This podcast focuses on developing an approach to constipation in children. After listening to this podcast the learner should be able to: understand the pathophysiology of constipation in pediatric patients, differentiate between organic and functional constipation, diagnose functional constipation from history and physical exam using the Rome IV guidelines, and develop an approach to treating functional constipation. This episode was developed by Harrison Anzinger, a second-year medical student at the University of Alberta, in collaboration with Dr. Jason Silverman, a pediatric gastroenterologist at the Stollery Children’s Hospital and Assistant Professor at the University of Alberta.
All that follows is from the above script:
Constipation is commonly defined as the infrequent, difficult, painful, or incomplete evacuation of hard stools. (1) Constipation is a very common pediatric condition. It is estimated that 3% of visits to a paediatrician are in some way related to constipation and at least 25% of visits to a
pediatric gastroenterologist are due to problems associated with constipation. (2) However, many patients suffering from constipation do not seek medical assistance due to a misunderstanding of the condition. Symptoms can become chronic in up to a third of patients often due to delayed
diagnosis and suboptimal treatment. (3)
This podcast will focus on developing an approach to constipation in children.
You are working in a primary care clinic. You see that your next patient is Phil, a 5-year-old boy with no significant medical history. Phil’s mother explains to you that since starting kindergarten earlier in the year, he has been having progressively worse periodic abdominal pain. When he
has this pain he is cranky, refuses to eat, and has even vomited on a few occasions. She also explains that since starting school he has been having regular soiling accidents despite successfully potty training over a year ago. What could be causing these symptoms in a child like Phil? Could these symptoms be caused by constipation?
Constipation can be subdivided based on etiology into organic and functional constipation.
Organic constipation is caused by an underlying anatomical or physiological abnormality.
In contrast, functional constipation is constipation in the absence of an organic cause.
We will begin by talking about functional constipation, which is responsible for the vast majority of constipation cases in children. Functional constipation commonly results from painful bowel movements often leading to behavioural changes with children withholding feces. (1)
In summary, kids with functional constipation can present with hard infrequent stools. However, they can also have small daily stools, overflow diarrhea, fecal incontinence, and rectal bleeding! These symptoms can make the diagnosis of functional constipation quite challenging, and it is often missed.
While the majority of cases of constipation are functional, it is critical to consider organic causes of constipation. While rare, due to the possibility of serious underlying disease, an organic
cause should be considered for all patients presenting with constipation. Any underlying pathophysiology that reduces or prevents the movement of feces through the colon can lead to
However, it’s important to understand that organic constipation should be considered on your differential and may present with a diverse set of signs and symptoms. We will now briefly discuss several of the more common causes of organic constipation and the red flag signs and symptoms they may present with.
• Firstly, is Hirschsprung disease, which is caused by a congenital absence of ganglioncells in the distal rectum, preventing the rectum from relaxing. Hirschsprung often
presents as failure to pass meconium within 48 hours of life. Hirschsprung disease should be considered in constipated children younger than 1 month, or if there is a
• Next, we have Hypothyroidism can be congenital or acquired. It can present with a goiter, fatigue and poor growth, in additional to constipation.
• Celiac Disease is an autoimmune enteropathy caused by gluten exposure. It may present with abdominal pain, failure to thrive (FTT), and other GI symptoms such as
vomiting, abdominal distention and anorexia. Celiac disease should also be considered if there is a family history.
• Next, Cystic Fibrosis is a complex multisystem disease of chloride transporters. It can presents with respiratory symptoms and GI symptoms such as failure to thrive,
malabsorption and meconium ileus.
• Spinal cord anomalies such as spina bifida or tethered cord can impair the neurologic supply to the bowels. They may have other associated findings such as spasticity of
the lower limbs, hyperreflexia or gait changes.
• Furthermore, Anorectal malformations such as imperforate anus or anal stenosis can cause constipation. These can often be seen on anorectal inspection. Anal stenosis may also present as thin, ribbon like stools.
• Lastly, several classes of drugs, such as opioids, antacids, antihypertensives, anticholinergic, and antidepressants are associated with constipation. (6)
Now that we understand the underlying pathophysiology of functional constipation, and areaware of several organic etiologies, we will move on to developing an approach to the history and physical exam.
The diagnosis of functional constipation is based on the Rome IV criteria, and can be made based on history and physical exam alone as long as no organic etiologies are suspected.
To meet the Rome IV criteria, a child must meet 2 or more of the criteria at least once per week for at least one month. Furthermore, children with a developmental age greater than 4 must meet insufficient criteria for irritable bowel disorder.
The Rome IV criteria are as follows:
1. 2 or fewer defecations per week
2. History of retentive posturing or excessive stool retention
3. History of painful or hard bowel movements
4. Presence of large fecal mass in the rectum (fecal impaction)
5. History of large diameter stools that may obstruct the toilet if toilet trained.
6. At least 1 episode of incontinence per week after the acquisition of toileting skills
7. Lastly, after an appropriate evaluation, the patient symptoms must not be fully explained by another medical condition (5,7)
Use the Bristol Stool Chart to help parents and patients describe the stool. See The Bristol Stool Chart For The Evaluation Of Constipation With Additional Resources
Posted on June 2, 2019 by Tom Wade MD.
Be sure to review red flag symptoms such as passage of meconium in the first 48 hours of life, failure to thrive, poor growth, blood in the stools, perianal abnormalities and neurologic symptoms.
Children with functional constipation typically appear generally well. The are growing normally, and other than the possible presence of a palpable fecal mass, have few outward signs.
Therefore, a complete physical exam is important primarily to identify red flags indicating an
In the absence of red flags, functional constipation is typically diagnosed on history and physical exam alone. (1,9) While historically abdominal X-rays were used to assist in diagnosis of
functional constipation, they are of low diagnostic accuracy and have little evidence to justify their use. (8)
[Treatment of Functional Constipation]
Let’s take a minute and go back to our case. Phil’s mother tells you that Phil has been passing small rabbit-pellet feces after straining most days, and liquid stools several times per week
She mentions that Phil is very uncomfortable when he has his stomach pains. He often sits crossing his legs, and sometimes sits on his heels and rocks back and forth. Aha! you think…Sounds like retentive posturing!
You pull out your handy Bristol stool chart and Phil begins laughing hysterically. When asked about what his current stools look like he enthusiastically points at type 1 and type 6, and his
mother rolling her eyes confirms.
Phil tells you it hurts when he goes to the bathroom. He also says he hates using the toilet at school with all his friends around.
The physical exam is mostly unremarkable, and you notice no red flags suggesting organic constipation. Phil has been growing and gaining weight steadily and appears well. You do
appreciate a mass inferior to his umbilicus upon abdominal palpation. You note that Phil’s spine and anus appear normal and no neurological deficits appear to be present. Phil’s mother
confirms that they have no family history of gastrointestinal disorders other than constipation.
Phil is on no medication. After synthesizing these findings, you believe that the most likely diagnosis for Phil is functional constipation.
After confirming with your preceptor, you let Phil’s mother know that you believe Phil is constipated.
“That can do this to you doctor? How do we fix it! I can’t keep up with the laundry, it’s driving me mad!”
[Goals of Treatment]