Constipation (Children)
Constipation in children is very common, accounting for up to 25% of paediatric GI referrals.
It is usually functional (dietary, behavioural, or lifestyle-related) but may rarely be organic (neurological, endocrine, anatomical).
Early recognition and treatment prevent chronic complications such as faecal impaction and encopresis.
⚠️ Causes of Constipation
- Functional (most common) 🥦💧
- Low fibre diet, inadequate fluid intake.
- Withholding behaviour (fear of pain, unfamiliar toilets).
- Toilet training issues.
- Organic (less common) 🧬
- Hirschsprung disease → congenital absence of ganglion cells.
- Hypothyroidism → ↓ gut motility.
- Cystic fibrosis → inspissated stools, meconium ileus.
- Spinal cord lesions (e.g. spina bifida).
- Allergy → cow’s milk protein allergy in infants.
- Medication-related 💊
- Iron supplements, opioids, antacids, anticonvulsants.
🧾 Clinical Presentation
- Symptoms → infrequent stools, hard/painful defecation, abdominal pain, faecal incontinence (encopresis).
- Examination:
- Abdominal distension, palpable stool mass.
- Rectal exam (if red flags): faecal impaction, anal abnormalities.
- Growth and development → poor growth or neuro delay suggests organic disease.
🚨 Red Flags (Think Organic)
- Delayed passage of meconium (>48h after birth).
- Failure to thrive or weight loss.
- Bilious vomiting, abdominal distension.
- Abnormal neuro exam (spina bifida, lower limb weakness).
- Rectal bleeding (other than fissures).
🛠️ Management
Treatment is stepwise → disimpaction → maintenance → long-term lifestyle support.
- Lifestyle & Diet 🥦🥕
- High-fibre diet (fruit, vegetables, whole grains).
- Adequate hydration (water, not sugary drinks).
- Encourage regular physical activity.
- Behavioural Therapy ⏰
- Toilet sitting after meals (gastrocolic reflex).
- Positive reinforcement & reward charts.
- Avoid punishment → worsens withholding behaviour.
- Laxatives 💊
- Osmotic → polyethylene glycol (Movicol) or lactulose (first-line).
- Stimulant → senna, bisacodyl (short-term if osmotics fail).
- Lubricant → mineral oil (caution aspiration risk).
- Enemas/suppositories → for impaction, under supervision.
- Underlying causes 🔍
- Refer to specialists if Hirschsprung disease, hypothyroidism, or cystic fibrosis suspected.
📈 Monitoring & Follow-Up
- Regular review of stool frequency, consistency (Bristol stool chart).
- Parental education to avoid stopping laxatives too early (risk of relapse).
- Check growth, nutrition, and psychosocial wellbeing.
🧠 Exam Pearls
- 💡 Most constipation in children is functional - organic causes are rare but must be ruled out if red flags present.
- 💡 Encopresis = overflow incontinence from faecal impaction.
- 💡 Movicol is first-line for both disimpaction and maintenance.
🖼️ Diagrams
📚 References
