Pediatric Functional Constipation

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Definition

Overview

Constipation can be broadly described as infrequent bowel movements or hard or dry stool. It can be further categorized into two subtypes, Organic and Functional Constipation.

Organic constipation happens in 5% of pediatric cases, and is the result of structural, neurologic, toxic/metabolic or intestinal disorders. This overview will focus on Functional Constipation (FC), which is more common and involving reasons beyond organic causes.

ROME IV Diagnostic Criteria for FC:

Must include 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome:

·      2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years

·      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 can obstruct the toilet

After appropriate evaluation, the symptoms cannot be fully explained by another medical condition.

NB: The ROME IV revisions published in May 2016, highlight that while functional bowel disorders (functional diarrhea, functional constipation, IBS with predominant diarrhea [IBS-D], IBS with predominant constipation [IBS-C], and IBS with mixed bowel habits) have their own distinct diagnostic criteria, they are considered to be on a continuum rather than independent entities (see Figure 1) and may share similar treatment strategies.

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FC definition is not to be confused with:

Intractable constipation: Constipation not responding to treatment for at least 3 months. For children with severe intractable constipation that is unresponsive to pharmacological management, referral to a specialized pediatric gastroenterologist is recommended. Surgery may be indicated as a last resort.

Fecal impaction: Hard mass in the lower abdomen identified during a physical exam, or a dilated rectum filled with a large amount of stool on rectal examination, or excessive stool in the distal colon viewed on abdominal Xray. Long term constipation can develop into fecal impaction. Fecal impaction can cause pain and vomiting, and may require emergency treatment or hospitalization.

Prevalence

The prevalence of pediatric FC ranges from 0.7-29.6%. The wide range reported may be due to the use of different FC criteria and cultural influences. Peak incidence of constipation occurs at the time of troilet training with no sex differences. FC is distributed equally amoung different social classes with no relationship to family size, orfinal position of the child in the family, or parental age. Boys with constipation had high rates of fecal incontinence than girls.

Mechanism of Injury / Pathological Process

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Clinical Presentation

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Diagnostic Procedures

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Outcome Measures

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Medical Management

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Physiotherapy Intervention

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Resources

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