Constipation in children

by Abbas Jahangir · June 16, 2024

In case of constipation ( constipation ), there is a delayed or painful emptying of the stool . It lasts at least two weeks and is accompanied by substantial negative effects for the child. Stool frequency may or may not be reduced. If it lasts longer than two months, it may already be a chronic problem. Treatment consists of acute measures and frequent and long-lasting medical treatment .

The so-called Rome IV criteria are used to define constipation . According to them, at least two of the following symptoms must be present for at least six months:

two or fewer bowel movements per week,
pronounced “retention maneuvers” (= an attempt to prevent the emptying of the stool ),
painful or hard stools,
more than one episode of painful stool per week,
a palpable amount of stool during a medical examination of the rectum or abdominal cavity ,
occasional passing of large amounts of stool,
in children who were already “clean”, at least once a week “stool soiling”.

What frequency of stool is considered normal is defined relatively broadly from a medical point of view:

for non-breastfed babies and children in general: 1x to 2x a day, up to 3x a week,
in breastfed children 5x to 6x a day, up to 1x in 14 days.

What causes constipation?

Constipation can have various causes and should be clarified by a doctor. Parents can hardly prevent its development, but at least the factors that contribute to it can be prevented. In children older than one year, about 90% are functional constipation , which means that the causes are organically morphological in nature. In rare cases, certain congenital or acquired diseases contribute to chronic constipation ( e.g. bowel disease , reduced thyroid function ). Furthermore, there are numerous external, i.e. exogenous, disruptive factors, e.g.:

irritation (irritation) when wiping,
changes in daily routine and surroundings,
mobility limited due to injury,
lack of fluids and fiber ,
the transition in the diet of an infant from breast milk to artificial food,
certain medications
primary psychological factors, e.g. depression , sexual abuse.

How can constipation be overcome?

There are hardly any answers to the question of how to prevent functional constipation. In any case, it makes sense to avoid external disturbing factors as much as possible. The most common cause in children is when their bowel movements are painful. So they begin to retain stool, creating a vicious circle. Also too early and under stress, or with reluctance to repeatedly try to see if the stool can be emptied, can contribute to the development of functional constipation. So parents should not put pressure on their child to have a bowel movement, but should be patient.

What symptoms can occur?

With constipation, stool frequency may be reduced, but this may not always be the case. The various difficulties that can be caused by stool retention are particularly relevant.

In particular, the following symptoms often appear:

abdominal pain , mostly recurring and short-lasting,
lack of urge to defecate
pain during bowel movements,
stools of larger dimensions and usually hard,
spontaneous leakage of stool ( faecal incontinence , encopresis),
tearing of the skin (fissure) or inflammation around the anus ,
traces of blood in the stool ,
urination (enuresis),
nausea,
vomiting
flatulence,
enlarged abdomen,
loss of appetite
rapture,
not thriving.

How is the diagnosis made?

Constipation can usually be determined on the basis of a medical record and a pediatric examination. After a detailed interview ( anamnesis ), the pediatrician examines the patient. A digital rectal examination is also often necessary . To do this, the doctor inserts a finger into the child’s anus and uses tactile sensations to assess the anus and adjacent organs . In case of fear and reluctance in the child, a short application of sedatives is possible .

Other examinations are primarily:

findings from blood and urine ,
pressure measurement in the anus (anorectal manometer),
rectal biopsy ,
double-contrast examination of the colon ,
rectoscopy ( rectal endoscopy ).

Sometimes an examination using ultrasound , X-ray , magnetic resonance , etc. may also be needed .

Notes that parents keep can also help to accurately assess stool frequency.

How is constipation treated?

First, acute treatment should take place to empty the intestine, followed by maintenance treatment with drugs accompanied by a balanced diet with sufficient fluid intake.

Acute treatment

The anus is first emptied with the help of orally administered laxatives – preferably PEG (polyethylene glycol, e.g. macrogol), occasionally also lactulose – or by means of an enema (rinse), always for a period of three to six days.

Maintenance treatment with laxatives :

Initially, parents and children should be educated about the mechanisms of constipation.

Laxatives should be administered for several months after acute bowel emptying. PEGs are preferably used for this.
As a support, pain-relieving ointments can be applied before passing stool.
For children from four years of age who are developed in a way that corresponds to their age, a non-stressful toilet trial is recommended:

ask to go to the toilet for 15 to 30 min. after the main meal or during the urge to go to the toilet,
distraction, in the case when the child tries to “retain” the stool,
sessions that last no longer than 5 to 10 min.,
suitable seating on the toilet with the possibility to put your feet,
reward for passing a stool,
pleasant environment (=hygienic toilet and its space).

Enemas do not bring any benefit, so they are not recommended for maintenance treatment.

Diet

Children should receive a healthy diet and drink enough water in proportion to their age. In the first months of treatment, administration of soluble fiber is also recommended .

Prognosis

Despite therapy , around 40% of treated children still suffer from constipation even after reaching the age of five, and this is still 20 to 30% after reaching the age of ten. Functional constipation is therefore in many cases a lengthy matter that requires patience.