What is Pediatric Functional Constipation?
Functional constipation is a common issue found in children, with around 3% of children worldwide experiencing it. It’s defined as functional constipation when there is no physical reason causing it, which happens to be the case for nearly 95% of children. This condition shows up in healthy children who are aged 1 year and above, and it’s especially common among children in preschool.
Usually, people have bowel movements on a regular schedule, and while the frequency can differ from person to person, passing stool should not involve significant straining or discomfort. Functional constipation is often identified when bowel movements become difficult or less frequent than usual, if passing stool becomes painful, if the stool is hard, and/or there’s a feeling of not being able to completely empty the bowels. Often, it’s not caused by any serious health condition or physical defect. Instead, it typically involves a mix of factors like stress, diet, coping mechanisms, environmental conditions, and social support.
What Causes Pediatric Functional Constipation?
Functional constipation is a common issue seen in young children, particularly during the period of toilet training. While some individuals might be naturally more prone to constipation, there are usually specific events or triggers that can cause functional constipation.
One of the most common causes is a painful or scary experience of going to the toilet. Even a single occurrence of this can result in functional constipation.
On the other hand, there are different factors at play depending on the child’s age:
For toddlers, a switch in their diet from breast milk to formula or cow’s milk might cause their stools to become dry and hard. This can lead to small tears in the skin around the anus, called anal fissures, which can be quite painful. Stress from toilet training, whether due to pressure from parents, anxiety, or the child’s own stubbornness, could also lead to the child developing functional constipation.
For older children, unpleasant toilet facilities outside of home, sexual abuse, injury to the area around the anus, or intentionally holding in stool while playing can all contribute to functional constipation.
Risk Factors and Frequency for Pediatric Functional Constipation
Functional constipation is a common problem among children across the world, but its frequency can vary depending on the region. In Europe, it is estimated that between 0.7% and 12% of children experience this issue. In North and South America, the percentage ranges from 10% to 23%, which includes not only children but also infants and adolescents. Meanwhile, in Asia, the prevalence of functional constipation varies wildly from 0.5% to 29.6%.
Signs and Symptoms of Pediatric Functional Constipation
Functional constipation is identified by evaluating a person’s medical history and physical examination. The patient’s bathroom habits, including the frequency and texture of bowel movements, as well as any associated issues and the length of time they’ve been experiencing symptoms, will be asked about. It’s common for patients to report either small, hard bowel movements resembling pebbles, or infrequent, surprisingly large bowel movements. Sometimes, bright red blood may accompany larger, harder stools, suggesting rectal fissures.
Other symptoms such as weakness, stomach pain, vomiting, and urinary issues could indicate a medical cause for the constipation. Issues like lower body weakness, abdominal pain, vomiting, bed-wetting, or involuntary stooling can happen along with functional constipation. More information about the patient’s medical history, such as any nerve issues, surgeries, or chronic conditions like underactive thyroid, Hirschsprung disease, or cystic fibrosis, will be sought.
A comprehensive physical examination will also be carried out. This includes looking at factors like growth metrics and vital signs. Specific signs, such as protruding eyes, a delayed eyelid reaction, or thyroid problems, can hint at an underactive thyroid. If a hard mass can be felt in the abdomen, that could indicate a blockage of stool in the bowel. Other things to watch for are an enlarged belly, which could point to prune belly syndrome, any lumps in the belly, or other abnormalities. Severe stomach pain might require more investigation for conditions such as appendicitis or twisted ovary. The lower back area will be inspected for any unusual marks or features that could imply a hidden spinal defect. The doctor will also check if the anus is normally positioned and functioning. While not always performed, a rectal exam can help confirm hard stool in the rectum, check for lumps in front of the sacrum, and assess the tightness of the rectum. Any abnormal muscle strength, reflexes, senses, or muscle volume in the legs may also be noticeable.
Testing for Pediatric Functional Constipation
The Rome IV medical standards differentiate between functional constipation in infants and children over 4 years old.
For infants up to 4 years old
According to these guidelines, infants who have at least two of the following symptoms for a month or defecate two or fewer times a week might have constipation:
1. A trend of holding in stool.
2. Painful or hard bowel movements.
3. Passing large-sized stools.
4. A giant mass of feces in the rectum.
For children who have learned to use the toilet, a couple of additional signs of constipation may include:
1. At least one incident of stool incontinence (lack of control over bowel movements) per week, following mastery of toilet training skills.
2. Passing stools so large that they might clog the toilet.
For children over 4 years
The guidelines for diagnosing functional constipation in children over 4 years old require the presence of at least two of the following symptoms once a week for a minimum of one month, provided the child has not been diagnosed with irritable bowel syndrome:
1. Two or fewer bowel movements in the toilet per week.
2. At least one accident of incontinence (loss of bowel control) per week.
3. A tendency to withhold stool or a pattern of excessive voluntary retention of stool.
4. Painful or hard bowel movements.
5. A large mass of stool in the rectum.
6. Passing large-sized stools that might clog the toilet.
Once other medical conditions have been considered and ruled out, the symptoms alone can be sufficient to diagnose functional constipation in a child.
If a child’s symptoms and physical examination are consistent with functional constipation, specific tests may not be necessary. However, children who do not respond to treatment, who have unusual symptoms, or who raise concerns during physical examination might need additional testing or a referral to a specialist. A TSH test can check for an underactive thyroid gland (hypothyroidism), and a lead level test can be helpful if lead poisoning is suspected. Hirschsprung disease, in which the nerves in the bowels do not function properly, should be considered, especially in young children or challenging cases. A contrast enema (an X-ray of the large intestines, aided by a contrast dye) and a referral for a possible biopsy (tissue sample examination) are other strategies to diagnose or rule out Hirschsprung disease.
Finally, while not necessary for a diagnosis of functional constipation, imaging studies might help rule out other suspected conditions. An abdominal X-ray might be useful to diagnose a large mass of stool blocking the rectum, especially in a child whose abdomen is difficult to examine, but this is not a routine procedure.
Treatment Options for Pediatric Functional Constipation
The first step in treating severely blocked-up stool, also called disimpaction, is to remove the hardened stool from your colon. This allows your colon to return to its normal size and function. Traditionally, methods such as manually removing the stool, using suppositories, and administering enemas were used. Some treatment options include enemas with different solutions such as glycerin, saline, molasses, and even olive oil.
However, for children, a medication called polyethylene glycol (PEG 3350) is often the go-to treatment. It’s proven to be effective, safe, and generally well-tolerated. You mix this medication with a bit of water or juice, and it’s often recommended to drink it over a span of three hours. If no significant change is observed after first treatment, the same dose can be repeated the next day. If there is still no response after two days of treatment or if there is an experience of significant abdominal discomfort, persistent vomiting, or other concerns, the family is advised to seek medical reassessment.
The second step of treatment aims to prevent the accumulation of hard stool. During this phase, the medication helps keep your stool very soft while your colon returns to normal size and function. Different types of laxatives and stool softeners can be used for this.
It’s also important to engage in non-medication related measures. Despite the absence of scientific evidence supporting the routine use of particular diets, structured behavioral therapy, or use of prebiotics and probiotics in treating constipation, there are some general guidelines. For instance, consuming an average amount of fiber and fluids, and regular physical activity is advised. If the child is toilet trained, they should regularly sit on the toilet after the same meal each day, in an attempt to regulate their bowel movements. The bowels are often more active after eating, so this habit can help reduce the risk of constipation by “training” the body to have a daily bowel movement. After starting treatment, a follow-up appointment with the doctor is usually scheduled in 1 to 3 weeks to assess how well the treatment is working and to discuss the next steps in managing the condition.
What else can Pediatric Functional Constipation be?
Constipation can be caused by several different factors. These include various physical abnormalities like blocked anal passages and abnormal growths near the tailbone, metabolic conditions such as underactive thyroid, cystic fibrosis, and lead poisoning, and nervous system conditions like spinal defects and Hirschsprung disease. Other causes can be toxins, such as the botulinum toxin found in honey, and certain medicines like opioids. Irritable bowel syndrome can also cause constipation in older children.
There can be concerning signs that an organic disorder might be causing constipation. These include:
- General symptoms like fever, bloated belly, weight loss, poor weight gain, less appetite, and bloody diarrhea
- Constipation starting before 1 month of age
- Delayed first bowel movement after birth
- Failure to grow normally
- Periods of diarrhea and explosive stools
- Abnormal findings on a nerve function test such as low muscle tone, absence of testicular reflex, and less reflexes in the lower limbs.
- No improvement with treatment
Usually, a detailed medical history and physical examination can rule out most of these conditions. Warning signs for a nerve-related cause could include weakness in the lower limbs or loss of control over bladder function. Additional testing might be needed for children younger than 1 year old, children not growing normally or children who do not get better with treatment. The physical check-up should focus on examination of the belly and nerve function in the lower limbs. It’s also important to check the spine for signs of spinal cord defects like birthmarks and large dimples with hair in the center line.
The rectum is checked to make sure it looks and is located as it should be. A rectal exam might be uncomfortable, but it can check for muscle tone in the rectum, presence of hard stool in the vault, and a large abnormal growth near the tailbone. Finally, reviewing growth charts can give clues, as slowing down of growth or changes in the growth pattern might be signs of underlying problems.
What to expect with Pediatric Functional Constipation
After a child develops regular bathroom habits and begins using the toilet on their own, the need for frequent bathroom trips and the use of laxatives can decrease. The dosage of laxatives is slowly lessened to prevent accidental bowel leakage and to maintain 1 to 2 bowel movements per day.
If a child continues to suffer from recurring bowel blockage or ongoing accidental leakage, this could suggest the treatment hasn’t been successful. It may be necessary to review the educational elements of the treatment plan or other components. The most common reasons for the treatment not being effective include incorrect dosage of medication, or stopping the medication too soon.
It’s been noted that half of the patients referred to children’s gut experts recover after 6 to 12 months, as shown by having 3 or more bowel movements per week without any accidental leakage and without the need for laxatives. Around 10% continue to do well while still taking laxatives, but 40% still experience symptoms, even with the use of laxatives.
Possible Complications When Diagnosed with Pediatric Functional Constipation
While constipation might be a bit unpleasant for kids, it’s typically not a big deal. However, if constipation is left untreated, it can lead to problems.
Here are possible issues that could arise from untreated constipation:
- An anal fissure, which means a tear in the skin around the bum, can lead to pain and bleeding.
- Rectal prolapse might happen. This is when the rectum, the last part of the large intestine, sticks out from the anus.
- Hemorrhoids, also known as piles, can occur.
- Encopresis might happen. This is when hard-poop accumulates in the colon and rectum, and soft poop leaks out.
Recovery from Pediatric Functional Constipation
If treatments for constipation, such as daily use of laxatives, aren’t working even when used correctly, it might be necessary to do more tests to find out the real issue.
For those who continue to struggle with chronic constipation despite following medical advice and making changes to their lifestyle, two tests might be useful. These are anorectal manometry and balloon expulsion tests. They can help to find out if there’s a problem with how the muscles in the rectum and pelvic floor are working, or if there’s a physical issue causing the constipation.
One such issue could be dyssynergic defecation, a condition where people can’t empty their bowels completely because the muscles in the pelvic floor aren’t working as they should during a bowel movement. These tests can also identify if a person has a condition called internal anal sphincter achalasia, or any other physical causes of constipation.
For children who have ongoing constipation without clear cause and not responding to common treatments including laxatives and pelvic physical therapy, a different approach might help. This may include the use of botulinum toxin injection, a type of medicine that can help relax muscles.
Preventing Pediatric Functional Constipation
Preventing and managing constipation in children is largely about educating caregivers and families, and taking steps to avoid things that might contribute to this issue. These steps often involve spotting things that might cause constipation, like certain eating habits, high-stress environments, or behaviors, with the goal of not letting constipation become a problem or get worse. Health professionals will often provide advice to parents and caregivers on how to spot signs of constipation, promoting meals rich in fiber, and encouraging healthy habits when using the restroom.
Educating the patient is key in raising awareness about how important it is to have regular bowel movements, and correcting any false beliefs about constipation. By giving families information on how to recognize symptoms, measures to prevent it, and correct timing of interventions, healthcare providers can significantly help in avoiding the occurrence of constipation and promoting the best possible gut health in children. This proactive strategy follows the ideas of preventive medicine and gives caregivers and children the tools they need to manage and stop constipation, a condition common in children, from happening.