Constipation in children is one of the most frequent complaints that a mother will express to her pediatrician. It is generally defined as lack of consistent stooling, bulky stools, or pain, with or without defecation. The Northern American Society of Gastroenterology, Hematology, and Nutrition defines constipation as a delay or difficulty in defecation that is present for two weeks or more. The incidence of constipation ranges from 0.7% to 29.6% worldwide and is a top ten complaint that pediatricians often evaluate.
Definition of constipation with symptoms > 2 weeks
1. Less than 3 bowel movements per week
2. Greater than 1 episode of fecal leakage weekly
3. Large bulky stool that cause rectal outlet obstruction
4. Child having withholding posture and behavior
5. Painful bowel movements.
The majority of children with constipation have functional constipation which accounts for 95% of all cases. Functional constipation is most commonly related to fecal retention as the child is trying to avoid unpleasant defecation. There are no physiological or anatomical reasons for constipation. The peak incidence occurs between 2 and 4 years of age when toilet training starts.
Several risk factors have been identified with constipation. Low consumption of dietary fiber is the leading cause along with increased body weight, reduced physical activity, lower parental educational level, positive family history, and psychological factors.
Red flags to differentiate functional constipation with organic constipation
1. Constipation starting extremely early in life (< 1 month) or family history of Hirschsprung dz. 2. Abdominal distention 3. Passage of meconium >48 hours
4. Ribbon stools or blood in the stools in the absence of anal fissures
5. Failure to thrive
7. Bilious vomiting
8. Lack of lumbosacral curve; pilonidal dimple covered by tuft hair
9. Midline pigmentary abnormalities of the lower spine; sacral dimple/agenesis
10. Anteriorly displaced anus
11. perianal fistula; perianal scars
12. abnormal position of anus/Patulus anus/flat buttocks
13. abnormal thyroid gland
14. tight, empty rectum in the presence of palpable abdominal fecal mass
15. absence of anal wink or cremesteric reflex
16. decreased lower extremity tone and/or strength/reflex