Evaluation and Treatment of Constipation

in Children and Adolescents

SAMUEL NURKO, MD, and LORI A. ZIMMERMAN, MD, Boston Childrens Hospital, Boston, Massachusetts

Childhood constipation is common and almost always functional without an organic etiology. Stool retention can
lead to fecal incontinence in some patients. Often, a medical history and physical examination are sufficient to diag-
nose functional constipation. Further evaluation for Hirschsprung disease, a spinal cord abnormality, or a metabolic
disorder may be warranted in a child with red flags, such as onset before one month of age, delayed passage of meco-
nium after birth, failure to thrive, explosive stools, and severe abdominal distension. Successful therapy requires
prevention and treatment of fecal impaction, with oral laxatives or rectal therapies. Polyethylene glycolbased solu-
tions have become the mainstay of therapy, although other options, such as other osmotic or stimulant laxatives, are
available. An increase in dietary fiber may improve the likelihood that laxatives can be discontinued in the future.
Education is equally important as medical therapy and should include counseling families to recognize withholding
behaviors; to use behavior interventions, such as regular toileting and reward systems; and to expect a chronic course
with prolonged therapy, frequent relapses, and a need for close follow-up. Referral to a subspecialist is recommended
only when there is concern for organic disease or when the constipation persists despite adequate therapy. (Am Fam
Physician. 2014;90(2):82-90. Copyright 2014 American Academy of Family Physicians.)

C
CME This clinical content onstipation is one of the most to every other day after the preschool years.9
conforms to AAFP criteria common chronic disorders of Many healthy breastfed infants go several
for continuing medical
education (CME). See childhood, affecting 1% to 30% days or longer without a bowel movement.2
CME Quiz Questions on of children worldwide.1 Consti- Thus, less frequent defecation patterns may
page 74. pation is responsible for 3% of all primary be normal and must be considered in the
Author disclosure: No rel- care visits for children and 10% to 25% of context of stool caliber, associated symp-
evant financial affiliations. pediatric gastroenterology visits.2 Children toms, and physical examination findings.
Patient information: with constipation cost the health care sys-

Handouts on this tem three times as much as children with- Etiology and Pathophysiology
topic are available at out constipation,3 and the negative effect on Outside of the neonatal period, childhood
http://familydoctor.
quality of life often persists into adulthood.4 constipation is usually functional (i.e., there
org/familydoctor/en/
diseases-conditions/ is no evidence of an organic condition).2,10
constipation.html and Definition Functional constipation is most commonly
http://familydoctor.org/ The Rome III criteria are the most accepted caused by painful bowel movements that
familydoctor/en/kids/
toileting/stool-soiling-and-
criteria for diagnosing childhood constipa- prompt the child to voluntarily withhold
constipation-in-children. tion (Table 1).5,6 However, the time duration stool. To avoid the passage of another pain-
html. does not need to be fulfilled to start therapy ful bowel movement, the child will contract
because there is evidence that early treat- the anal sphincter or gluteal muscles by stiff-
ment favorably affects outcome.2 ening his or her body, hiding in a corner,
rocking back and forth, or fidgeting with
Normal Defecation Patterns each urge to defecate. Parents often confuse
Parents often worry that their childs bowel these withholding behaviors as straining
movements are too infrequent. The num- to defecate. Withholding of stool can lead
ber of bowel movements a child has in a day to prolonged fecal stasis in the colon with
decreases with age and reaches adult fre- reabsorption of fluid, causing the stool to
quencies during the preschool years.7,8 An become harder, larger, and more painful to
infant averages three to four stools a day in pass. Over time, as the rectum stretches to
the first week of life, two stools a day later in accommodate the retained fecal mass, rectal
infancy and the toddler years, and once a day sensation decreases, and fecal incontinence

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 Constipation in Children

Clinical Diagnosis
Table 1. Rome III Diagnostic Criteria for Diagnosing A history and physical examination are
Functional Constipation in Children usually sufficient to distinguish functional
constipation from constipation caused by
At least two of the following in a child with a developmental age younger than an organic condition.2,10 A medical history
four years*
should include the familys definition of
Two or fewer bowel movements per week
constipation and a careful review of the fre-
At least one episode of incontinence per week after the acquisition of
toileting skills quency, consistency, and size of stools; age
History of excessive stool retention at onset of symptoms; timing of meconium
History of painful or hard bowel movements passage after birth; recent stressors; previous
Presence of a large fecal mass in the rectum and active therapies; presence of withhold-
History of large diameter stools that may obstruct the toilet ing behaviors, pain, or bleeding with bowel
movements; abdominal pain; fecal incon-
At least two of the following in a child with a developmental age of four years
or older with insufficient criteria for irritable bowel syndrome
tinence; and systemic symptoms (Table 2).2
Two or fewer bowel movements in the toilet per week The presence of withholding behaviors sup-
At least one episode of fecal incontinence per week ports the diagnosis of functional constipa-
History of retentive posturing or excessive voluntary stool retention tion. Further evaluation may be warranted
History of painful or hard bowel movements in children with red flags that might suggest
Presence of a large fecal mass in the rectum an organic etiology (Table 3).2
History of large diameter stools that may obstruct the toilet Physical examination should include a
review of growth parameters, an abdominal
*Criteria must be fulfilled for at least one month. Accompanying symptoms may examination, an external examination of the
include irritability, decreased appetite, and/or early satiety, and they may disappear perineum and perianal area, an evaluation
immediately following passage of a large stool. of the thyroid and spine, and a neurologic
Criteria must be fulfilled at least once a week for at least two months.
evaluation for appropriate reflexes (cremas-
Adapted with permission from Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood
teric, anal wink, patellar). A digital exami-
functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;
130(5):1533, and Hyman PE, Milla PJ, Benninga MA, Davidson GP, Fleisher DF, Tamin- nation of the anorectum is recommended
iau J. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenter- to assess for perianal sensation, anal tone,
ology. 2006;130(5):1524.
rectum size, anal wink, and amount and
consistency of stool in the rectum. However,
in children with normal neonatal courses or
may develop. This cycle commonly coincides with toilet clear withholding behaviors, or in whom trauma is sus-
training, changes in routine or diet, stressful events, ill- pected, the rectal examination may be deferred. A test
ness, or lack of accessible toilets, or occurs in a busy child for occult blood in the stool should be performed in all
who defers defecation. infants with constipation and in any child with constipa-
tion who has pain, failure to thrive, diarrhea, or a family
Fecal Incontinence history of colon cancer or polyps. The presence of a hard
Fecal incontinence is the voluntary or involuntary pas- mass in the lower abdomen combined with a dilated rec-
sage of feces in the underwear or in socially inappropri- tum filled with hard stool indicates fecal impaction.
ate places in a child with a developmental age of at least Abdominal radiography is of limited value in diagnos-
four years. It occurs in 1% to 4% of school-aged children ing chronic constipation because it lacks interobserver
and is almost always associated with underlying consti- reliability and accuracy.2,14,15 It should be reserved for
pation.11 Fecal incontinence may also be associated with specific clinical circumstances in which a rectal exami-
urinary incontinence. nation is unreasonable (e.g., in a child with a history of
The pathophysiology of fecal incontinence is poorly trauma) or the diagnosis is uncertain.
understood. An interaction of behavioral and physio-
logic factors is thought to cause long-standing functional Differential Diagnosis
constipation with overflow incontinence.12 Families may Table 4 outlines the differential diagnosis of consti-
incorrectly confuse fecal incontinence for diarrhea or pation in children and the recommended diagnostic
lack of attention. Fecal incontinence often improves evaluations.2 The age of the patient must be carefully
when the stool retention is treated.13 considered.

July 15, 2014 Volume 90, Number 2 www.aafp.org/afp American Family Physician83
Constipation in Children
Table 2. Components of a Medical History in the Evaluation of Childhood Constipation

Components Clinical significance

Frequency, consistency, and size of stools Larger, hard stools may be a sign of withholding; normal bowel movement
frequency associated with symptoms may indicate irritable bowel syndrome

Age of onset Infants younger than one month with constipation have a relatively greater
likelihood of an organic etiology

Pain or bleeding with passing stools May suggest stools that are hard enough to produce fissures or that are associated
with an allergy

Abdominal pain It is important to see if pain is relieved or affected by defecation (may suggest
irritable bowel syndrome); rule out other causes because abdominal pain is often
misdiagnosed as being related to constipation

Timing of first bowel movement after birth Lack of a bowel movement in first 48 hours suggests Hirschsprung disease

Fecal incontinence Suggests fecal impaction

Withholding behaviors Important contributor to constipation in younger children; behavior interventions

may be beneficial

Systemic symptoms (e.g., fever, vomiting, weight May indicate an organic etiology, such as Hirschsprung disease
loss, decreased appetite)

Social history, including toilet training, stressors May be associated with the onset of constipation

Review of current and previous therapies including It is important to ascertain how the patient has been treated previously and if
diet, behavior, medications medication dosages were appropriate

Assess adherence and effectiveness of previous It is important to understand factors that may influence the treatment outcome
and current treatments

Information from reference 2.

Table 3. Red Flags Suggesting an Organic Cause of Constipation in Children

Red flags Suggested diagnoses

Onset before one month of age Congenital malformation of anorectum or spine, Hirschsprung
disease, allergy, metabolic/endocrine condition
Delayed passage of meconium (more than 48 hours after birth) Hirschsprung disease, cystic fibrosis, congenital malformation of
anorectum or spine
Failure to thrive Hirschsprung disease, malabsorption, cystic fibrosis, metabolic condition
Abdominal distension Hirschsprung disease, impaction, neurenteric problem (e.g., pseudo-
obstruction)
Intermittent diarrhea and explosive stools Hirschsprung disease
Empty rectum Hirschsprung disease
Tight anal sphincter Hirschsprung disease, anorectal malformations
Pilonidal dimple covered by tuft of hair Spinal cord abnormality
Midline pigmentary abnormalities of lower spine Spinal cord abnormality
Abnormal neurologic examination (absent anal wink, absent crema Spinal cord abnormality
steric reflex, decreased lower extremity reflexes and/or tone)
Occult blood in stool Hirschsprung disease, allergy
Extraintestinal symptoms (vomiting, fever, ill-appearance) Hirschsprung disease, neurenteric problem
Gushing of stool with rectal examination Hirschsprung disease
No history of withholding or soiling Hirschsprung disease, neurenteric problem, spinal cord abnormality
No response to conventional treatment Hirschsprung disease, neurenteric problem, spinal cord abnormality

Information from reference 2.

84 American Family Physician www.aafp.org/afp Volume 90, Number 2 July 15, 2014
 Constipation in Children

YOUNG INFANTS delayed passage of meconium (more than 48 hours after

The likelihood of an organic etiology for constipation birth) or other red flags, even in the setting of normal
is relatively greater in infants younger than six months, findings on barium enema examination. Hirschsprung
and particularly in those younger than three months. disease is the most common cause of lower intestinal
Hirschsprung disease must be considered in infants with obstruction in neonates. A delayed diagnosis can result
in enterocolitis, a potentially fatal complica-
tion that causes fever; abdominal distension;
Table 4. Differential Diagnosis of Constipation in Children and explosive, bloody diarrhea.16 Patients
with suspected Hirschsprung disease should
Recommended diagnostic
be referred to a medical center with a pedi-
Conditions evaluation
atric gastroenterologist and surgeon for con-
Functional constipation History and physical firmatory testing with rectal suction biopsy.
examination; no testing If Hirschsprung disease is excluded in an
Anatomic malformations of the colon and rectum infant with delayed passage of meconium,
Imperforate anus, anal or colonic stenosis, Physical examination, cystic fibrosis and other anatomic malfor-
anteriorly displaced anus barium enema mations should be considered. The physical
examination of a young infant should assess
Spinal cord abnormalities
Meningomyelocele, spinal cord tumor or Spinal magnetic
the position and patency of the anus and
trauma, tethered cord resonance imaging, include a neurologic examination to evalu-
anorectal manometry, ate for congenital anomalies of the anus and
urodynamics spine (e.g., anteriorly displaced anus, anal
Metabolic conditions stenosis, imperforate anus, spina bifida, teth-
Hypothyroidism Thyroid studies ered cord). Breastfed infants require special
Hypercalcemia, hyperkalemia Serum calcium and consideration because in the absence of red
potassium levels flags or other medical issues, they require
Diabetes mellitus Fasting glucose level no further workup for infrequent bowel
Diabetes insipidus Serum and urine movements.
osmolarity
OLDER CHILDREN
Neuropathic gastrointestinal disorders
Hirschsprung disease, internal anal sphincter Anorectal manometry, Further evaluation is indicated in older chil-
achalasia rectal suction biopsy dren with red flags or with intractable con-
Visceral myopathy/neuropathy Colonic manometry stipation despite strict adherence to therapy.
Drug use/toxin exposure
Laboratory studies may be performed to
Opiates, phenobarbital, anticholinergics and History, drug level
evaluate for systemic diseases, such as thy-
attention-deficit/hyperactivity disorder roid disease, other metabolic diseases, celiac
drugs, antacids and sucralfate (Carafate), disease, or lead toxicity. Motility studies (e.g.,
antidepressants, antihypertensives anorectal manometry) can assess for sphinc-
Lead toxicity Lead level
ter abnormalities, such as Hirschsprung dis-
Other systemic disorders ease or a nonrelaxing internal anal sphincter.
Celiac disease Tissue transglutaminase Magnetic resonance imaging of the spine
IgA, total IgA, may be necessary to evaluate for a tethered
endoscopy cord, spinal cord tumor, or sacral agenesis.17
Cystic fibrosis Sweat test
A trial of a cows milkfree diet may also
Cows milk protein intolerance Cows milk elimination
be considered because constipation can be
Connective tissue disorder, mitochondrial Special testing
disorders
caused by intolerance to cows milk, espe-
Psychiatric disorders Psychological and
cially in young children with anal fissures.2,18
psychiatric evaluation
Treatment
IgA = immunoglobulin A. The treatment of functional constipation
Information from reference 2. requires parental education, behavior inter-
ventions, measures to ensure that bowel

July 15, 2014 Volume 90, Number 2 www.aafp.org/afp American Family Physician85
Constipation in Children
Constipation in Infants Younger than Six Months
Constipation

EDUCATION AND BEHAVIOR MODIFICATION

History, physical examination,
occult blood testing Education is the first step in treatment. Edu-
cational materials for parents on constipa-
tion and fecal soiling are available at http://
Delayed passage of meconium
(more than 48 hours after birth)? www.gikids.org. It is important to explain
that fecal incontinence occurs from invol-
untary overflow of stool and not from vol-
Yes No untary defiance. Behavior modification with
Red flags? (Table 3) regular toileting (for five to 10 minutes) after
meals combined with a reward system is
often helpful. Parents should be encouraged
Yes No
to maintain a positive and supportive atti-
Referral for evaluation of Exclusively tude throughout treatment and expect grad-
possible organic etiologies breastfed (older ual improvement with occasional relapses.
(e.g., Hirschsprung than two weeks)?
disease, cystic fibrosis)
Although behavior modification and edu-
cation are important, intensive behavior ther-
Yes No apy does not seem to add to treatment success,
except in rare cases in which the patient has
Most likely Functional
normal constipation underlying behavior problems.20 Biofeedback
has not been shown to be effective in children
with functional constipation.2,21
Treatment: Education and diet
modification (e.g., fruit juice, DIETARY CHANGES
such as prune; increased fluids;
verification of formula preparation) Dietary changes are often advised in children
with constipation.21 An increased intake of
Effective?
fluids and absorbable and nonabsorbable
carbohydrates (e.g., sorbitol in prune, pear,
and apple juice) can help soften stools, par-
Yes No ticularly in infants. The recommended dos-
Maintenance Medication: Lactulose,
age of prune juice for infants is 2 oz per day.
therapy sorbitol, polyethylene glycol It can be diluted with 2 oz of water for pal-
solutions (Miralax), occasional atability. Studies have shown that children
glycerin suppository
with constipation have a lower fiber intake
than other children. An increased intake
Effective? of dietary fiber may improve the likelihood
that a child will be able to discontinue laxa-
tive therapies.22 The addition of a probiotic
Yes No
(e.g., Lactobacillus GG) may be helpful in
Maintenance If therapy fails despite good some children with functional constipation,
therapy adherence and education,
although the studies are preliminary.23
refer for further evaluation

DISIMPACTION
Figure 1. Algorithm for evaluation and management of constipation When fecal impaction is present, disim-
in infants younger than six months.
paction with oral or rectal medication is
Information from references 2, 10, and 19.
required before initiation of maintenance
therapy. Oral medications are less invasive
movements occur at normal intervals with good evacua- but require more patient cooperation and may be slower
tion, close follow-up, and adjustment of medication and to relieve symptoms. A number of therapies are available
evaluation as necessary. Algorithms for the evaluation (Table 5).2,24-26 The advent of polyethylene glycolbased
and management of constipation in infants and older solutions (Miralax) has changed the initial approach to
children are presented in Figures 1 and 2.2,10,19 constipation in children because they are effective, easy

86 American Family Physician www.aafp.org/afp Volume 90, Number 2 July 15, 2014
 Constipation in Children
Constipation in Children Six Months Table 5. Therapies for Disimpaction in Children
and Older
Therapy Dosage
Constipation
Oral
Osmotics
History, physical examination Polyethylene glycol 1.5 g per kg per day
3350 (Miralax)*
Polyethylene glycol 25 mL per kg per hour via
Red flags? (Table 3)
solution (Golytely)* nasogastric lavage
Magnesium citrate < 6 years: 2 to 4 mL per kg per day
Yes No 6 to 12 years of age: 100 to 150 mL
per day
Referral Functional > 12 years: 150 to 300 mL per day
for further constipation
Stimulants
evaluation
Senna (Senokot) 2 to 6 years of age: 2.5 to 7.5 mL
(8.8 mg per 5 mL); to 1 tablets
Fecal impaction?
(8.6 mg per tablet) per day
6 to 12 years of age: 5 to 15 mL; 1 to
2 tablets per day
Yes No
Bisacodyl (Dulcolax) 2 years: 5 to 15 mg (1 to 3 tablets)
Initiate oral or rectal medi- per day in a single dose
cations for disimpaction Lubricants
Mineral oil 15 to 30 mL per year of age per day
Effective? Rectal agents
Enemas (one per day)
Saline 5 to 10 mL per kg
No Yes
Mineral oil 15 to 30 mL per year of age up to
Referral Functional constipation 240 mL
for further without impaction Phosphate soda 2 to 12 years of age: 66-mL enema
evaluation
(should not to be used in children
< 2 years because of the risk of
Treatment: Education, behavior electrolyte abnormality)
modification, diet modification,
> 12 years: 133 mL
oral medications, close follow-up
Suppository (one per day)
Bisacodyl 2 years: 5 to 10 mg ( to
Effective after two weeks? 1 suppository)
Glycerin* to 1 infant suppository; adult
suppository for those older than
Yes No 6 years

Maintenance Reassess, reeducate, monitor Other

therapy treatment adherence,
Manual (used rarely;
change medications
general anesthesia
needed)

Effective?
*May be used in infants < 1 year.
Information from references 2, and 24 through 26.
Yes No

Maintenance therapy Referral for further evaluation first-line treatment, the overall data do not clearly dem-
onstrate superiority of one laxative.29
Figure 2. Algorithm for evaluation and management of
MAINTENANCE THERAPY
constipation in children six months and older.
Information from references 2, 10, and 19. The goal of maintenance therapy is to avoid reaccumu-
lation of stool by maintaining soft bowel movements,
to administer, noninvasive, and well tolerated.27 Rectal preferably occurring once a day. Given a robust placebo
therapies and polyethylene glycol are similarly effec- response, there is insufficient evidence to support the
tive in the treatment of fecal impaction in children.28 effectiveness of laxative therapies over placebo in the
Although some evidence supports polyethylene glycol as treatment of childhood constipation.30 However, most

July 15, 2014 Volume 90, Number 2 www.aafp.org/afp American Family Physician87
Constipation in Children
Table 6. Maintenance Therapies for Children with Constipation

Therapy Dosage Adverse effects

Osmotics
Polyethylene glycol 3350 0.5 to 0.8 g per kg up to 17 g per day Anaphylaxis, flatulence
(Miralax)*
Lactulose 1 mL per kg per day once or twice per day, single dose or in Abdominal cramps, flatulence
two divided doses
Magnesium hydroxide < 2 years: 0.5 mL per kg per day Infants are susceptible to magnesium
2 to 5 years of age: 5 to 15 mL per day overdose (hypermagnesemia,
hyperphosphatemia, hypocalcemia)
6 to 11 years of age: 15 to 30 mL per day
12 years: 30 to 60 mL per day
Medication may be given at bedtime or in divided doses
Sorbitol (e.g., prune juice) 1 to 3 mL per kg once or twice per day in infants Similar to lactulose

Stimulants
Senna (Senokot) 1 month to 2 years of age: 1.25 to 2.5 mL (2.2 to 4.4 mg) at Idiosyncratic hepatitis, melanosis coli,
bedtime (< 5 mL per day); 8.8 mg per day hypertrophic osteoarthropathy,
2 to 6 years of age: 2.5 to 3.75 mL (4.4 to 6.6 mg) or tablet analgesic nephropathy
(4.3 mg) at bedtime (< 7.5 mL or 1 tablet per day)
6 to 12 years of age: 5 to 7.5 mL (8.8 to 13.2 mg) or 1 tablet
(8.6 mg) at bedtime (< 15 mL or 2 tablets per day)
> 12 years: 10 to 15 mL (26.4 mg) or 2 tablets (17.2 mg) at
bedtime (< 30 mL or 4 tablets per day)
Bisacodyl (Dulcolax) > 2 years: 5 to 15 mg (1 to 3 tablets) once per day Abdominal cramps, diarrhea,
hypokalemia, abnormal rectal
mucosa, proctitis (rare), urolithiasis
(case reports)

Lubricants
Mineral oil Children: 5 to 15 mL per day Lipoid pneumonia if aspirated,
Adolescents: 15 to 45 mL per day theoretical interference with
absorption of fat-soluble substances,
foreign body reaction in intestine

*First-line therapy.
May be used in infants < 1 year.
Information from references 2, and 24 through 26.

studies show that the addition of laxatives is usually nec- formulations limits the practical use of stimulant laxa-
essary and more effective than behavior modification tives in younger children. In the primary care setting,
alone.31 Although the use of enemas has been advocated stimulant laxatives should be reserved for rescue ther-
in the past, recent studies have shown that the addition apy when an osmotic laxative is ineffective. Patients
of enemas to oral laxative regimens does not improve requiring constant administration of stimulant laxatives
outcomes in children with severe constipation.32 should be evaluated further.
Table 6 summarizes maintenance therapies.2,24-26 Over-
all, polyethylene glycol achieves equal or better treatment Long-Term Prognosis
success than other laxatives, such as lactulose or milk of Most children with functional constipation require pro-
magnesia,30,33,34 although it may be associated with more longed treatment and have frequent relapses.19 Studies
episodes of fecal incontinence.27 The dose of polyethylene have shown that only 60% of children with constipation
glycol can be adjusted according to treatment response. achieve treatment success after one year of therapy. Chil-
Maintenance doses of medications need to be continued dren with fecal incontinence or who are younger than
for several weeks to months after a regular bowel habit four years at onset of constipation are particularly at risk
is established. Children who are toilet training should of poor long-term outcomes.35
remain on laxatives until toilet training is well established.
Stimulant laxatives (e.g., bisacodyl [Dulcolax], senno- Referral
sides) may be required in some children, although data Referral to a pediatric gastroenterologist may be needed
on their use in children are limited. The lack of liquid when a child with constipation has red flags for organic

88 American Family Physician www.aafp.org/afp Volume 90, Number 2 July 15, 2014
 Constipation in Children

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

A history and physical examination are usually sufficient to distinguish functional constipation from C 2, 10
constipation caused by organic conditions.
Abdominal radiography is of limited value in diagnosing chronic constipation because it lacks interobserver C 2, 14, 15
reliability and accuracy.
Polyethylene glycolbased solutions (Miralax) are effective, easy to administer, noninvasive, and well A 27, 30, 34
tolerated in children with constipation.
The addition of laxatives is more effective than behavior modification alone in children with constipation. B 30, 31
The addition of enemas to oral laxative regimens does not improve outcomes in children with severe B 32
constipation.
Most children with functional constipation require prolonged treatment. C 19, 35

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

disease or the constipation is unresponsive to adequate 2. Tabbers MM, Dilorenzo C, Berger MY, et al. Evaluation and treatment of
functional constipation in infants and children: evidence-based recom-
therapy. Subspecialists may pursue newer medical thera- mendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol
pies, such as lubiprostone (Amitiza), which acts on chlo- Nutr. 2014;58(2):265-281.
ride channels in the intestine,36 or onabotulinumtoxinA 3. Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C.
(Botox) injected into a nonrelaxing sphincter.37 Surgical Health utilization and cost impact of childhood constipation in the
United States. J Pediatr. 2009;154(2):258-262.
therapies, such as antegrade colonic enemas, have also
4. Bongers ME, van Wijk MP, Reitsma JB, Benninga MA. Long-term prog-
been shown to improve continence in children with nosis for childhood constipation: clinical outcomes in adulthood. Pedi-
intractable constipation.38 Motility testing often helps atrics. 2010;126(1):e156-e162.
guide management in children with intractable consti- 5. Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastro-
intestinal disorders: child/adolescent. Gastroenterology. 2006;130(5):
pation.19,39 Although most children have functional con- 1527-1537.
stipation, it is important to reevaluate those who do not 6. Hyman PE, Milla PJ, Benninga MA, Davidson GP, Fleisher DF, Taminiau J.
follow the expected course. Childhood functional gastrointestinal disorders: neonate/toddler. Gas-
troenterology. 2006;130(5):1519-1526.
Data Sources: A PubMed search was completed using the keywords 7. Tunc VT, Camurdan AD, Ilhan MN, Sahin F, Beyazova U. Factors associ-
constipation, child, pediatric, functional constipation, and incontinence. ated with defecation patterns in 0-24-month-old children. Eur J Pediatr.
Also searched were the Cochrane database, Essential Evidence Plus, and 2008;167(12):1357-1362.
guidelines from the North American Society for Pediatric Gastroenterol-
8. Corazziari E, Staiano A, Miele E, Greco L; Italian Society of Pediatric
ogy, Hepatology, and Nutrition and the National Institute for Health and Gastroenterology, Hepatology, and Nutrition. Bowel frequency and
Care Excellence. Search dates: February 24, 2012, and October 2013. defecatory patterns in children: a prospective nationwide survey. Clin
Gastroenterol Hepatol. 2005;3(11):1101-1106.
9. Fontana M, Bianchi C, Cataldo F, et al. Bowel frequency in healthy chil-
The Authors dren. Acta Paediatr Scand. 1989;78(5):682-684.
SAMUEL NURKO, MD, is director of the Motility and Gastrointestinal Dis- 10. Bardisa-Ezcurra L, Ullman R, Gordon J; Guideline Development Group.
orders Center at Boston (Mass.) Childrens Hospital, and is an associate Diagnosis and management of idiopathic childhood constipation: sum-
professor in the hospitals Department of Medicine. mary of NICE guidance. BMJ. 2010;340:c2585.

11. van der Wal MF, Benninga MA, Hirasing RA. The prevalence of
LORI A. ZIMMERMAN, MD, is an attending physician in gastroenterology encopresis in a multicultural population. J Pediatr Gastroenterol Nutr.
and nutrition in the Department of Medicine at Boston Childrens Hospital. 2005;40(3):345-348.
12. van den Berg MM, Bongers ME, Voskuijl WP, Benninga MA. No role for
Address correspondence to Samuel Nurko, MD, Boston Childrens Hos- increased rectal compliance in pediatric functional constipation. Gastro-
pital, 300 Longwood Ave., Boston, MA 02115 (e-mail: samuel.nurko@ enterology. 2009;137(6):1963-1969.
childrens.harvard.edu). Reprints are not available from the authors.
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