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LauraMerras-Salmio
PiaLehmusjärvi
PäiviPeldan
MichaelaNylund

Constipation in Children

Essentials

  • Symptoms of constipation typically begin at the age of 2-3 years.
  • History taking and careful clinical assessment are sufficient for diagnosing functional constipation.
  • Treatment must be started quickly with adequate doses of medication. Macrogols are safe to use even for several years. There is no risk of habituation because they do not affect the function of the intestinal wall.

Background

  • The global prevalence of functional constipation in childhood is about 10%.
  • Constipation places a significant burden on the child and the family: in addition to intestinal symptoms, there may be mental symptoms and even school problems.
  • As many as 50% of patients with constipation still have symptoms and need medication after 5 years.
  • Functional constipation may begin in infancy (after starting to eat pureed food) or at any other age.
  • First symptoms typically occur at the age of 2-3 years.

Symptoms of functional constipation

  • Defecation is difficult: it may be painful, or it may not be possible to empty the bowel despite attempts.
  • When needing to defecate, an infant, in particular, may assume an abnormal position (standing, unable to relax).
  • Stools may be hard (often lumpy) or there may be loose stools leaking past a hard faecal mass in the rectum.
  • Soiling (due to the said overflow)
  • Crampy abdominal pain
  • There may be bowel movements only 1-2 times a week, with huge amounts of stools passed at a time.

Diagnosis of functional constipation in a child

  • Careful clinical assessment (abdominal palpation, in particular) and careful history taking are usually quite sufficient.
    • Time of onset of the symptoms, frequency of bowel movements, stool consistency, pain, toilet behaviour, possible withholding of faeces, blood in stools or black stools, soiling or overflow diarrhoea, whether previously treated (and what treatment was used), familial predisposition, meal rhythm, eating and drinking
    • Passing of meconium as a neonate (abnormal after the age of48 h)
    • Growth data should always be checked.
  • No routine laboratory tests (such as tests for hypothyroidism, coeliac disease or hypercalcaemia) are recommended for children with no abnormality of growth or weight, and no other clinical finding or history (autoimmune diseases, calcium metabolism disorders or suspicion of these) at the time of diagnosis.
  • Digital examination may sometimes confirm the diagnosis (hard faecal mass in the rectum) but it is not necessary for diagnosis and there is no need to repeat it.
  • The anus and the surrounding area should be carefully inspected for any rash, marks of soiling, the location of the anus and exclusion of anal fissure. The skin and structural changes in the lower back and buttocks should also be assessed.
  • No imaging is recommended. In severe cases that are truly resistant to medication or if Hirschprung's disease is suspected, imaging and special examinations should be arranged through specialized care.
  • Allergy testing is not recommended. Reducing cow's milk in the diet by reducing the amount of milk drunk may alleviate constipation, particularly if large amounts of milk have been consumed. Complete elimination of milk is not recommended, and moderate milk intake (about 5 dl/day) should be gradually resumed while monitoring the response.
  • Infant dyschezia (in a baby < 4 months) without passage of solid stools is usually due to incoordination of the anal sphincters and will resolve spontaneously. Laxatives do not help, and rectal stimulation is not recommended as long-term treatment.

Need for further examination and referral for specialized care

  • Warning signs
    • Decreased relative weight or poor growth Normal and Abnormal Growth in Childhood
    • Vomiting
    • Abnormal-looking (taut, bulging) abdomen
    • Abnormal finding on palpation
      • In a slim child, a faecal mass due to constipation can often be clearly felt down on the left side on palpation. If this is the case, abdominal ultrasonography can be used for differential diagnosis also in primary health care.
    • Significant and/or recurrent rectal bleeding in the absence of a detected fissure
      • There may still be a fissure but a careful, experienced examiner is needed to detect it Anal Problems in Children.
      • The family should be told that rectal cancer is an adult disease and that children do not have haemorrhoids, either.
    • Abnormal finding in perianal examination: fistula openings, abnormal location or appearance of the anus, absent cremasteric reflex, oblique gluteal sulcus, perianal rash
  • Constipation in an infant less than 1 month of age should always be assessed in specialized care. Assessment in specialized care should often also be considered if an infant less than 4 months of age has severe or persistent symptoms.
  • Constipation that is resistant to medication (first make sure of compliance and that maximum doses have been used) or that causes significant psychosocial harm, as well as soiling should be assessed at a paediatric outpatient clinic. Depending on symptoms and findings, assessment by a child psychiatrist or a paediatric surgeon may also be necessary.

Treatment Behavioural and Cognitive Interventions for Defaecation Disorders in Children, Lactulose Versus Polyethylene Glycol for Chronic Constipation, Laxatives for the Management of Childhood Constipation

  • It is important to begin the treatment of constipation in a child quickly because a delay of more than 3 months from the onset of symptoms correlates with prolonged symptoms.
  • Normal intake of fibre and water and a normal amount of physical exercise are recommended for the treatment of constipation. It is useful to discuss and provide instructions for all of these.
  • Probiotics, biofeedback and behavioural therapy have not been shown to benefit the treatment of functional constipation in children.
  • Sugar-based (osmotic) drugs (macrogol, lactulose) should be the first choice. They are safe even in the long term because their effect is based on softening the faecal mass.
  • The efficacy of dietary sugar molecules (in prunes sorbitol, in malt extract barley-based carbohydrates) in the treatment of constipation in children has not been studied or compared with medication.
  • Babies typically develop constipation when starting to eat solid pureed food. Dietary modification by adding prune puree or juice, for example, to the diet may sometimes help. Changing the formula or drinking water in addition to the formula may sometimes help. In breastfed babies, in particular, stool frequency varies a lot: intervals may often be as long as 10 days, and this is fine as long as the stools are soft and the baby is feeling good. Defecation may be facilitated by (relaxation produced by) lower limb exercise and gentle abdominal massage.

Treatment of faecal impaction

  • See Table T1.
  • Polyethylene glycol (PEG, or macrogol) and enemas are equally effective but oral PEG is the primary choice in children. In severe cases, treatment started with enemas is more rapidly effective. Medication for emptying the bowel for colonoscopy can be used for child patients, too, according to the instructions given in the package.
  • In case of overflow diarrhoea, the most effective possible treatment should be started quickly to remove faecal impaction. During the first week, soiling may even become worse. Restoring the distended bowel to its normal tone will take several weeks.

Maintenance treatment of functional constipation

  • See Table T1.
  • PEG is more effective than lactulose, milk of magnesia or placebo. It is therefore recommended for maintenance treatment of functional constipation in children.
  • Lactulose is recommended if PEG products are not available or cannot be used.
  • Enemas do not improve the efficacy of maintenance treatment of ordinary functional constipation.
  • Milk of magnesia or stimulant laxatives (see below) can be considered as additional medication.
  • The child and the family should be instructed in a regular bowel movement schedule that is suitable for the family, as well as regular physical exercise and meal schedules. The defecation posture when sitting on the toilet seat or potty must be suitable for the child (feet on the ground or on a support). Rewarding at first just for sitting on the toilet seat or potty creates the right kind of a positive atmosphere.

Medicinal products and doses recommended for the treatment of constipation in children

Treatment of faecal impactionMaintenance treatment of constipation
PEG (macrogol)
  • 1.5 g/kg/day for 3-6 days
  • 0.5-1.0 g/kg once daily is the recommended initial dose to be subsequently adjusted according to response.
  • Additional medication should be considered if the dose is > 2 g/kg/day or > 36 g/day.
Lactulose 667 mg/ml-
  • 1.5-3 ml/kg once or twice daily; no more than 45 ml/day.
  • Can be given to children of any age. If full doses are used, consider additional medication or change of medication.
Enema with docusate sodium + sorbitol
  • Age > 1 year: 120 ml once or twice
  • Weight > 40 kg: 240 ml once or twice

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Products for emptying the bowel for colonoscopy
  • As instructed in the package (not if the patient is vomiting or in case of suspected obstruction)
-
Additional medication as necessary or for short-term treatment
Milk of magnesia-
  • 2-5 yrs: 0.4-1.2 g/day
  • 6-11 yrs: 1.2-2.4 g/day
  • 12-18 yrs: 2.4-4.8 g/day
Sodium picosulfate-
  • 3 months - 4 yrs: 2.5-10 mg once daily
  • 4-18 yrs: 2.5-20 mg once daily
Enema with sodium citrate dihydrate + sodium lauryl sulfoacetate
  • >3 yrs: 5 ml
  • <3 yrs: 2.5 ml
  • This drug is insufficient for the treatment of severe faecal impaction.

Duration of treatment

  • The treatment should continue for at least 2 months. There should have been no symptoms for at least 1 month before starting to gradually reduce the medication. If the child is only just learning to control the bowel, the treatment of constipation should not be interrupted until bowel control has been achieved.
  • Treatment can continue for several years, as necessary, because it is important to avoid the bowel getting used to constipation (PEG and lactulose will not change bowel function or cause dependence).

References

  • Tabbers MM, DiLorenzo C, Berger MY et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014;58(2):258-74. [PubMed]
  • Colombo JM, Wassom MC, Rosen JM. Constipation and Encopresis in Childhood. Pediatr Rev 2015;36(9):392-401; quiz 402. [PubMed]

Evidence Summaries ⬆