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The Light is an initiative by the Sri Lanka College of Paediatricians aimed at advancing paediatric knowledge in Sri Lanka, benefiting both healthcare professionals and the general public.44/1, Gnanartha Pradeepa Mawatha, Last Modified March 26th, 2025
INTRODUCTION
Constipation refers to the difficulty in having regular and comfortable bowel movements. Various definitions of childhood constipation exist in the scientific literature, ranging from straightforward explanations, like trouble passing stools, to more complex descriptions. This variation in definitions has led to inconsistent data, confusing healthcare professionals, researchers, and the public. To address this issue, a clear and universally accepted definition was needed to facilitate scientific research and the everyday management of children. As a result, a group of clinicians and researchers in gastroenterology developed the Rome criteria to define all functional gastrointestinal disorders, including constipation. There have been four iterations of the Rome criteria for functional constipation in children, and its latest, the Rome IV criteria, are given in box 1.0. It defines constipation using multiple criteria.
| Diagnostic criteria must include at least 2 of the following features of constipation for a minimum of 1 month, occurring at least once per week in a child with a developmental age of at least four years, with insufficient criteria to diagnose irritable bowel syndrome. |
| Two or fever defecations in the toilet per week |
| History of retentive posturing or excessive volitional stool retention |
| History of painful or hard bowel movements |
| The presence of a large fecal mass in the rectum |
| History of large-diameter stools, which may obstruct the toilet |
| After appropriate evaluation, the fecal incontinence cannot be explained by another medical condition |
Box 1.0: Rome IV criteria for functional constipation in children
Types of Constipation in Children
a) Functional constipation (Normal-transit constipation)
Functional constipation is the most common type in children, making up 95% of cases.
b) Slow transit constipation (STC)
Slow transit constipation is a condition where the movement of stool through the colon is prolonged. Typically, the colon contracts in a rhythmic way to push waste material toward the rectum for elimination. The exact cause of slow transit constipation (STC) is poorly understood.
c) Constipation due to rectal evacuation disorders
Stool evacuation requires coordinated activity between increasing intrarectal pressure with relaxation of the anal sphincter complex and the pelvic floor muscles. When the coordination is dysfunctional between the abdominal, pelvic floor, and rectal muscles, it is difficult to evacuate stools, leading to rectal evacuation disorders.
PATHOPHYSIOLOGY
The primary cause of constipation in young children is stool withholding due to the fear of passing hard stools, which can be painful. Factors that may lead to this first painful experience include minor illnesses requiring bed rest, trauma, dietary changes, or postponing defecation while distracted. Hard stools can damage the fragile anal canal lining, inducing significant pain and prompting children to withhold stools. The large intestine absorbs water from retained stools, making them drier and harder, leading to larger fecal masses. When children eventually pass these masses, the pain worsens, creating a vicious cycle of pain, and withholding those results in severe constipation.
Younger children can occasionally have motility issues in the large intestine, which affect their ability to move stool toward the lower bowel. These disorders may result from various diseases impacting nerve cells and muscles in the intestine, causing stool stasis and constipation.
In older children, constipation can result from various factors. A common cause is intentionally delaying bathroom visits due to being engaged in activities or feeling too lazy. Over time, this habit can lead to constipation.
More complex medical reasons for constipation in this age group include:
CLINICAL PRESENTATION
In addition to the features mentioned in the Rome IV criteria (Box 1.0), other factors that suggest constipation are listed below.
Alarming/red flag symptoms and signs of Constipation
Constipation is usually a straightforward condition that can be easily diagnosed using the Rome Criteria. However, it can be a feature of a more serious underlying health problem in some children. The features listed in Box 3.0 guide what to watch out for and when to take constipation more seriously.
MANAGEMENT
Investigations
Current evidence does not support the routine investigations below to diagnose functional constipation. However, if a patient has any alarming symptoms or refractory constipation, some of the tests can be performed to exclude organic causes.
Treatment
Non-pharmacological interventions
1.Education of the parents
Parents should be clearly informed about the benign nature and common pathophysiological mechanisms of functional constipation. Any precipitating factors identified should be eliminated or modified by appropriate advice (e.g., in a child with exclusive milk feeding, (semi) solid diet supplementation should be instituted; drugs causing constipation should be stopped; any psychosocial factor operating needs to be addressed).
2. Toilet training
Most children show readiness to begin training between 18 months and three years. However, some children might not be fully toilet-trained until closer to 4 years old, and that’s perfectly normal.
Toilet training plays a crucial role in treating young children with constipation. It had been shown as a valuable adjunct therapy to laxatives.
Successful toilet training requires patience, consistency, and a supportive environment. Maintaining a routine, such as taking the child to the toilet after each main meal, is essential. Positive reinforcement should be used, and it’s crucial to avoid punishments.
3. Diet, fiber, and water intake
Although a low-fibre diet is a known risk factor for functional constipation, several trials have failed to show the benefits of a high-fibre diet in alleviating symptoms of constipation. Therefore, it is best to recommend consuming the standard daily fiber requirement (0.5 grams per kilogram of body weight). A fiber-rich diet, including cereals, whole pulses, vegetables, salads, and fruits, is recommended to improve dietary fiber intake when deficient. Although commonly believed, increasing physical activity does not help improve bowel movement.
Pharmacological Interventions for constipation in children
It consists of an initial phase of disimpaction in patients with fecal impaction and a maintenance phase with laxatives.
1. Fecal disimpaction
This implies clearing the colon and removing any hard fecal matter. After this, maintenance laxative therapy can help prevent stool retention and restore the normal size and tone of the rectum, which is essential for proper stool expulsion. Both polyethylene glycol (PEG) and enemas effectively disimpact faeces.
DISIMPACTION REGIMEN | ||
| 1st line (Home) | Child <1yr: 0.5-1 sachet daily Child 1-5yrs: Day 1: 2 sachets, Days 2 & 3: 4 sachets daily, Days 4 & 5: 6 sachets daily, then 8 sachets daily Child 5- 12 yrs: Day 1: 4 sachets, then increase in steps of 2 sachets daily to a maximum of 12 sachets daily Child 12- 18 yrs: [Use adult formula Macrogol 3350] Day 1: 4 sachets increased in steps of 2 sachets daily to a maximum of 8 sachets. | |
| *All children undergoing disimpaction should be reviewed within a week. *Add a stimulant laxative if Movicol does not lead to disimpaction after 2 weeks *Substitute a stimulant laxative alone or in combination with lactulose if polyethylene glycol is not tolerated. *As a guide, the starting maintenance dose might be half the disimpaction dose | ||
| 2nd line (Hospital) | Kleanprep (macrogol 3350) Orally or via NG tube In all ages, start with 10ml/kg for the first 30 minutes, then: Age 1-5 years: 200mls/ hour, max 2L in 24 hours Age 6-10 years: 300mls/ hour, max 3L in 24 hours Age 11 and upwards: 400mls/ hour, max 4L in 24 hours Phosphate enema Once per day for 3 to 6 days if PEG is not available. E.g. Sodium phosphate 2–18 y: 2.5 mL/kg, max 133 mL/dose | |
2. Maintenance therapy
There are different classes of laxatives are used to relieve constipation. They work by softening hard stools, increasing the bulk of the stool, or stimulating bowel movements.
There are four main types:
| Type of laxative | Name | Dose | Side effects | comments |
| Osmotic laxative | Polyethylene Glycol | 0.5-1g/kg /day >1 year of age | Bloating Abdominal pain/cramps Vomiting Loose stools | Safe for both short and long-term use |
| Lactulose | 2.5 ml BD: 1-12 mo 2.5-10 ml BD: 1-5 yrs 5-20 ml BD: 5-18 yrs | Abdominal distension/discomfort | Lactulose undergoes fermentation in the colon | |
| Stimulantlaxative | Bisacodyl | 5 mg/day: 3-10 yrs 5-10mg/day > 10 yrs | ||
| Sodium Picosulphate | 2.5-10mg/day: 1mo-4yrs 2.5-20mg/day: 4-18 yrs |
Maintenance Therapy
| 1st line Polyethylene Glycol 3350+Electrolytes (Movicol) | Child <1yr: 0.5-1 sachet daily Child 1-5yrs: Day 1: 2 sachets, Days 2&3: 4 sachets daily, Days 4&5: 6 sachets daily, then 8 sachets daily Child 5- 12 yrs: Day 1: 4 sachets, then increase in steps of 2 sachets daily to a maximum of 12 sachets daily Child 12- 18 yrs: [Use adult formula Macrogol 3350] Day 1: 4 sachets increased in steps of 2 sachets daily to a maximum of 8 sachets. |
| *Adjust the dose according to the response. *Add a stimulant laxative if Movicol does not work. *Continue for several weeks after regular bowel habit is established: this may take several months. * Children who are not toilet-trained should remain on laxatives until toilet training is well established. * Do not stop medication abruptly: gradually reduce the dose over months. * Some children may require laxative therapy for several years. A minority may require ongoing laxative therapy. | |
Indications to refer to a specialist in Gastroenterology
References
1. 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):258-274. doi:10.1097/MPG.0000000000000266.
2. Yachha SK, Srivastava A, Mohan N, et al. Management of Childhood Functional Constipation: Consensus Practice Guidelines of Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition and Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics. Indian Pediatr. 2018;55(10):885-892.
3. Management guideline of Childhood, Oxford University Hospitals, NHS Foundation Trust, United Kingdom.
Authors:
Dr. Wathsala Hathagoda
Prof. Shaman Rajindrajith