Symptoms and diagnosis of constipation in infants and children

Tabbers, 2014

Constipation is a common problem in children. Frequency of defecation varies widely, but it decreases with age and stabilises by 4 years, with the normal range from 3 stools per day to one stool every 3 days. Functional faecal retention from stool withholding behaviour can occur with secondary faecal overflow incontinence.

The diagnosis of functional constipation (based on the 2016 Rome IV criteria) is made if a child has had one month of at least 2 of the following:

  • 2 or fewer defecations per week
  • history of excessive stool retention
  • history of painful or hard bowel movements
  • history of large diameter stools
  • presence of a large faecal mass in the rectum
  • at least one episode per week of incontinence after the acquisition of toileting skills
  • history of retentive posturing or excessive volitional stool retention (in toilet-trained children)
  • history of large diameter stools, which may obstruct the toilet (in toilet-trained children)Rome Foundation Inc., 2016.

Functional constipation is the most common aetiology of constipation in children; organic causes are found in only a small number of children (hypothyroidism, coeliac disease, hypercalcaemia and food protein non–immunoglobulin E allergies). Rare causes of constipation in children include slow-transit constipation, pelvic floor muscle dyssynergia, medications, sexual abuse, spinal cord abnormalities and Hirschsprung disease.

The diagnosis of functional constipation in children is usually based on symptoms and physical examination findings. Useful information includes:

  • age at onset of symptoms
  • frequency and consistency of stools
  • diet
  • associated symptoms and signs:
    • pain when passing stools
    • abdominal pain
    • faecal incontinenceTabbers, 2014.

Consider additional investigations or referral to a paediatrician if the child has any of the following red flag symptoms:

Abdominal X-ray has no role in the diagnosis of functional constipation in children, but it may be useful in otherwise healthy children with altered bowel habits to diagnose faecal overflow incontinence. Serial abdominal X-rays have no role in the management in constipation in children.