creation date: 2026-09-15 16:20
tags: Pathologies
Constipation (Pediatric)
Background
Definitions
Constipation is a common condition for neonates, infants, and children.
Etiology & Pathogenesis
In many cases, constipation is functional. Pediatric bowel movements often do not fully empty the rectum resulting in a gradual buildup of stool. The persistently distended rectum stops signalling the brain to toilet resulting in constipation.
In less than 5% of cases, constipation may be due to other causes:
- Infant dyschezia (ineffective defecation)
- Hirschsprung disease
- Slow-transit constipation
- Cow’s milk intolerance
- Anorectal anomalies
- Cystic fibrosis
- Celiac disease
Risk Factors
For infants, functional constipation may occur:
- After introduction of solid foods
- During toilet training
- During start of school
Other risk factors for constipation include:
- Painful defecation
- Toilet training issues
- Dietary considerations (high intake of processed foods, decreased fibre intake)
Clinical Presentation
Signs & Symptoms
Findings relating to constipation may include:
- Abdominal pain and tenderness
- Abdominal distension
Associated findings include:
- Vomiting
- Poor appetite
- Lethargy
History & Physical Exam
Diagnosis
Criteria
Diagnosis of functional constipation requires at least two of the following:
- On average ≤2 defecations per week
- On average, at least one episode of fecal incontinence per week (if toilet trained)
- History of retentive posturing, straining, or inappropriate stool retention
- History of painful or hard bowel movements
- Presence of a large fecal mass in the rectum
- History of large-diameter stools
Work-up
Work up may include:
- Abdominal x-ray for distension
- Abdominal ultrasound
Differential
Red Flags / Complications
Alarm signs for organic causes are:
Acute
- Delayed passage of meconium (>48 hours)
- Fever, vomiting, or diarrhea in young infant
- Rectal bleeding
- Severe abdominal distension
Chronic
- Constipation from birth or early infancy
- Ribbon stools (very narrow in diameter)
- Urinary incontinence or bladder disease
- Weight loss or poor weight gain
- Delayed growth
- Extraintestinal symptoms (especially neurologic deficits)
- Physical findings suggesting possible anorectal disorder
- Congenital anomalies or syndromes associated with Hirschsprung disease
Management
Initial Management
Initial management consist of breaking up hardened stool within the rectum. This consist of:
- PEG-3350 TID
- Enema
This regimen typically lasts 2-3 days but in more severe cases (eg. ongoing for a month), it may require up to a week or even more.
Maintenance
Once a consistent stooling schedule of loose stools have been established, a maintenance dose of one dose PEG-3350 daily titrated to have type 5 stool (“milkeshake-like”) for 6 months.
This is to allow for the rectum to return to its normal size.