Version May 2024
INTRODUCTION — Constipation is a common problem throughout childhood and is often accepted as a normal variation that will resolve as children get older. The opportunity for early intervention is often missed and may result in complications, such as anal fissure, stool withholding, and fecal incontinence (also known as encopresis). The prevention of constipation focuses on timely anticipatory guidance regarding diet, toilet training, and toileting behaviors. The treatment of constipation depends upon the age of the child and the duration of symptoms. It may involve education, dietary changes, behavior changes, and pharmacotherapy, alone or in combination [1,2].
In clinical practice, it is useful to distinguish between relatively recent-onset constipation compared with that of longer duration of symptoms. Therefore, we will focus this topic review on recent-onset constipation (eg, symptoms present for fewer than eight weeks).
Evaluation and management of children who have persistent or frequently recurrent symptoms of constipation (eg, symptoms for several months) is described separately:
●(See "Constipation in infants and children: Evaluation".)
●(See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis".)
DEFINITIONS
Constipation — Constipation is a disorder in which a child passes infrequent bowel movements (two or fewer per week), has painful defecation, or passes large-caliber and hard stools that may require excessive straining.
Functional constipation — Functional constipation describes persistently difficult, infrequent, or seemingly incomplete defecation without evidence of a primary anatomic or neurologic cause. This definition is operationalized by the "Rome IV" diagnostic criteria, which require at least two of six symptoms describing stool infrequency, hardness, and large size; fecal incontinence; or volitional stool retention for at least one month (table 1) [3,4]. Some children may have rectal impaction and overflow fecal incontinence, which typically develops because they have learned to withhold stool, usually to avoid pain during bowel movements. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis".)
Recent-onset versus chronic constipation — Although a diagnosis of functional constipation requires symptom duration of at least one month, there is no other consensus definition to categorize constipation based on duration. However, in clinical practice, it is useful to distinguish between patients with new-onset constipation compared with those having a longer duration of symptoms:
●Recent-onset constipation – We consider constipation to be "recent-onset" if symptoms have been present for eight weeks or less. These children often respond to a short-term intervention, such as administration of laxatives for several days or weeks, or a brief behavioral intervention, as described in the remainder of this topic review.
●Chronic constipation – We consider constipation to be chronic if symptoms have been present for three months or more, which may include multiple episodes of symptoms. These children typically require longer treatment with laxatives and more intensive and sustained behavioral support. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)
These categories are simply tools to guide clinical practice. They are not mutually exclusive, since those with recent-onset constipation may eventually evolve into a chronic case requiring longstanding management. These categories may not capture patients with either intermittent or intermediate duration of symptoms. For many patients, the chronicity of the constipation only becomes clear during the course of ongoing evaluation and management.
PREVENTION AND MONITORING — Discussion of dietary and bowel habits should be part of routine health supervision visits for children of all ages. In particular, anticipatory guidance and supervision should be focused on the developmental stages when constipation is most likely to occur [5,6]:
●Introduction of solid foods or cow's milk
●Toilet training
●School entry
If the parent(s)/caregivers are given appropriate and timely education, these episodes may be anticipated and prevented or, if not prevented, quickly treated with temporary interventions. Complaints of simple constipation should not be ignored. Painful bowel movements can lead to withholding of stool [7], worsening constipation, and eventual fecal impaction and fecal incontinence. This progression often occurs insidiously, so the caregiver may be unaware of the problem.
The pathogenesis of constipation in each of these contexts is summarized briefly below since it is relevant to the provision of anticipatory guidance. This is reviewed in more detail elsewhere. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)
Transition to solid diet or introduction of cow's milk — As an infant transitions to a solid diet, caregivers should be vigilant for signs of constipation. Constipation tends to develop in this context because the transitional diet often includes inadequate amounts of fiber and fluid [8]. In some infants, cow's milk or anal fissures contribute to the problem [9]. For prevention and initial treatment of mild constipation, ensuring adequate fiber and fluid intake may be helpful. By contrast, there is little evidence that adding liquid or fiber in excess of the recommended amount to the diet is effective in treating severe chronic constipation. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)
●Fiber – For infants and children younger than two years, a reasonable goal for fiber intake is approximately 5 grams/day. This can be accomplished by providing several servings daily of pureed vegetables, fruits, and a fiber-containing infant cereal. Most vegetables and fruits supply approximately 1 gram of fiber per serving, but prunes and peas can supply up to 2 g. Rice infant cereal supplies a negligible amount of fiber, whereas whole wheat, barley, and multigrain cereals supply 1 to 2 grams per serving [10]. (See "Dietary recommendations for toddlers and preschool and school-age children", section on 'Fiber'.)
●Fluid intake – There is no need to increase fluid intake beyond maintenance requirements, unless there is evidence that the child is dehydrated. However, it is reasonable to ensure that maintenance fluid requirements are met (see "Maintenance intravenous fluid therapy in children"). The minimum daily fluid intake depends upon the child's weight. As examples:
•5 kg infant – 16 fluid ounces (500 mL) daily
•10 kg child – 32 ounces (960 mL) daily
•15 kg child – 42 ounces (1260 mL) daily
•20 kg child – 50 ounces (1500 mL) daily
●Cow's milk – For some infants and toddlers, transitioning from breast milk or formula to cow's milk also appears to trigger constipation, although this association has not been firmly established. If the development of constipation is temporally associated with transition to cow's milk, it is reasonable to do a two-week trial of a cow's milk-free diet (by substituting soy-based transition formula or calcium-fortified soy milk). If the symptoms improve, continue the milk-free diet for 6 to 12 months, then reintroduce cow's milk. Cow's milk also appears to play a role in constipation in some older children 6 to 12 years of age, especially those with atopic manifestations and perianal fissures [9,11]. The diet of these children should also be reviewed to ensure that they are receiving adequate amounts of calcium and fiber. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Cow's milk intolerance'.)
●Anal fissures – Passage of large stool can cause anal fissures, which make defecation painful and can lead to stool-retentive or avoidance behavior, which may in turn lead to persistent or chronic symptoms. Anal fissures can also occasionally be caused by vigorous wiping of the anus during diaper changes.
Toilet training — When children are around toilet-training age, caregivers and clinicians should be vigilant for signs of developing constipation. Prevention and initial management of constipation in this age group involve taking a relaxed approach to toilet training, providing foot support for sitting on the toilet (for comfort and to relax the pelvic floor) (figure 1), ensuring adequate fiber intake, and avoiding excessive cow's milk in the diet. (See "Toilet training".)
These strategies address the common triggers of constipation in this age group, which are:
●Stool withholding – Toilet training may trigger constipation because toddlers may not respond to the need to defecate and/or because children using adult-sized toilets without foot support may not have sufficient leverage to successfully evacuate their stools. If stool passage is painful, toddlers may begin to withhold stool, compounding the problem and leading to a vicious cycle of withholding, which leads to larger and harder stools and more pain upon defecation. Once the withholding cycle has started, it can only be reversed by making the stools soft and passage of stools pain free. Preventive measures include delaying toilet training until the child shows signs of readiness and using a relaxed, "child-oriented" approach to toileting, in addition to the dietary measures described. If children show signs of stool withholding, it is often necessary to use short-term dietary interventions or laxatives and sometimes to hold off on toilet-training efforts. Anal fissures should be identified and treated. (See 'Toddlers and children' below and "Toilet training".)
●Inadequate fiber – For prevention of constipation, we suggest a goal for fiber intake equal to the child's age plus 5 to 10 g/day, as recommended by a consensus conference on dietary fiber in childhood [12]. This translates to between 7 and 15 grams of fiber daily for children two to five years of age. Giving more than this fiber goal has no proven benefit for the management of constipation in children [2]. The National Academy of Medicine recommends a somewhat higher goal for fiber intake: 14 g/1000 kcals in the diet [13], which translates to approximately 15 to 20 g/day in toddlers and young children. (See "Dietary recommendations for toddlers and preschool and school-age children", section on 'Fiber'.)
Of note, consumption of excessive amounts of fiber can increase the risk of fecal impaction in children with stool-withholding behaviors. Therefore, for children with stool withholding or a history of fecal impaction, extra fiber intake should be encouraged only after colorectal tone has been restored, eg, after several months of successful treatment with laxatives. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Dietary changes'.)
●Excessive cow's milk – The excessive consumption of whole cow's milk (>32 fluid ounces [960 mL] per day) can slow intestinal motility and satiate the child, thereby diminishing the intake of other fluids and foods that promote soft stools, such as water, fruits, and vegetables [14,15]. Milk intake of 24 ounces per day (720 mL) is sufficient to meet the daily calcium requirement of children between one and five years of age. (See "Dietary recommendations for toddlers and preschool and school-age children", section on 'Dairy products'.)
School entry — Transitioning to school can trigger constipation because of stool withholding if the child is reluctant to use the toilet at school or because the change in schedule interferes with toileting. Moreover, as children reach school age, they often use the bathroom by themselves and parents/caregivers may not be aware of the frequency or type of stools.
To avoid these problems, clinicians should encourage parents/caregivers to regularly ask about their child's bowel movements. The parents/caregivers also should be encouraged to monitor whether their child is holding back from or embarrassed about using the toilet at school. In addition, parents/caregivers should promote routine, unhurried time on the toilet after meals. Finally, continued attention to fiber intake may help (table 2A-C). The goal for fiber intake for a six-year-old child is 11 to 16 grams/day (based on the child's age plus 5 to 10 grams/day as recommended by the consensus conference on dietary fiber in childhood [12]). Giving more than this fiber goal has no proven benefit for management of constipation in children [2].
TREATMENT — When a child has signs or symptoms of constipation, even if it is of short duration (ie, less than two weeks), it is important to intervene promptly to prevent the cycle of stool withholding that can lead to worsening or recurrent or chronic constipation. The intervention should include a follow-up plan to ensure that the constipation has resolved and the child achieves an appropriate stooling pattern (ie, regular bowel movements and fecal continence if appropriate for the child's age).
Infants — Constipation that develops in infants after the neonatal period is typically triggered by dietary changes, such as the transition to solids or cow's milk. The constipation is likely to respond to dietary interventions, as discussed below, but, in many cases, the dietary change can be brief.
Assessment — Infants with severe or recurrent constipation, and especially those with symptoms since birth, should be carefully evaluated for possible organic causes. Alarm signs that suggest the possibility of an organic cause are summarized in the table (table 3). Evaluation of an infant with constipation is described separately. (See "Constipation in infants and children: Evaluation".)
Infant dyschezia is a common cause of constipation-like symptoms in young infants. "Dyschezia" describes ineffective defecation, manifested as straining in the absence of constipation. Infant dyschezia is defined as at least 10 minutes of straining and crying followed by successful or unsuccessful passage of soft stool in an otherwise healthy infant. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Infant dyschezia'.)
Recent-onset constipation — For recent-onset constipation in infants, interventions include:
●For infants who have not yet begun solid foods, recent-onset constipation can be treated by the addition of undigestible, osmotically active carbohydrates to the formula, titrating the dose to induce a daily bowel movement. One such option is the addition of sorbitol-containing juices (eg, apple, prune, or pear) as a short-term intervention. For infants four months and older, two to four ounces of 100 percent fruit juice per day is a reasonable starting dose. For infants younger than four months, a reasonable starting dose is one to two ounces of diluted prune juice (eg, approximately one ounce of juice mixed with one ounce of water). Alternatively, lactulose (approximately 1 mL/kg daily) can be added to the formula. Follow-up and counseling should be provided to avoid excessive juice intake after the episode of constipation has resolved due to potential adverse effects of juice on diet quality and subsequent weight gain, either inadequate or excessive [16]. (See "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'Foods to avoid and foods not to avoid'.)
●For infants who have begun solid foods, sorbitol-containing fruit purees can be used. To increase the fiber content of the infant's solid foods, multigrain or barley cereal may be substituted for rice cereal and pureed peas or prunes can be substituted for other pureed fruits and vegetables. Dark corn syrup has been used in the past. However, current preparations of dark corn syrup may or may not contain the glycoproteins that are fermented into osmotically active particles in the colon, so the syrup may be ineffective for treating constipation.
●Glycerin suppositories or rectal stimulation with a lubricated rectal thermometer can be used occasionally if there is very hard stool in the rectum. These interventions should not be used frequently, because tolerance may develop; in addition, glycerin may irritate the anus or rectal mucosa.
Infants with persistent constipation should be reevaluated because constipation that presents early in life carries a higher likelihood of an organic cause. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Differential diagnosis'.)
Nonresponse or relapse — Infants with additional episodes of constipation should be treated with the same dietary interventions as described above for recent-onset constipation. Those who do not respond may need additional measures to address fecal impaction. Glycerin suppositories or rectal stimulation with a lubricated rectal thermometer can be used if necessary to remove desiccated stool in the rectum [1,2], but these should not be used frequently, because infants can become behaviorally conditioned to depend upon rectal stimulation to initiate stooling [1,17].
In infants older than six months who have ongoing or recurrent constipation despite dietary interventions, we suggest treatment with osmotic laxatives, such as polyethylene glycol 3350 without electrolytes (PEG 3350, eg, MiraLax), lactulose, or sorbitol [1,2,18]. The medication should be given daily and the dose adjusted to achieve soft stools at least once daily. Short-term, judicious use of senna is acceptable; when using senna, avoid prolonged contact of stool with skin. Delay in starting laxatives has been suggested as a risk factor for poor long-term outcomes in children with early-onset constipation and painful bowel movements. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Treatment of constipation in infants'.)
Mineral oil, enemas and bisacodyl are not recommended in infants, because of potential adverse effects.
Toddlers and children
Recent-onset constipation — For children one year and older with recent-onset constipation, the first step in management is to provide education to the parent(s)/caregivers, including age-appropriate toileting advice, sometimes in conjunction with laxative therapy depending on the severity of the symptoms (algorithm 1):
●For those with hard stools and straining but minimal pain and no withholding behavior, bleeding, or anal fissure, dietary changes may be sufficient. Foods naturally high in fiber (ie, ≥3 grams of fiber per serving) (table 2B) should be recommended, along with adequate fluid intake (32 to 64 ounces [960 to 1920 mL] per day) [2]. Information regarding a high-fiber diet and a sample menu for a 7- to 10-year-old child that can be printed out and given to parents/caregivers is provided in the tables (table 2A, 2C).
●For those with stool-withholding behavior, pain while defecating, rectal bleeding, or anal fissure, we suggest initial treatment with PEG with or without electrolytes (PEG 3350, eg, MiraLAX) [2]. The recommended dose of PEG is 0.4 g/kg/day (table 4). If the child has a fecal impaction, a higher dose of PEG (1 to 1.5 g/kg/day) for a maximum of six consecutive days can be used. Alternatively, if PEG is not available, milk of magnesia or lactulose should be considered safe alternatives. The use of PEG is discussed in more detail separately. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Polyethylene glycol'.)
Anal fissures can be treated topically with petroleum jelly. Meanwhile, the dietary measures described above should be implemented to help avoid recurrent constipation. (See 'Toilet training' above.)
Nonresponse or relapse — For toddlers and children who fail to respond or who relapse after the initial treatment, it is important to identify and appropriately address continuing dietary problems and/or any precipitating events (algorithm 1). Precipitating events may include recurrent episodes of painful defecation (eg, due to anal fissure, hard stool), fear of using the bathroom at school, inadequate treatment and premature weaning of laxatives, and inadequate time to use the bathroom after meals or at school. (See 'Prevention and monitoring' above.)
These children may need one or more of the following interventions during the time that precipitating factors are being addressed.
●Optimize dietary fiber intake – Children with recurrent constipation should have a dietary evaluation to ensure recommended dietary fiber intake (age plus 5 to 10 grams daily). If dietary fiber intake is inadequate, fiber supplements can be used. Fiber supplements that are safe for children are available over the counter (eg, psyllium, wheat dextrin, or methylcellulose). However, to be effective, children who use these supplements should also consume 32 to 64 ounces (960 to 1920 mL) of water or other nonmilk liquids per day. Also, excessive fiber intake should be avoided in children with stool-withholding behaviors or a history of fecal impaction, as discussed above. (See 'Toilet training' above.)
●Laxatives – Children with recurrent constipation also may need one or two doses of a laxative (table 4) at the onset of an episode to clean out the hard stool and stimulate regular bowel movements. A maintenance regimen of laxatives should be considered if the stools remain hard or large in diameter or continue to cause pain, as described for chronic constipation (table 5). Stopping laxatives prematurely can reinforce retentive behavior and promote recurrent or chronic constipation. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Details on medications'.)
●Disimpaction – Children who have not had a bowel movement for several days and cannot pass a stool may have fecal impaction. Such children may be treated with a higher dose of oral laxative for up to one week, or a sodium phosphate enema (using the appropriate-sized enema for the child's age) followed by an oral laxative (table 4). Repeated sodium phosphate enemas are not recommended.
More details about these interventions, as well as parental education and behavior modification, are discussed in more detail in a separate topic review. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)
FOLLOW-UP — Follow-up is important to avoid worsening cycles of recurrent constipation. For children with a single episode of constipation, parents/caregivers should be encouraged to call if the constipation does not resolve quickly or if it recurs. For children with recurrent constipation, we suggest scheduling follow-up visits to determine whether the constipation is optimally managed.
Although it is not necessary for every child to have a daily bowel movement, intervention to soften and increase the stool frequency is essential if hard or painful stools persist. Early intervention may help to prevent fecal retention, which may progress to chronic constipation and encopresis. (See "Functional fecal incontinence in infants and children: Definition, clinical manifestations, and evaluation" and "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Contributing factors'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Constipation".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Constipation in children (The Basics)" and "Patient education: Giving your child over-the-counter medicines (The Basics)")
●Beyond the Basics topic (see "Patient education: Constipation in infants and children (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Prevention – Routine health supervision should include discussion of dietary and bowel habits and anticipatory guidance about triggers and symptoms of constipation. Early intervention during new or recurrent episodes of constipation can prevent complications such as anal fissure, stool withholding, chronic constipation, and encopresis. (See 'Prevention and monitoring' above.)
●Common triggers – Times when constipation is likely to occur include:
•Infant transitioning to a solid diet – The transitional diet often includes inadequate amounts of fiber and fluid. To avoid constipation, the diet should include at least 5 grams of fiber daily in complementary foods (eg, pureed fruits, vegetables, or cereals) and adequate amounts of fluids. Anal fissures or irritation also may contribute to constipation; these can be caused by vigorous wiping during diaper changes. (See 'Transition to solid diet or introduction of cow's milk' above.)
•Toilet training – Children of toilet-training age are susceptible to constipation because of inappropriate pressure on the child around toilet training or uncomfortable positioning on the toilet (figure 1), stool withholding, inadequate fiber intake, and/or excessive milk intake. Preventive measures include increasing fiber and decreasing milk intake; delaying toilet training until the child shows signs of readiness; and using a relaxed, "child-oriented" approach to toilet training. If the child shows signs of stool withholding, it is often necessary to use short-term dietary interventions or laxatives and sometimes to postpone toilet-training efforts. (See 'Toilet training' above.)
•School entry – Transitioning to school can trigger constipation because of stool withholding if the child is reluctant to use the toilet at school or because the change in schedule interferes with toileting. To avoid these problems, the parent(s)/caregivers should be encouraged to promote routine, unhurried time on the toilet; monitor whether their child is reluctant to use the toilet at school; and encourage adequate fiber intake (table 2A-C). (See 'School entry' above.)
●Management in infants
•Warning signs – Infants with severe or recurrent constipation, especially those with constipation from birth, should be carefully evaluated for possible organic causes, including Hirschsprung disease. Alarm signs are outlined in the table (table 3). (See 'Assessment' above and "Constipation in infants and children: Evaluation".)
•Acute management – Episodes of constipation in infants can be treated by the addition of undigestible, osmotically active carbohydrates to the formula, such as sorbitol-containing juices (eg, apple, prune, or pear) or fruit purees. For prevention and maintenance, fiber intake can be increased by feeding multigrain or barley cereal and pureed peas or prunes. Glycerin suppositories or rectal stimulation with a lubricated rectal thermometer can be used occasionally but not frequently. (See 'Infants' above.)
•Recurrence – Infants with additional episodes of constipation should be treated with the same interventions as described above for recent-onset constipation. In infants older than six months who have ongoing or recurrent constipation despite dietary interventions, osmotic laxatives such as lactulose or polyethylene glycol (PEG) 3350 may be required. (See 'Infants' above.)
●Management in toddlers and children
•Acute management – Management of isolated episodes of constipation in toddlers and children is summarized in the algorithm (algorithm 1). (See 'Recent-onset constipation' above.)
-For toddlers and children with hard stools and straining but minimal pain and no withholding behavior, bleeding, or anal fissure, dietary changes may be sufficient.
-For those with stool-withholding behavior, pain while defecating, rectal bleeding, or anal fissure, we suggest initial treatment with an osmotic or lubricant laxative rather than dietary intervention alone (Grade 2B). Appropriate choices include PEG without electrolytes (PEG 3350, eg, MiraLax) or lactulose given for at least a few days until the stool is consistently soft (table 4). Meanwhile, dietary changes should also be instituted to prevent relapse.
-Parents/caregivers should be encouraged to follow up if the constipation does not resolve quickly or if it recurs.
•Nonresponse or relapse – Toddlers and children who fail to respond or who relapse after the initial treatment should be treated with a course of laxatives (table 4), ensuring that daily fiber intake in the diet or with supplements is adequate (table 2A-B), and/or fecal disimpaction if necessary (using higher doses of oral laxatives for up to one week or a sodium phosphate enema). Meanwhile, possible precipitating factors should be addressed. Follow-up visits should be scheduled to ensure that the constipation is optimally managed. A maintenance regimen of laxatives should be considered if the stools remain hard or large in diameter or continue to cause pain, as described for chronic constipation (table 5). (See 'Nonresponse or relapse' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges George D Ferry, MD, who contributed to earlier versions of this topic review.
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
