Constipation in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dushka Riaz, MD

Synonyms and keywords: Constipation in kids

Overview

Constipation in childhood is the delay or difficulty in passing stool for more than two weeks. It is one of the most common pathologies that presents to a pediatrician.

Historical Perspective

• [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
• In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
• In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

Classification

• Constipation in children may be classified according to [classification method] into two subtypes/groups:

• Functional - This is the most common type of constipation in children.
• Organic
• [group3]

• Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].

Pathophysiology

• The pathogenesis of constipation in children is most often characterized by painful stools causing the child to withhold to avoid the pain developing a vicious cycle of constipation. Withholding behavior causes the rectum to absorb and retain water from the fecum further creating a harder stool. The eventual defecation of the fecum is difficult and can create anal fissures exacerbating withholding behavior. Repeated accumulation of the fecum can result in dilation of the colon with a loss of sensation leading to slow transit time.
• On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Constipation in children may be caused by functional or organic causes.

• Functional causes include:
  • Fecal retention to avoid a painful stool
  • Developmental disorder component ie ADHD, Autism
  • Psychological
  • Genetic predisposition
  • Poor fiber intake, low fluid intake or malnutrition

• Organic causes include:
  • Neuromuscular disorders such as congenital megacolon, cerebral palsy, neurofibromatosis
  • Anatomic lesions such as gastroschisis
  • Systemic diseases such as cystic fibrosis, diabetes mellitus, hyper or hypothyroidism, Down syndrome
  • Drug exposure such as narcotics, codeine, antidepressants, and lead poisoning
  • Other causes such as cow's milk allergy or celiac disease

Differentiating Constipation in Children from other Diseases

Constipation must be differentiated from infantile dischezia, Hirschsprung’s disease,

• Infantile Dischezia is a pelvic floor dysfunction that results in diarrhea or constipation presenting in the neonatal period. It is caused by the child not being able to coordination the increased pressure in the abdomen with the relaxation of the pelvis. The disorder is self resolving as the child learns to muscle coordination and does not require any intervention.
• Hirschsprung's disease can present with difficulties in passing stool in the neonatal period because of colonic agangliosis. However Hirschsprung's disease would also present with bilious vomiting, refusal to feed, and fever caused by severe enterocolitis.

Epidemiology and Demographics

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [disease name].

• Constipation in children is more commonly observed among patients aged two to four years old because of the learning process of toilet training.

Gender

• [Disease name] affects men and women equally.

• [Gender 1] are more commonly affected with [disease name] than [gender 2].
• The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

• There is no racial predilection for [disease name].

• [Disease name] usually affects individuals of the [race 1] race.
• [Race 2] individuals are less likely to develop [disease name].

Risk Factors

• Common risk factors in the development of constipation in children are low fiber intake, stressful events such as bullying and familial changes, cow's milk protein allergy, sedentary lifestyle, low birth weight and consumption of processed foods.

Natural History, Complications and Prognosis

• The majority of patients with [disease name] remain asymptomatic for [duration/years].
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

• In the Paris Consensus Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met for more than 8 weeks:

• Less than 3 bowel movements per week
• More than one fecal leakage episode per week
• Rectal obstruction caused by large diameter stools
• Withholding behavior
• Painful defecation

• In the Rome III Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met; with children over four years old requiring to have the symptoms for a minimum of two months:

• Less than 2 bowel movements per week
• Fecal incontinence episode after achieving complete bowel control
• Rectal obstruction caused by large diameter stools
• Withholding behavior
• Painful defecation
• Large fecal mass seen in digital rectal examination

Symptoms

• [Disease name] is usually asymptomatic.
• Symptoms of [disease name] may include the following:

• [symptom 1]
• [symptom 2]
• [symptom 3]
• [symptom 4]
• [symptom 5]
• [symptom 6]

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].
• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

MRI may be helpful in the diagnosis of constipation in children. Findings on MRI suggestive of lumbosacral spine abnormalities may be helpful to identify neuropathic causes of dysfunction include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].