Indian J Pediatr (December 2013) 80(12):1021–1025
DOI 10.1007/s12098-013-1133-5
PEDIATRICS IN GENERAL PRACTICE
Guest Editor: Bhim S. Pandhi
Chronic Constipation
Jaya Agarwal
Received: 23 April 2013 / Accepted: 10 June 2013 / Published online: 14 August 2013
# Dr. K C Chaudhuri Foundation 2013
Abstract The lack of information about management of
chronic constipation in children amidst general physicians
has necessitated this review. A literature search in PubMed
was conducted with regard to epidemiology, clinical fea-
tures, investigation and management of chronic constipation
in children. English language studies published over the last
20 y were considered and relevant information was extracted.
Constipation is a common problem among children; the
commonest cause is functional (95 %). An elaborate history
and thorough physical examination are only essential things
required to make a diagnosis of functional constipation. Man-
agement consists of disimpaction, followed by maintenance
therapy with oral laxative, dietary modification and toilet
training. A regular follow-up with slow tapering of laxative
is the must for effective treatment. Early withdrawal of laxa-
tive is the commonest cause of recurrence.
Keywords Functional constipation . Oral laxatives
Introduction
Childhood constipation is a common problem. It accounts for
3 % of visits to general pediatric clinics and as many as 30 %
of visits to pediatric gastroenterologists in western countries
[1]. As per North American Society of Pediatric Gastroenter-
ology Hepatology and Nutrition (NASPGHAN) criteria, it is
defined as a delay or difficulty in defecation, present for ≥2 wk
and sufficient to cause significant distress to the patient [2].
The normal frequency of bowel movements varies with age,
J. Agarwal (*)
Division of Pediatric Gastroenterology, Department of Medical
Gastroenterology, Asian Institute of Gastroenterology,
Hyderabad, Andhra Pradesh 500082, India
e-mail: drjaya.agarwal@gmail.com
but if stools are soft and passage is painless then it cannot be
termed as constipation.
Prevalence
The worldwide prevalence of functional constipation in chil-
dren varies from 0.7 % to 29.6 % [3, 4]. The exact burden of
this problem in Indian context is not known. Nonetheless it is
a frequent presenting complaint of substantial number of pa-
tients in any pediatric or general physician outpatient clinic.
Encopresis or soiling which is the involuntary leakage of feces
into the undergarments may be an indication of constipation. An
epidemiological study in Sri Lanka reported that fecal inconti-
nence occurred in 2 % of the general pediatric population, of
which 82 % was associated with constipation [5].
Etiology
It is estimated that in more than 95 % of cases constipation is
functional in nature, while only 5 % or less have organic cause
in children [1, 3]. A recent study from Lucknow has clearly
shown that 85 % of children visiting tertiary care hospital with
complaints of constipation had functional constipation as eti-
ology [6]. However if presentation is in neonatal period,
organic causes like Hirschprung disease and hypothyroidism
should be looked for. Common causes of constipation in
children are listed in Table 1.
Pathogenesis
Fecal continence is maintained by involuntary muscles, inter-
nal anal sphincter and voluntary muscle contractions in peri-
neum. The external anal sphincter is under voluntary control.
The urge to defecate is triggered when stool comes in lower
1022
Table 1 Etiology of constipation
Acquired Congenital
1. Functional (95 %) 1. Hirschsprung’s disease
2. Anal lesions: Pelvic mass 2. Anorectal defects: Anteriorly
placed anus, anal stenosis
3. Neurologic conditions: Cerebral 3. Neurogenic: Spinal cord
palsy, autism (Tethered cord,
myelomeningocoele)
4. Endocrine: Hypothyroidism,
diabetes insipidus, diabetes
mellitus, hypercalcemia
5. Drug induced: Opiates,
anticholinergic, phenobarbitone,
vincristine, lead, antispasmodics
rectum. If a child doesn’t want to defecate, he or she tightens
the external anal sphincter and squeezes the gluteal muscle
pushing feces higher in the rectal vault and reduce the urge to
defecate. In response to the urge, they refuse to sit on the toilet,
rise on their toes, cross their legs, scream and turn red. These
actions are termed as withholding manoeuvre which parents
mistake as an attempt to defecate. The longer that feces remain
in the rectum, the harder it becomes due to continued absorp-
tion of water. Passage of a hard or large stool may cause a
painful anal fissure. The cycle of avoiding bowel movements
because of a fear of painful defecation may progress to stool
retention and infrequent bowel movements, a condition that
is termed functional constipation. With prolonged duration
of constipation, liquid stool from the proximal colon may
percolate around hard retained stool and pass per rectum
involuntarily called as encopresis or fecal soiling.
Evaluation
A detailed history and thorough clinical examination is must
for making correct diagnosis about etiology of constipation.
In history, emphasis should be to ask about history of
delayed meconium passage, onset of constipation, withhold-
ing maneuvers, encopresis if any, dietary and medication
history (esp. antispasmodics, codeine containing cough
preparations).
Examination should include anthropometry by plotting on
growth chart to look for any growth failure, abdominal
examination for distension or palpable fecal mass, anal in-
spection for position, anal wink, soiling and fissure and per
rectal examination for fecal impaction, sphincter tone, and
gush of stool on withdrawal of finger. One shouldn’t forget
to see back and spine for any meningomyelocele, tuft of hair
and do complete neurological examination. Presence of any
of the red flags as shown in Table 2 should raise suspicion for
organic cause of constipation and need for further workup.
Indian J Pediatr (December 2013) 80(12):1021–1025
Table 2 Red flags on history and examination
• Delayed passage of meconium (>48 h)
• Failure to thrive
• Absence of withholding maneuvers
• Bladder dysfunction
• Empty rectal ampulla on P/R examination
• Abnormal neurological examination
Laboratory and Radiological Investigations
In a classic case of functional constipation with no red flags
(Table 2), no investigations are required to make a diagnosis. At
times ultrasound abdomen or X-ray abdomen can be done to
see fecal impaction. Barium enema should be asked only when
suspicion for Hirschprung’s is high to avoid unnecessary radi-
ation exposure (Table 3). Anorectal manometry is a non-
invasive, safe tool to demonstrate the presence of the recto–anal
inhibitory reflex, which is absent in children with Hirschprung
disease. Thyroid profile should be done to exclude hypothy-
roidism in an infant presenting with constipation and delayed
milestones or prolonged unconjugated hyperbilirubinemia.
Management
Treatment of childhood functional constipation consists of a
four-step approach involving education (pathophysiology of
constipation and the necessity of long-term treatment),
disimpaction, prevention of re-accumulation of feces by
maintenance therapy and behavioral therapy. Long-term
follow-up is important for treatment success.
Counseling consists of detailed explanation about the
problem with a diagram and need for prolonged treatment.
Behavioral therapy is advise on toilet training i.e., regular
sitting in toilet (~5 min after major meals even when no result),
unhurried time on the toilet for initial months (after 2–3 y of age)
should be stressed upon. Keep diary of stool frequency, consis-
tency, pain, soiling, laxative dose. Reward system (positive re-
Table 3 Salient differences between functional constipation and
Hirschprung’s disease (HD)
Features Functional Hirschprung’s
constipation disease
H/o delayed meconium No Common
passage at birth
Onset 1–2 y of age Since birth
Encopresis Common None
Growth failure No Common
Per rectal examination Fecoliths or stool Empty
Indian J Pediatr (December 2013) 80(12):1021–1025 1023

enforcement) may help in some cases. Reinforcement of spon-
taneous use of the toilet and keeping clean underwear should be
done. Persistent use of diapers delays toilet training.
Diet modification means increased intake of fluids and
absorbable and non-absorbable carbohydrate. Ideal fiber in-
take is age in years + 5 g. High fiber diet includes whole grains,
whole pulses/beans, green leafy vegetables, fruits like guava,
pomegranate, dates, amla, apple with peel. One should avoid
fine wheat flour (maida) and its products like noodles, vermi-
celli, bakery products and predominantly milk-based diet.
Pharmacological therapy consists of disimpaction and
maintenance laxative therapy. Drugs commonly used are
listed in Table 4.
Disimpaction should be done if fecoliths are palpable per
rectally or felt on abdominal examination. It can be done by
either oral or rectal route. Oral route is preferred as it’s nonin-
vasive while rectal route is invasive and adds to fear of the
child. According to results from a prospective trial, rectal
enema treatment and oral laxative treatment are equivalent as
first-line therapy in children with rectal fecal impaction [7]. For
oral disimpaction Polyethylene glycol with or without electro-
lytes is given at dose of 25 mL/kg/h upto 1,000 mL/h until clear
colonic content is evacuated or given as 1–1.5 g/kg/d over 4 h/d
for 3 d as home disimpaction. Ryle’s tube may be required for
administration in small children. Single dose of prokinetic i.e.,
5 to 10 mg of metoclopramide by mouth 15 to 30 min before
the lavage can be given to prevent nausea and vomiting.
Disimpaction by enema should be resorted to only in few
cases with no response to oral route. Phosphate enema
(proctoclysis) is better than normal saline enema. For infants,
glycerine suppositories should be used for disimpaction.
Maintenance treatment besides regular of laxatives, high
fibre diet and toilet training are essential component to
prevent accumulation of feces in rectum. Options for laxa-
tives with their doses are given in Table 4. A recent Cochrane
review concluded that in children with constipation, PEG is
superior to lactulose for the outcomes of stool frequency per
week, form of stool, relief of abdominal pain and the need for
additional products [8]. Few things to be kept in mind are
titrate dose according to response, correct dose is the one that
produces at least one soft stool daily without any soiling.
Maintain initial “correct dose” for minimum of 3–4 mo and
thereafter attempt gradual tapering. Follow up at 2 wk after
disimpaction and then monthly till regular bowel movement
is achieved. Check stool frequency and compliance to drug
and toilet training. Therapy is required for long duration,
6 mo to 1 y in majority. Rescue treatment with stimulants
(senna, bisacodyl) may be required for a short course in
refractory cases but it’s contraindicated in infants. Follow-
up is essential after stopping drug therapy as relapses are
common. An algorithm for management is given in Fig. 1.
Outcome
In a systematic review, treatment success was achieved in
60 % (± laxative use) at 1 y of therapy and 56±11.3 %
recovered and were off laxatives at 5–10 y of follow up [9].

Table 4 List of laxatives—dosage and side effects

Drug Class Dose Side effects

Polyethylene glycol Osmotic laxative For disimpaction: Dissolve 1 pack in Nausea, bloating, cramps, vomiting
(PEG 3350 and PEG 4000) 2 L of water then @ 20 mL/kg/h max
1 L/h total 4–5 L
Maintenance dose 0.2–0.8 g/kg/d
Lactulose Osmotic laxative 1–3 mL/kg/dose in 2–3 doses Bloating, abdominal distension
Lactitol Osmotic laxative 1–3 mL/kg/dose in 2–3 doses Bloating
Magnesium hydroxide Osmotic laxative 1–3 mL/kg in 1–2 divided doses Abdominal distension, hyper magnesemia, metallic
taste. Avoid in patient with renal failure
Docusate sodium Lubricant 100–400 mg in divided doses Cramps, abdominal pain
Mineral oil Lubricant 1–3 mL/kg/d once daily or in divided dose Not for infants
Lipoid pneumonia if aspirated
Bisacodyl Stimulant <2 y: 5 mg suppository Abdominal pain, diarrhea
5 mg/10 mg tab ≥2 y: 10 mg suppository
5 mg suppository >6 y: 1–2 oral tablets (5 mg)
Senna Stimulant 2–4 y: 3.75–15 mg/d Abdominal pain, skin rash and fixed drug eruption rarely
Tab 12 mg 4–6 y: 3.75–30 mg/d
6–18 y: 7.5–30 mg/d
Sodium picosulfate Stimulant <4 y: 2.5–10 mg once a day Abdominal cramps, diarrhea
Tab 10 mg 4–18 y: 2.5–20 mg once a day
Syp 5 mg/5 mL
1024 Indian J Pediatr (December 2013) 80(12):1021–1025

Fig. 1 Approach to a case of

Chronic constipation
chronic constipation

History and physical examination

Are there any Red Flags?

No Yes

Functional constipation Evaluate further

Assess fecal impaction

No

Disimpact Maintenance Dietary advise

laxative therapy Toilet training

In follow-up, check for effectiveness:

- Response and compliance
- Dose titration
- Recurrence of impaction

No Yes

Organic etiology?
Gradual weaning
Specialized tests

Stop medication
Follow-up

However constipation persisted in nearly 30 % into adulthood
[10]. Early withdrawal of laxative is the commonest cause of
recurrence. Other common reasons of therapy failure are fixed
dose laxative therapy, with no disimpaction done at start or no
explanation of behavioral therapy [11].
Conclusions
Chronic constipation is a common problem. Majority of
childhood constipation is functional. Detailed history,
examination and counseling are crucial in management.
It requires prolonged tailored therapy and follow-up.
Presence of red flags and non-response despite adequate
treatment and good compliance suggests need for further
investigations.
Conflict of Interest None.
Role of Funding Source None.
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