A 2019 study published in BMC Pediatrics analyzed the prevalence of constipation in 1113 Asian children (aged 6.5 to 48 months), out of which 89 children were diagnosed with functional constipation (FC). The association of FC with underweight was statistically significant compared to the normal growth curve (14.3% vs 7.2%, p= 0.008), in addition to the association of FC with urban resident children than rural children (9.6% vs 5.6%, p= 0.013). Furthermore, children with stressful life events (physical or verbal violence) had significantly increased prevalence of FC (20.0 vs 7.8%, p= 0.046). The healthcare clinic visit of children with FC was also more frequent than children without FC (36.8% vs 13.1%, p <0.0001). Overall, 52.8% children underwent treatment for FC; 29.9% children received therapeutic care at home; however, only 24.1% received professional medical care1.
95% of constipation in children is idiopathic. The remaining 5% may have either anorectal malformations, metabolic and endocrine diseases, neuromuscular diseases or Hirschsprung disease. Other common risk factors in children include positive family history, slow gut transit, fecal impaction secondary to withholding behavior due to a past painful bowel movement, inadequate toilet training and stressful life events (domestic violence, sexual abuse)2.
According to the newest Rome IV diagnostic criteria, FC should include 2 or more of the following symptoms once weekly for a minimum of 1 month (after excluding the diagnosis of irritable bowel disease or other medical conditions). The symptoms should include ≤2 defecations in the toilet/week in a child of <4 years, at least 1 episode of fecal incontinence/week, retentive posturing/stool retention, painful/hard bowel movements, large-diameter stools obstructing the toilet or presence of a large fecal mass in the rectum 3.
Constipation is an underestimated but common health problem globally. The all-age prevalence of constipation is lower in Asian countries (10.8%) compared to North America (16%), Oceania (19.7%) and Europe (19.2%)4.
The worldwide median prevalence of constipation in children is 12% (0.7-29.6%)4. However, the problem may be underestimated in them due to a lack of self-recognized and self-reported constipation mounting to neglect in seeking medical attention5. Constipation in children also negatively impacts the quality of life and school performances with associated decrease in emotional and social functioning6.
European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology recommend that children with constipation should have a normal fiber intake, fluid intake and physical activity. Education and toilet training guidance for children <4 years of age is encouraged7. However, the use of prebiotics or probiotics, intensive behavioral therapy, biofeedback, multidisciplinary treatment and alternative treatments (acupuncture, yoga, homeopathy and mind-body therapy) are not recommended. Although limited evidence supports the benefits of pelvic physiotherapy (PPC) in children with FC or in children with organic cause of fecal incontinence and sacral nerve stimulation in FC refractory to conventional treatment, further studied are warranted8.
The resolution of FC in children is achieved with oral laxatives and/or rectal laxatives (enemas), which involves fecal disimpaction and pharmacologic maintenance therapy. PEG (polyethylene glycol), lactulose, milk of magnesia, mineral oil, bisacodyl, senna and sodium picosulfate are recommended as oral laxatives; whereas, bisacodyl, sodium docusate, sodium phosphate, sodium chloride and mineral oil are recommended as enemas7. Surgery is used as the final treatment option for intractable FC in children8.
Constipation is not a medical emergency; therefore, majority of the patients may not seek for medical care that may negatively impact the child in his developmental years. Furthermore, healthcare professionals encounter various challenges too, including neglect, non-adherence and unacceptability to counseling and treatment. Therefore, increasing awareness towards education of both medical practitioners and the general public is of utmost importance in managing childhood constipation at an early stage and preventing chronic constipation and its sequelae.
1. Walter AW, Hovenkamp A, Devanarayana NM, Solanga R, Rajindrajith S, Benninga MA. Functional constipation in infancy and early childhood: epidemiology, risk factors, and healthcare consultation. BMC Pediatrics. 2019;19(1):285.
2. Levy EI, Lemmens R, Vandenplas Y, Devreker T. Functional constipation in children: challenges and solutions. Pediatric Health, Medicine and Therapeutics. 2017;8:19–27.
3. Hyams JS, DiLorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology. 2016;150:1456-1468.
4. Mugie SM, Benninga MA, DiLorenzo C. Epidemiology of constipation in children and adults: a systematic review. Best Practice and Research. Clinical Gastroenterology. 2011;25(1):3–18.
5. Timmerman MEW, Trzpis M, Broens PMA. The problem of defecation disorders in children is underestimated and easily goes unrecognized: a cross-sectional study. European Journal of Pediatrics. 2019;178(1):33–39.
6. Bongers ME, van Dijk M, Benninga MA, Grootenhuis MA. Health related quality of life in children with constipation-associated fecal incontinence. The Journal of Pediatrics. 2009;154(5):749-753.
7. Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of Pediatric and Gastroenterology and Nutrition. 2014;58(2):258-274.
8. Van Mill MJ, Koppen IJN, Benninga MA. Controversies in the Management of Functional Constipation in Children. Current Gastroenterology Reports. 2019;21(6):23.