Constipation in Children


  • Prevalence ranges from 1-30%; majority (90-95%) is functional (i.e. no organic cause)

History and Examination

  • In a child <1 year
    • NB normal stool frequency averages around 4/day in the first week of life to 2/day at 1 year.  ‘Normal’ stool frequency (i.e. for that person- can be between 3/day and 3/week) is usually established by age 4.
    • Diagnosing constipation
      • < 3 stools/week (typically type 3/4 on BSC– i.e. hard, larger stool to rabbit dropping stool)
      • There may also be
        • Distress on passing stool
        • Bleeding associated with hard stools
        • Straining
      • Ask about past history of constipation and previous/current anal fissure
    • Determining idiopathic vs serious causes
      • Idiopathic
        • Meconium passed within 48 hours; onset of constipation at least several weeks after birth
        • Precipitating factors e.g. dietary change (e.g. formula change, weaning); insufficient fluid intake
        • Normal appearance of the anus/anal region (DRE rarely required)
        • Soft, flat (distension only consistent with age/size etc) abdomen
        • Normal well-being and growth/development
      • Red-flags
        • Onset within first few weeks of life; delay in passing meconium (full-term)
        • Ribbon stool pattern
        • Abdominal distension and vomiting
        • Weakness of legs/locomotor delay
        • Abnormal anal appearance e.g. fistula, fissure, bruising, anteriorly placed anus, tight anus, absent ‘anal wink’ (reflex of anal contraction with close sensation)
          • Abnormal lumbosacral/gluteal regions e.g. asymmetry
        • Failure to thrive/poor growth; poor well-being
        • Concern over child-abuse
    • A history of constipation followed by loose soiling suggests impaction
  • In a child >1 year
    • Stool pattern (as above- < 3/week; 3/4 on BSC)
    • There may also be
      • Poor appetite that may be relieved by passage of stool
      • Abdominal pain that may be relieved by passage of stool
      • Evidence of ‘retentive posturing’ (i.e. straight legged, tiptoes, arched back)
      • Straining, painful bowel movement and bleeding with hard stools
      • Anal pain
      • Past history of constipation or previous/current anal fissure
    • Idiopathic constipation is suggested by features described above plus
      • Poor diet/insufficient fluid intake
      • Acute infections
      • Domestic stress e.g. moving house, starting school, change in home circumstances
      • Timing of potty/toilet training
      • Fears/phobias
      • Medications
      • Anal fissure
    • Red flags are as above


  • If there are red flags, consider urgent referral.  If children <1 year does not respond to 4 weeks of treatment, consider urgent referral (DRE usually required).  If >1 year and does not respond to 3 months of treatment, consider referral.
  • The use of laxatives early on should be considered
    • Prior to laxative use, exclude (or treat) any impaction
      • Polyethylene glycol + electrolytes (Movicol) (escalating dose for disimpaction; half the dose for maintenance once impaction has resolved)
        • If this fails use stimulant laxative e.g. sodium picosulfate or senna
        • Do not use enemas in children unless under specialist care
  • Make sure to educate/advise about adequate fluid intake, good diet, ensure good toilet routine/behaviour- these will often aid symptoms
    • Aim for fluid intake of
      • 700ml (0-6 months); 800ml (7-12 months); 1300ml (1-3 years; around 900ml from drinks); 1700ml (4-8 years; around 1200ml from drinks)
      • 9-13 years
        • 2400ml boys (1800ml from drinks)
        • 2100ml girls (1600ml from drinks)
      • 14-18 years
        • 3300ml boys (2600ml from drinks)
        • 2300ml girls (1800ml from drinks)

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