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).
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):
For toilet-trained children additional criteria are published:
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).
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).
Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler: in Rome IV. Functional gastrointestinal disorders: Disorders of gut-brain interaction [SECTION II: FGIDs: Diagnostic groups _15]. Gastroenterology 2016; 150(6):1443–55. at: https://pubmed.ncbi.nlm.nih.gov/27144631
Koppen IJN, Lammers LA, Benninga MA, Tabbers MM. Management of Functional Constipation in Children: Therapy in Practice. Paediatric Drugs 2015; 17:349–60. at: https://pubmed.ncbi.nlm.nih.gov/26259965
Levy EI, Lemmens R, Vandenplas Y, Devreker T. Functional constipation in children: challenges and solutions. Pediatric health, medicine and therapeutics 2017; 8:19–27. at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774595/
Zeevenhooven J, Koppen IJN, Benninga MA. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers. Pediatric gastroenterology, hepatology & nutrition 2017; 20(1):1–13. at: pubmed.ncbi.nlm.nih.gov/28401050back