Feeding challenges


Constipation is characterised by two or fewer defaecations per week, stool retention, painful or hard bowel movements and/or hard or large stools leading to a delay or difficulty in defaecation (Benninga et al. 2016). Most cases have no organic cause and can be resolved by the use of non-pharmacological or pharmacological interventions (Levy et al. 2017).


Constipation is described as a delay or difficulty in defaecation. It is marked by two or fewer defecations per week, stool retention, painful/hard bowel movements and/or large/hard stools present for more than two weeks and causes sufficient distress. It is often accompanied by abdominal pain (Benninga et al. 2016; Koppen et al. 2015).

Constipation is a common health problem in infants and children, which decreases their – or their caregiver's - quality of life and generally leads to visits to paediatricians or general practitioners or – in severe cases – even hospital treatments (Koppen et al. 2015). Functional constipation occurs without underlying organic cause, which is the case for up to 95% of children. The remaining 5% of paediatric patients with constipation are related to organic causes, which include metabolic or endocrine disorders (Levy et al. 2017). The reported prevalence of functional constipation in infants and toddlers varies but usually ranges between 5 and 27%. Frequency in toddlers is reported to be higher than in infants (Zeevenhooven et al. 2017).

Rome IV criteria

According to the Rome IV criteria functional constipation is diagnosed if infants (up to 4 years) display at least two of the following symptoms for one month (Benninga et al. 2016):

  • "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 fecal mass in the rectum"

For toilet-trained children additional criteria are published:

  • "At least 1 episode/week of incontinence after the acquisition of toileting skills
  • History of large-diameter stools that may obstruct the toilet"


The pathophysiology of functional constipation is still not completely understood but is likely to be multifactorial. One important etiological factor, especially for young children, is withholding behaviour – which frequently occurs after a negative experience such as hard and painful bowel movements. This can lead to faecal impaction – the presence of a large faecal mass in the rectum or abdomen that often causes overflow faecal incontinence, i.e. the involuntary loss of soft stools (Levy et al. 2017; Benninga et al. 2016).

Management options

As functional constipation is a common healthcare problem worldwide, several management options are available and sectioned into non-pharmacological and pharmacological interventions. Non-pharmacological interventions involve education and demystification, toilet training, daily stool diary or dietary advice (e.g. sufficient fibre and fluid intake) (Koppen et al. 2015; Zeevenhooven et al. 2017; Benninga et al. 2016). Pharmacological intervention involves three steps: i) disimpaction; ii) maintenance treatment; and iii) weaning. Pharmacological interventions – adjacent to this three-step treatment – have several options ranging from laxatives (osmotic, stimulant or lubricant), enemas, rectal irrigation and additional drug therapies (Koppen et al. 2015; Benninga et al. 2016).