
resolves the problem. There may be a role for increased
dietary fiber if the diet is deficient.14 Normal intake should
be at least the patients age in year + 5 gm per day. In the
child with a clear history of intentional fecal withholding,
the treatment is 3-fold and should begin with education.
This implies explaining to the child and parents why
withholding stool leads to a vicious cycle of constipation
with or without fecal incontinence. When stool is retained
for long periods of time in the rectum, water is
reabsorbed, leading to an accumulation of desiccated
stool which is usually painful to evacuate. When a large
amount of desiccated stool is retained in the rectum, the
anus loses resting tone resulting in incontinence of small
amounts of fresh stool reaching the rectum. After
education, any fecal impaction in the rectum should be
removed with oral or rectal laxatives (Table 3).
Occasionally, a child with a massive rectal impaction
TABLE 3. Laxatives Used in The Treatment of Constipation in Children
Agent
Bulking Agent:
Psyllium
Lubricant:
Mineral oil
Osmotic Agents:
Lactulose
Barley malt extract
Sorbitol
Magnesium Hydroxide
Polyethylene glycol 3350
Polyethylene glycol electrolyte solution
Stimulants:
Senna
Bisacodyl
Enemas:
Phosphate enemas
700
62
requires manual disimpaction under anesthesia. A
laxative should then be prescribed at appropriate doses to
ensure evacuation of soft stools. The third and perhaps
the most important aspect of the treatment is a behavior
modification program. The child should be encouraged to
sit on the toilet and evacuate at specific times during the
day so as to establish a regular pattern of defecation.
Sitting after meals is recommended so as to take
advantage of the gastro-colic reflex. Rewarding success is
helpful particularly in the difficult child. The process of
establishing a regular bowel habit may take several
months and laxatives may need to be continued for the
length of time it takes to establish such a bowel habit. 3
After a regular bowel habit is established and the patient
is no longer withholding stool, the laxative should be
gradually weaned and the patient transitioned to dietary
management with emphasis on a balanced diet that
includes an adequate amount of fiber and adequate
amount of fluid intake.
OTHER TREATMENTS
In a selective number of patients with recalcitrant
functional constipation who are found at anorectal
manometry to have pelvic floor dyssynergia anorectal
biofeedback training may be beneficial.15 This therapy is
based on the principle of learning through reinforcement.
The patient is allowed to observe his/her abnormal
manometric tracing during simulated defecation; he or
she is then encouraged to correct the abnormality using
the dynamic manometric tracing for visual feedback.
Some difficult patients with or without abnormalities on
a colonic motility study may benefit from surgery 16
including resection of an abnormal left colon and
appendicocecostomy to provide access for daily
antegrade enemas.
Dose
Age (yrs) + 5 gms
1 3 ml/kg/day
1 - 3 ml/kg/day
2 10 ml/240 ml of juice or milk
1 3 ml/kg/day
1 3 ml/kg/day of 400 mg/5 ml
1 2 gm/kg/day
25 - 100 ml/kg over 6 hours. Max. 4 L For oral disimpaction
2.5 - 7.5 ml/day (2 - 6 yrs old and 5-15 ml/day in 6 12 yrs old)
0.3 mg/Kg/day. Max 10 mg
6 ml/kg. Max. 135 ml. Avoid in infants
Indian Journal of Pediatrics, Volume 73August, 2006
63
Constipation in Children
REFERENCES
1. Loening-Baucke V. Chronic constipation in children.
Gastroenterology 1993; 105 : 1557-1564.
2. Benninga MA, Voskuijl WP, Taminiau JA. Childhood
constipation: is there new light in the tunnel? J Pediatr
Gastroenterol Nutr 2004; 39 : 448-464.
3. Baker SS, Liptak GS, Colletti RB et al. Constipation in infants
and children: evaluation and treatment. A medical position
statement of the North American Society for Pediatric
Gastroenterology and Nutrition. [erratum appears in J Pediatr
Gastroenterol Nutr 2000 Jan;30(1):109]. J Pediatr Gastroenterol
Nutr 1999; 29 : 612-626.
4. Benninga M, Candy DC, Catto-Smith AG et al. The Paris
Consensus on Childhood Constipation Terminology (PACCT)
Group. J Pediatr Gastroenterol Nutr 2005; 40 : 273-275.
5. Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ, 3rd.
Functional constipation and outlet delay: a population-based
study. Gastroenterology 1993; 105 : 781-790.
6. Cheng C, Chan AO, Hui WM, Lam SK. Coping strategies,
illness perception, anxiety and depression of patients with
idiopathic constipation: a population-based study. Aliment
Pharmacol Ther 2003; 18 : 319-326.
7. Di Lorenzo C. Pediatric anorectal disorders. In: Rao SSC ed.
Gastroenterology Clinics of North America Disorders of the
Anorectum. Philadelphia; W.B. Saunders, PA, 2001; 30 : 269
287.
8. Borowitz SM, Cox DJ, Tam A, Ritterband LM, Sutphen JL,
Indian Journal of Pediatrics, Volume 73August, 2006
Penberthy JK. Precipitants of constipation during early
childhood. J Am Board Fam Pract 2003; 16 : 213-218.
9. Iacono G, Cavataio F, Montalto G et al. A. Intolerance of cows
milk and chronic constipation in children. New Engl J Med
1998; 339 : 1100-1104.
10. Swenson O, Sherman JO, Fisher JH. Diagnosis of congenital
megacolon: an analysis of 501 patients. J Pediatr Surg 1973; 8:
587-594.
11. Messineo A, Codrich D, Monai M, Martellossi S, Ventura A.
The treatment of internal anal sphincter achalasia with
botulinum toxin. Pediatr Surg Internat 2001; 17 : 521-523.
12. Wagener S, Shankar KR, Turnock RR, Lamont GL, Baillie CT.
Colonic transit timewhat is normal? J Pediatr Surg 2004; 39
: 166-169; discussion 166-169.
13. Di Lorenzo C, Hillemeier C, Hyman P et al. Manometry
studies in children: minimum standards for procedures.
Neurogastroenterol Motility 2002; 14 : 411-420.
14. Loening-Baucke V, Miele E, Staiano A. Fiber (glucomannan) is
beneficial in the treatment of childhood constipation. Pediatrics
2004; 113 : e259-264.
15. Croffie JM, Ammar MS, Pfefferkorn MD et al. Assessment of
the effectiveness of biofeedback in children with dyssynergic
defecation and recalcitrant constipation/encopresis: does
home biofeedback improve long-term outcomes. Clin Pediatr
2005; 44 : 63-71.
16. Youssef NN, Pensabene L, Barksdale E, Jr., Di Lorenzo C. Is
there a role for surgery beyond colonic aganglionosis and
anorectal malformations in children with intractable
constipation? J Pediatr Surg 2004; 39 : 73-77.
701
 64

Books Available

New Publications of The Indian Journal of Pediatrics

(i) Protocols in Neonatology (Xerox copy available)
Editors: V.K. Paul, A.K. Deorari and V.K. Bhutani
Price: Rs 150/-, US$ 15
(ii) Advances in Pediatrics-1
(Cardiology, Hematology & Oncology, Neurology and Genetics)
Editors: A. Saxena, P.S. Rao, V.P. Choudhry, L.S. Arya, V. Kalra and I.C. Verma
Price: Rs 275/-, US$ 30
(iii) Advances in Pediatrics-2
(Infections, Vaccines, Gastroenterology, Nutrition, Endocrinology and Nephrology)
Editors: A. Kumar, S.Y. Bhave, M.K. Bhan, A. Sibal, P.S.N. Menon, A. Bagga and R.N. Srivastava
Price: Rs 275/-, US$ 30
(iv) Recent Advances in Pediatric Cardiology
Editors: P. Syamasundar Rao and Anita Saxena
Price: Rs 300/-, US$ 30

1. 10% discount if two books ordered. (2). 15% discount if three or more books ordered. (3). Note : The price
listed in INR should add postage and handling charges of Rs 50/-

Order from:
The Indian Journal of Pediatrics,
125, Second Floor, Gautam Nagar,
New Delhi 110049
E-mail : ijp@vsnl.net, ijp.journal.vsnl.net@vsnl.net,
ijp@airtelbroadband.in, ijpsubs@airtelbroadband.in

FORTHCOMING PUBLICATION
PEDIATRIC EMERGENCY MEDICINE
by Suresh Gupta
1st Edition : 2006
Price : Rs. 300/-, US $ 30

The Pediatrics Emergency Medicine is a book which demystifies the course of action and events in the
emergency room to an inquisitive mind. The various pediatric problems such as ALTE, rabies, minor head
injury, syncope in children, shunt emergencies, painful hot joints. septic shock, dilemmas of using ABG vs
VBG, ER complaints in the first 28 days of life along with their preventive measures and guidelines such as
blue code, septic survival campaigns and WHO recommendations on post-exposure prophylaxis has been
excellently dealt with. The book is an excellent eye-opener to all the emergency room myths.

702 Indian Journal of Pediatrics, Volume 73August, 2006