Chronic constipation in infants and children

WHAT IS CONSTIPATION?Most physicians have no difficulty diagnosing and treating constipation.However, there may be slight differences in their definition of constipation.A useful working definition of constipation is a frequency of defecation of ≤ 2 times a week, and a stool consistency that is hard, dry and pellet-like or with cracks in the surface.The diagnostic criteria (i.e.Rome criteria) for functional gastrointestinal conditions, including constipation, have been developed and refined over the years.The most recent update, the Rome IV criteria, was published in 2016.(1) The Rome IV diagnostic criteria requires ≥ 2 of the following, occurring at least once a week for a minimum of one month: ≤ 2 defecations per week; ≥ 1 episode of faecal incontinence a week; retentive posturing; painful or hard bowel movements; large faecal mass in the rectum; and/or large-diameter stools that can obstruct the toilet.However, infrequent stooling in a thriving, fully breastfed baby is not considered constipation and requires only reassurance.A brief summary of rectal physiology is shown in Table I.Table II shows childhood milestones and life events that are associated with constipation. HOW RELEVANT IS THIS TO MY PRACTICE?Constipation in children is very common, with a reported frequency of up to 30%.(2) The vast majority (96%) of cases are due to functional causes.(3) Organic causes of constipation are uncommon and most can be ruled out clinically.They include the following: Hirschsprung disease, hypothyroidism, hypercalcaemia, spina bifida/spina bifida occulta and medications that slow down intestinal motility.Red flags for referral to a paediatrician are: delayed passage of meconium beyond 48 hours of life and vomiting with abdominal distension; young age of < 6 months; developmental delay or behavioural problems; failure to thrive; failure to respond to standard treatment; and frequent encopresis.Physical examination findings that require referral to a paediatrician are: significant abdominal distension, abnormal position of the anus and suspicion of spina bifida (e.g.absent lower limb reflexes, palpable bladder, absent anal reflex, tuft of hair on the spine or deep sacral dimple).Beneath the surface, chronic constipation in children is actually a complex condition, contrary to what one might think.Biological, psychological and social factors interact in the everchanging context of a developing child.This is not to say that all children with chronic constipation need to be managed by a paediatrician or psychologist.When more primary care physicians realise that chronic constipation is a genuine medical problem, parents will also come to the same conclusion and both will be better able and motivated to help the child.Most children with chronic constipation are caught in a vicious cycle (Fig. 1).The cycle can start at any point and deepen its roots with each revolution.Many parents seek help relatively late, after their child has experienced constipation for several months.A rule of thumb in counselling parents is that the duration of 'treatment' for the constipation should be roughly equal to the length of time the child has been constipated prior to seeking help.This vicious cycle must be broken for successful and sustained management of constipation, as complications may otherwise occur.These include poor appetite, failure to thrive, encopresis (the involuntary soiling of underwear with stool), anal fissures and cystitis (the faecal-loaded distal rectum may compress on the bladder neck, predisposing a patient to CMEArticleChronic constipation in infants and children