Evaluation of an infant or child with constipation

History	Implications
Was there delayed passage of meconium (ie, first meconium after 48 hours of life)?	Suggests Hirschsprung disease.
Onset of constipation:
Was constipation present from birth or early infancy?	More likely to be an organic cause (eg, Hirschsprung disease).
Was there a preceding change in diet or diarrheal illness?	Suggests functional constipation.
Was the onset around the time of toilet training or around a precipitating event?	Suggests functional constipation.
Were there problems with toilet training (eg, child resistance, fear, or late mastery)?	Suggests functional constipation.
Stool quality and appearance:
Is defecation painful?	Suggests functional constipation.
Are the stools hard or soft?	Soft stools suggest cause other than constipation (eg, dyschezia in an infant). Hard stool in the rectum suggests functional constipation and withholding.
Does the stool form pellets in the diaper or toilet? Does it clog the toilet?	Supports diagnosis of functional constipation.
Is there blood on the stool?	Possible anal fissure, which can cause or result from functional constipation. Alternatively, might be caused by colitis.
If the child is toilet trained, does he or she have "accidents" in the underwear?	Indicates fecal incontinence, which is usually due to functional constipation and withholding, leading to fecal impaction.
Does the child have stool-withholding behavior ("dance," hide, or appear to be trying not to have a bowel movement)?	Suggests functional constipation with stool withholding.
Dietary issues:
Is the diet unusual? Are there sources of fiber? Is there adequate fluid?	Low fluid intake occasionally contributes to constipation.
Did the constipation coincide with a change in diet (eg, transition to solid foods in infants or to milk)?	Suggests functional constipation, possibly cow's milk protein intolerance.
Are there underlying medical problems, congenital anomalies, abnormal growth, or developmental delay?	Consider neurogenic causes of constipation; some congenital syndromes are associated with Hirschsprung disease (eg, Down syndrome). Congenital malformations, such as kidney and urinary tract anomalies, also raise concerns for anorectal, sacral, and spinal abnormalities, which can interfere with defecation.
What treatments have been tried, and what was the response?	Informs clinical management.
Is there a family history of functional constipation, Hirschsprung disease, or celiac disease?	Each of these causes has some familial patterns.
Physical examination
Abdominal distension	Severe distension raises concern for organic disease.
Palpable stool mass	Consistent with constipation from any cause, but lack of palpable stool does not rule out constipation.
Mass in suprapubic area	Common finding in patients with rectal stool impaction, but can also suggest sacral teratoma.
Cutaneous changes in the lumbosacral area (dimple, hair tuft, lipoma, or deviation of the gluteal cleft)	Suggests spinal dysraphism.
Soiled underwear (fecal incontinence)	In the presence of rectal stool impaction, suggests overflow incontinence and functional constipation.
Absent anal wink or cremasteric reflex, decreased lower extremity tone or strength	Suggests neurologic dysfunction.
Anal fissure or scarring	Anal fissures may be a cause or a consequence of functional constipation.
Anteriorly displaced anus or perianal fistula	Suggests anorectal anomaly.
Digital rectal examination:
Anal sphincter tone	Increased tone suggests Hirschsprung disease; low tone suggests neurogenic constipation.
Size of rectal vault	Large vault is consistent with chronic functional constipation.
Impacted stool (hard or soft)	Soft stool suggests possibility of anorectal dysfunction, including Hirschsprung disease. Hard and large-diameter stool in the rectum suggests functional constipation with stool withholding.
Explosive expulsion of stool after the examination (squirt sign)	Suggests Hirschsprung disease.

Graphic 79830 Version 7.0

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Evaluation of an infant or child with constipation