diagnosis and treatment of functional constipation in infants and children

Functional constipation is a common problem in children. Although some guidelines exist for management of childhood constipation (1) there are no such guidelines for Egyptian children.

Functional constipation constituted 30% of pediatric gastroenterology outpatient practice, 4-5% of all referrals to pediatric gastroenterology tertiary care centers and 0.8-1% of all pediatric cases in medical colleges (1).

Normal stool frequency is; <1-month age: 3-4 times/day; 1 month to 1-year age: 1.5-2 times/day; 1 to 2-year age: 1-2 times/day, mostly formed; older than 2-year age: 1 time/day. While constipation is a delay or difficulty in defecation sufficient to cause significant distress to the patient (3,4).

When the duration of constipation is less than 4 weeks, it is considered as acute constipation and when the duration is more, it is chronic constipation; in addition to two or more of the following criteria: (a) defecation frequency ≤2 times per week, (b) fecal incontinence ≥1 times per week after the acquisition of toileting skills, (c) history of excessive stool retention, (d) history of painful or hard bowel movements, (e) presence of a large mass in the rectum or on per abdomen examination, (f) history of large-diameter stools that may obstruct the toilet (7).

The term “Fecal Incontinence”, currently used instead of the terms soiling or encopresis, is defined as passage of stools in the undergarment and is classified as: (a) Constipation-associated fecal incontinence and (b) non-retentive fecal incontinence: diagnosed only if there is no constipation and normal anal sphincter tone, and symptoms last for more than 2 months in a child with a developmental age of ≥4 years (1).

The term “Refractory constipation” is defined as constipation not responding to optimal conventional treatment for at least 3 months, despite good compliance. These patients should be referred to a pediatric gastroenterologist for evaluation (2).

History and examination are relevant in making a diagnosis of constipation and differentiating functional and organic constipation as follows:  Dietary history; like intake of fruits and vegetables and refined foods (e.g., bakery), beverages etc. in older children, nature of feeds (breast vs top feeds) and details of supplementary feeds in younger babies, exclusive and prolonged milk intake with minimal solids in young infants, In addition to evidence of important precipitating factors of functional constipation;, (a) premature initiation of toilet training (normally toilet training should start not before 24 months in a developmentally normal child) (b) drugs and inter-current illnesses, (c) quick and abrupt transition of diet e.g. liquid to solid, breastfeeding to bottle feeding and (d) change in local environment (start of schooling) and psychosocial factors (3,5,6).

Characteristics of functional constipation in infants up to 4 years must include 2 or fewer defecations per week or 1 month of at least 2 of the following: (a) History of excessive stool retention, (b) History of painful or hard bowel movements, (c) History of large-diameter stools, (d) Presence of a large fecal mass in the rectum. While in toilet-trained children, the following additional criteria may be used: (a) At least 1 episode/week of incontinence after the acquisition of toileting skills, (b) History of large-diameter stools that may obstruct the toilet. Children greater than four years must have 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome: (a) 2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years, (b) At least 1 episode of fecal incontinence per week, (c) History of retentive posturing or excessive volitional stool retention, (d) History of painful or hard bowel movements, (e) Presence of a large fecal mass in the rectum, (f) History of large diameter stools that can obstruct the toilet (7).

Organic causes of constipation include; Abnormalities of the colon and rectum (e.g., chronic intestinal pseudoobstruction, anal stenosis, anal/colonic stricture, post NEC/IBD and ectopic anus), Neuropathic lesions (e.g., Hirschsprung disease and intestinal neuronal dysplasia), Spinal cord lesions (e.g., spina bifida, meningomyelocele,  sacral agenesis, tethered cord and tumors), Metabolic (e.g., hypothyroidism, hypo/hyper-calcemia, hypokalemia and uremia), Systemic disorders (e.g.,  celiac disease, cystic fibrosis and diabetes mellitus) and Drugs (e.g., analgesics, anticholinergics, iron, sympathomimetics, psychotropics, NSAIDs and antacids) (6 ).

The aim of this adapted clinical practice guideline (CPG) is to provide evidence-based recommendations for for diagnosis and treatment of functional constipation in infants and children.These recommendations were adapted from the relevant evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN: JPGN 2014;58: 258–274 CPG(s) using a formal methodology for CPG adaptation: the Adapted-ADAPTE.