Constipation in Children Initial Assessment

Clinical Presentation

The following are the signs and symptoms of constipation:

• Absence of bowel movement for several days (may be normal in breastfed infants)
• Encopresis (soiling of undergarments due to involuntary leakage of feces)
• Large, hard, and dry stools or frequent small pellets
• Irregular stool texture
• Foul smelling wind and stools
• Blood in stool
• Pain while defecating
• Excessive flatulence
• Withholding or straining to stop passage of stools
• Abdominal pain
• Distention or discomfort
• Poor appetite
• Crankiness or unhappy, irritable mood
• Lack of energy
• Body malaise

Constipation in Children_Initial Assesment

History

The following are key components in history taking: In children <1 year old, stool patterns (<3 complete stools per week, hard large stool, “rabbit droppings”), symptoms associated with defecation (distress while defecating, bloody hard stool, straining), and previous history of constipation or previous or current anal fissure; and in children >1 year of age, stool patterns (<3 complete stools per week, overflow soiling, “rabbit droppings”, large hard infrequent stools), symptoms associated with defecation (poor appetite that improves with passage of large stool, waxing and waning of abdominal pain with passage of stool, straining, anal pain), and previous episode(s) of constipation, previous or current anal fissure, painful bowel movements with bleeding associated with hard stools.  

Medical history taking should also include previous treatment (eg diet, medications, adherence), family history, medical history (eg time of passage of meconium, condition at birth, growth), developmental history (eg school performance), and psychosocial history (eg family and peer interactions, temperament). 

Physical Examination

A complete physical examination should be performed, with focus on the abdomen (eg distension, palpate the liver and spleen, fecal mass), anus (eg position, presence of stool, erythema, skin tags, fissures), rectum (eg anal wink, anal tone, fecal mass, presence and consistency of stool, explosive stool on removal of the finger), back and spine (eg dimple, tuft of hair), and neurology (eg tone, strength, cremasteric and deep tendon reflexes).  

A digital rectal exam (DRE) is done to assess the tone in the rectum and the presence of impaction. A DRE should be done only by healthcare professionals capable of interpreting anatomical abnormalities or diagnosing Hirschsprung disease. DRE is not to be performed in children >1 year of age with red flag signs and symptoms. It is advisable for <1-year-old-patients diagnosed with idiopathic constipation unresponsive to optimum treatment within 4 weeks. No confirmatory imaging tests are indicated if fecal impaction is present on DRE. An abdominal X-ray may be needed if a rectal exam cannot be done or is traumatic for the child.

Diagnosis or Diagnostic Criteria

Functional Constipation  

Functional constipation is constipation that cannot be explained by any anatomical, physiological, radiological, or histological abnormalities. It is also known as idiopathic constipation, functional retention or fecal withholding. It is the most common cause of constipation. It is commonly caused by painful bowel movements with resultant voluntary withholding of feces by a child who wants to avoid unpleasant defecation.  

Functional constipation is considered present when the following are detected in the history, such as passage of stool within 2 days of birth, hard large-caliber stools, encopresis, painful defecation, bloody stools, decreased appetite, abdominal pain with bowel movement, diet low in fluid and fiber, high in milk products, avoids the toilet. In the PE there is, normal appearance of the anus and the surrounding area, soft or mild distention of the abdomen, stool is palpable in the lower left quadrant, normal anal placement and sphincter tone, rectum distended and filled with stool, positive anal wink and cremasteric reflex. It must be noted that manifestations of functional constipation can overlap with those of irritable bowel syndrome, functional diarrhea, and functional distention.  

Rome IV diagnostic criteria for functional constipation in infants and children up to 4 years of age:

• ≥2 of the following present for at least 1 month:
  • Two or fewer defecations per week
  • History of retentive posturing or excessive volitional stool retention
  • History of painful or hard bowel movements
  • Presence of a large fecal mass in the rectum
  • History of large diameter stools that may obstruct the toilet
• For children already potty-trained, additional criteria are as follows:
  • Incontinence of ≥1 episode per week after learning toilet skills
  • History of large-diameter stools causing toilet clogging

Rome IV diagnostic criteria for functional constipation in children and adolescents ≥4 years of age:

• ≥2 of the following present at least once per week for at least 1 month
  • Two or fewer defecations per week
  • At least 1 episode of fecal incontinence per week
  • History of retentive posturing or excessive volitional stool retention
  • History of painful or hard bowel movements
  • Presence of a large fecal mass in the rectum
  • History of large diameter stools that may obstruct the toilet
• Above symptoms unrelated to another disease