Constipation in children

Children have different bowel movement patterns than adults. In addition, there is a wide spectrum of normalcy when considering children's bowel habits.[1] On average, infants have 3-4 bowel movements/day, and toddlers have 2-3 bowel movements per day. At around age 4, children develop an adult-like pattern of bowel movements (1-2 stools/day). Children benefit from scheduled toilet breaks, once early in the morning and 30 minutes after meals.[2][3] The Rome III Criteria for constipation in children can help to define and diagnose constipation for various age groups.[4]

While it is difficult to assess an exact age at which constipation most commonly arises, children frequently experience constipation in conjunction with life-changes. Examples include: toilet training, starting or transferring to a new school, and changes in diet.[1] Especially in infants, changes in formula or transitioning from breast milk to formula can cause constipation. Fortunately, the majority of constipation cases are not tied to a medical disease, and treatment can be focused on simply relieving the symptoms.[5]

Studies have shown a link between diets low in dietary fibres and high in processed foods, such as fast food, and childhood constipation.[6]

The diameters of different segments of the large intestine can be compared to the width of lumbar vertebra 2 for more consistent reference ranges on abdominal x-rays.[10]

Ratios of large intestinal segments compared to lumbar vertebra 2, as 75th percentile, meaning that 25% of children normally have a ratio higher than this.[10]

The Rome process suggests a diagnosis of constipation in children fewer than 4 years old when the child has 2 or more of the following complaints for at least 1 month.[5] For children older than 4 years, there must be 2 of these complaints for at least 2 months:

• 2 or fewer bowel movements per week
• Passing large bowel movements
• On physical exam, a doctor may find large amounts of feces within the child's rectum.
• A child who is already toilet trained has at least 1 accident per week involving a bowel movement.
• Child demonstrates withholding behavior in which he or she actively tries not to pass a bowel movement.
• Hard stools
• Pain with defecation.

For children, the degree of constipation may be scored by the Leech or the Barr systems:

Areas used for the Leech system of constipation grading.

• The Leech system assigns a score of 0 to 5 based on the amount of feces:[11]

• 0: no visible feces
• 1: scanty feces visible
• 2: mild fecal loading
• 3: moderate fecal loading
• 4: severe fecal loading
• 5: severe fecal loading with bowel dilatation

These score are assigned separately for the right colon, the left colon and the rectosigmoid colon, resulting in a maximum score of 15. A Leech score of 9 or greater is regarded as positive for constipation.[11]

• The Barr system rates both the amount and consistency of the faeces, and assigns a score separately for the ascending colon, transverse colon, descending colon and rectum. Its maximum score is 22, and a score of 10 or greater is regarded as positive for constipation.[12]

Osmotic laxatives (ex. polyethylene glycol, milk of magnesia, lactulose, etc) are recommended over stimulant laxatives (ex. sennosides, bisacodyl, etc).[13]

Lactulose and milk of magnesia have been compared with polyethylene glycol (PEG) in children. All had similar side effects such as flatulence, watery stools, stomach pain and nausea, but PEG was more effective at treating the symptoms of constipation.[4][14][15]

An increased intake in fibre or fibre supplements have been shown to improve the symptoms of constipation in comparison to placebo; however, the evidence is limited.[6] Fibre helps improve the symptoms of constipation through the action of soluble and insoluble fibres. Soluble fibres facilitate the production of a gel-like substance.[6] This increases stool size, and improves compactness, making it easier to remove the stools from the body.[6] Insoluble fibres also increase the size of the stool, and triggers the gastrointestinal tract to contract, facilitating further movement of gastro-intestinal contents.[6]

More evidence is needed to evaluate other non-pharmacological interventions. Probiotics are thought to provide healthy bacteria that can aid in stimulating contractions in the gastrointestinal tract to help gastrointestinal contents move forward in the body.[16] Probiotics, increased hydration, and dry cupping were found to be ineffective in the treatment of childhood constipation; however, better studies on these subjects need to be done.[6]

There is wide variation in the rates of constipation as reported by research in various countries.[17] The variation in research data makes it challenging to describe the true global situation.[17]

Approximately 3% of children have constipation, with girls and boys being equally affected.[5] With constipation accounting for approximately 5% of general pediatrician visits and 25% of pediatric gastroenterologist visits, the symptom carries a significant financial impact upon our healthcare system.[1]

Constipation is often emotionally stressful for children and their caregivers.[18] It is common for parents to bring their children to doctors for this condition.[18] The experience of going to a doctor for this can be stressful.[18]

Too often, children at doctors receive unnecessary health care when they get medical imaging for constipation.[19] Children should only get tests when there is an indication.[19]