Constipation in Children: IAP Guidelines
Chronic constipation in children is a very common and increasingly encountered problem in office practice. While <5% children with constipation have a definitive organic etiology (e.g., congenital, surgical, neurological, and endocrine conditions) for constipation, the vast majority of children have no proven cause and are labeled as functional constipation. The normal stool frequency in children is mentioned in Table 1.
| TABLE 1: Defecation frequency in children. | |
| Age | Average number of stools per day |
| <1 month | 3–4 |
| 1 month to 1 year | 1.5–2 |
| 1–2 years | 1–2 |
| 2–18 years | 1 |
The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Constipation in Children. The lead author for these guidelines on Constipation in Children is Dr. Srinivas S along with co-author Dr. Mohit Vohra and Dr. Vibhor Borkar. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.
Following are the major recommendations of guidelines:
Functional constipation is considered when any of the two or more criteria to be fulfilled to label as constipation. The criteria include:
Stool frequency ≤2 per week
History of hard and painful bowel movements
History of retention of stools
Large diameter stool obstructing the Indian pots
Fecal incontinence
Per abdomen or per rectum examination reveals fecal mass.
Clinical Evaluation:
The history taking and examination must include information regarding time of onset of constipation, passage of meconium, growth and developmental milestones, and history of withholding in order to differentiate functional constipation from organic causes (Table 2).
The presence of a mass or palpable fecaloma on abdominal examination might suggest the presence of fecal impaction (inability to pass/evacuate hard and large diameter stools) which often causes abdominal pain or fecal soiling.
A perianal examination (for the presence of fissure/sentinel skin tags) and examination of the spinal area for any possible underlying spinal/neurological conditions is recommended.
The history taking should include the following points in detail:
Age of onset of symptoms: Surgical causes are more common in infantile onset constipation. Functional constipation typically occurs later.
Passage of meconium after birth: Delayed passage of meconium is observed with Hirschsprung's disease.
Stool characteristics: Amount, consistency, and frequency of stools.
Pain during defecation and blood streaks on stool or drops after stools may suggest presence of anal fissure.
Retentive postures during defecation are often a "habit" mostly seen in younger children with functional constipation who dread the act of passing painful stools.
Urinary symptoms: Increased frequency, burning micturition, and urinary incontinence may suggest coexisting urinary tract infection or voiding dysfunction.
| TABLE 2: Red flag symptoms and signs pointing to common organic causes. | |
| Signs and symptoms | Probable cause for constipation |
| Short stature, decrease in height velocity, delayed development/poor scholastics, lethargy, cold intolerance in older children | Hypothyroidism |
| Delayed passage or failure to pass meconium, failure to thrive, abdominal distension, history of recurrent enterocolitis | Hirschsprung's disease |
| Tuft of hair at back of the spine or any other abnormal neurological signs in lower limbs | Spinal cord abnormalities and spinal dysraphism |
| Significant perinatal history, delayed development, feeding abnormalities, regression of acquired milestones | Cerebral palsy and neurodegenerative disorder |
| Recurrent respiratory infections, meconium ileus, and failure to thrive | Cystic fibrosis |
| TABLE 3: Different regimens used for fecal disimpaction. | ||
| Home-based disimpaction regimen | Dosage | Side effects/comments |
| Polyethylene glycol | 1.5–2 g/kg/day in two divided doses for 3–6 days | Well tolerated but slower to act |
| Oral agent— Polyethylene glycol | 25 mL/kg/h orally or by nasogastric tube over 4–6 hours |
distension, and nausea |
| Rectal agent, e.g., sodium phosphate enemas | 2.5 mL/kg (2–18 years old) | |
| TABLE 4: Commonly used laxatives and dose used in children and their mechanism of action. | ||||
| Types of laxatives | Name of laxative | Dose | Mechanism of action | Side effect |
| Osmotic laxatives | Polyethylene glycol | 0.5–1 g/kg/day | Large inert molecule which retains intraluminal water | Nausea and bloating |
| Lactulose | <1 year 2.5 mL BD 1–<5 years: 2.5–10 mL BD 5–20 years 5–20 mL BD | Nonabsorbable synthetic disaccharides product which retains intraluminal water | Bloating and abdominal discomfort | |
| Lactitol | 200–400 mg/kg/ day | Synthetic monohydrate product which retains intraluminal water | Mild bloating | |
| Stimulant laxatives | Sodium picosulfate | 2.5–10 mg per day up to 4 years 2.5–20 mg per day up from 4–18 years | Converts into active metabolite by intestinal bacteria which increases the peristalsis | Nausea, crampy abdominal pain, occasionally loose motions |
- The diagnosis of functional constipation may be considered in the absence of red flag signs.
- Organic causes are more common in infantile onset constipation.
- Identification and treatment of fecal impaction is important for successful maintenance laxative therapy.
- Long-term maintenance laxative therapy along with toilet training is often needed for best outcome.
- Education and counseling of parents is important to ensure compliance and successful outcomes.
- Refractory constipation should be referred to a pediatric gastroenterologist for further evaluation.
- Sujatha B, Velayutham DR, Deivamani N, Bavanandam S. Normal bowel pattern in children and dietary and other precipitating factors in functional constipation. J Clin Diagn Res. 2015;9(6): SC12-5.
- Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-74.
- Yachha SK, Srivastava A, Mohan N, Bharadia L, Sarma MS, Indian Society of Pediatric Gastroenterology, et al. Management of Childhood Functional Constipation: Consensus Practice Guidelines of Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition and Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics. Indian Pediatr. 2018;55(10):885-92.
The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/
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