17/2/2016

Constipationininfantsandchildren:Evaluation

OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Constipationininfantsandchildren:Evaluation
Author
ManuRSood,FRCPCH,MD

SectionEditor
BUKLi,MD

DeputyEditor
AlisonGHoppin,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jan2016.|Thistopiclastupdated:Apr01,2015.
INTRODUCTIONConstipationaffectsupto30percentofchildrenandaccountingforanestimated3to5
percentofallvisitstopediatricians[1].Thepeakprevalenceisduringthepreschoolyearsinmostreports.
Thereisnoconsistenteffectofgenderontheprevalenceofchildhoodconstipation.
Complaintsrangefrominfrequentbowelevacuation,hardsmallfeces,difficultorpainfulevacuationoflarge
diameterstools,andfecalincontinence(voluntaryorinvoluntaryevacuationoffecesintotheunderwear,also
knownasencopresis)[2,3].Mostbutnotallchildrenwithfecalincontinencehaveunderlyingconstipation.
Functionalconstipationisresponsibleformorethan95percentofcasesofconstipationinhealthychildrenone
yearandolder,andisparticularlycommonamongpreschoolagedchildren[4].Althoughitiscommon,itis
importanttoevaluateaffectedchildrentoidentifythefewthathaveorganiccausesofconstipation.Moreover,
childrenwithfunctionalconstipationwillbenefitfrompromptandthoroughtreatmentinterventions.Delayedor
inadequateinterventionmayresultinstoolwithholdingbehaviorwithworseningconstipationandpsychosocial
consequences.
Theevaluationofaninfantorchildwithconstipationinchildrenwillbereviewedhere.Relatedinformationis
availableinthefollowingtopicreviews:
(See"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis".)
(See"Functionalfecalincontinenceininfantsandchildren:Definition,clinicalmanifestationsand
evaluation".)
(See"Chronicfunctionalconstipationandfecalincontinenceininfantsandchildren:Treatment".)
(See"Preventionandtreatmentofacuteconstipationininfantsandchildren".)
EVALUATIONEvaluationofachildwithconstipationreliesprimarilyonafocusedhistoryandphysical
examinationfurthertestingisperformediftheinitialevaluationraisesconcernforanorganiccauseof
constipation.
HistoryThehistoryshouldfocusonfeaturesthatsuggestfunctionalconstipation(table1)andalsoassess
forfeaturesthatraiseconcernforsomerarebutseriousorganiccausesofthesymptom(table2).Thehistory
shouldbeobtainedfromtheparentsorcaretakers,andalsofromthechild,ifthisisappropriateforhisorher
age.Thepartnershipestablishedwiththefamilyshouldcontinueuntiltheconstipationisresolved,toensure
thatsymptomsdonotprogressandbecomemoreproblematic[5].
Inaninfant,apparentstrainingduringdefecationdoesnotnecessarilyindicateconstipation.Ifaccompaniedby
thepassageofsoftstoolsinanotherwisehealthyinfant,thissymptomisknownas"infantdyschezia"(see
"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon'Infant
dyschezia').Organiccausesofconstipationshouldbeconsideredifthestrainingbehaviorisaccompaniedby
hardstoolsorifwarningsignsarepresent.Themostimportantorganiccausesofconstipationininfantsare
Hirschsprungdiseaseandcysticfibrosis.Inparticular,ahistoryofdelayedpassageofmeconiumshouldraise
concernsaboutthepossibilityofHirschsprungdisease,asmorethan90percentofnormalnewbornsbutonly
10percentofinfantswithHirschsprungdiseasepassmeconiumwithinthefirst24hoursoflife.(See
"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon
'Differentialdiagnosis'and'Alarmsigns'below.)
AlarmsignsAlarmsignsfromthehistorythatsuggestthepossibilityoforganiccausesinclude(table3)
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

1/24

17/2/2016

Constipationininfantsandchildren:Evaluation

[6,7]:
Acutesigns

Delayedpassageofmeconium(firstmeconiumpassedafter48hoursoflife)(table4)
Fever,vomiting,ordiarrhea
Rectalbleeding(unlessattributabletoananalfissure)
Severeabdominaldistension

Chronicsigns

Constipationpresentfrombirthorearlyinfancy
Ribbonstools(verynarrowindiameter)
Urinaryincontinenceorbladderdisease
Weightlossorpoorweightgain
Delayedgrowth(eg,decreasingheightpercentiles)
Extraintestinalsymptoms(especiallyneurologicdeficits)
CongenitalanomaliesorsyndromesassociatedwithHirschsprungdisease(eg,Downsyndrome)
FamilyhistoryofHirschsprungdisease

PsychosocialandenvironmentalfactorsWhenfunctionalconstipationissuspected,particular
attentionshouldbegiventopsychosocialorenvironmentalfactorsthatmayhaveinfluencedthechild'sbowel
activities.Thesefactorsincludeahistoryofpainfulevacuation,difficultieswithtoilettraining,stoolwithholding,
introductionofcow'smilk,anddiet.Dietaryfactorsthatsometimescontributetoconstipationincludelowfiber
content(fewfruitsorvegetables)andlowfluidintake,althoughtheseassociationsareweak.(See"Functional
constipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon'Etiology'.)
Findingssupportingafunctionaletiologyinclude:
Onsetofconstipationcoincideswithdietarychange(eg,introductionofcow'smilk),toilettraining,or
painfulbowelmovement
Stoolwithholdingbehavior(table5)
Goodresponsetoconventionallaxatives
Iffeasible,parentsshouldprepareafivetosevendaysymptomanddietaryhistorybeforebringingthechildfor
theevaluation[8],takingcaretorecordstoolfrequency,appearance,andanypaininvolved.Thepointatwhich
theconstipationwasfirstnoted,andanypotentialrelationshipwithacoincidentevent,shouldbesought.
ConstipationandbladderdysfunctionAnorectalandlowerurinarytractfunctionareinterrelated.Asa
result,constipationisoftenassociatedwithbladderdysfunction,includingbladderoveractivity(urge),increased
ordecreasedvoidingfrequency,andbladderunderactivity[9].Thisrelationshipbetweenabnormalboweland
bladderfunctionisreferredtoasthebowelbladderdysfunction,alsoknownasdysfunctionalelimination
syndrome.Althoughbladderdysfunctioniscommonlyassociatedwithfunctionalconstipation,neurogenic
disordersmustalsobeexcluded.Successfultreatmentoftheconstipationisanimportantcomponentof
treatingthebladderdysfunction[10].(See"Etiologyandclinicalfeaturesofbladderdysfunctioninchildren",
sectionon'Constipationandbowelbladderdysfunction'.)
PhysicalexaminationThephysicalexaminationshouldincludeanevaluationoftheperianalarea,including
theappearanceandlocationoftheanus,andsensoryandmotorfunction.Adigitalrectalexaminationis
includedforselectedcases(table1andtable3)[7]:
ExternalexaminationThegeneralphysicalexaminationshouldincludeassessmentofgrowthand
abdominaldistension,andabdominalorpelvicmasses.Findingssuggestiveofspinaldysraphisminclude
sensoryandmotordeficits,apatulousanus,urinaryincontinence,anabsentcremastericreflex,increased
pigmentation,vascularnevi,orhairtuftsinthesacrococcygealarea[11].(See"Closedspinaldysraphism:
Clinicalmanifestations,diagnosis,andmanagement",sectionon'Cutaneous'and"Functionalconstipationin
infantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon'Differentialdiagnosis'and
"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon'Other
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

2/24

17/2/2016

Constipationininfantsandchildren:Evaluation

causes'.)
Onneurologicexamination,findingssuggestingneurologicdysfunction(duetospinaldysraphismorother
cause)includeapatulousanus,absentanalwink,absentcremastericreflex,decreasedlowerextremitytoneor
strength,andabsenceofadelayintherelaxationphaseofthelowerextremitydeeptendonreflexes(which
suggestshypertonia).
Theperineumshouldbeinspectedforabnormalitiesofanorectaldevelopment,whichrepresentaspectrum
fromhighimperforateanustoanteriorlydisplacedanus(figure1)[12].Whenthecommunicationisabnormally
closetothefourchetteorscrotum,theanusisconsidered"anteriorlydisplaced"or"ectopic".Ananteriorly
displacedanusiseasilyoverlooked.Theabnormalityissuggestedbynotingthattheanalopeningisnot
locatedinthecenterofthepigmentedareaoftheperineum(picture1AB).Thediagnosisissupportedby
measuringtheAnalPositionIndex(API),whichisdefinedastheratiooftheanusfourchette/scrotumdistance
tothecoccyxfourchette/scrotumdistance.Measurementsaremosteasilymadebyplacingastripofclear
tapeonthelongitudinalaxisoftheperineum,markingthepositionsofthecoccyx,anus,and
fourchette/scrotum,thenremovingthetapeformeasurementagainstastandardruler.Normalratiosare
discussedelsewhere.(See"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferential
diagnosis",sectionon'Anorectalanomalies'.)
DigitalanorectalexaminationAdigitalanorectalexaminationisnotroutinelynecessaryforthe
evaluationofpatientswithatypicalhistoryandsymptomsoffunctionalconstipation.Thisisbecausethe
digitalanorectalexaminationisunpleasantforthechildandhasonlymoderatesensitivityandspecificityfor
detectingorconfirmingconstipationinthisgroupofpatients[7].However,someprovidersperformadigital
examinationinselectedcasesofsuspectedfunctionalconstipationbecauseitmayrevealafecalimpaction
thatrequiresacleanoutapproach(initiationoftreatmentwithhighdosesoflaxativesand/orenemas),orthe
presenceofoccultbloodthatrequiresfurtherdiagnostictesting.
Adigitalexaminationissuggestedforthefollowinggroupsofpatients[7]:
Infantswithconstipation
Childrenwithsymptomssinceearlyinfancy
Infantsorchildrenwithotheralarmsignsthatsuggestorganicdisease(table3)
Childreninwhomthepresenceordegreeofconstipationisunclear(eg,meetingonlyoneRomeIII
criterion)
FindingssuggestiveofHirschsprungdiseaseincludeatightanalcanalwithanemptyampulla.Theremaybe
anexplosivereleaseofgasandstoolafterthedigitalrectalexamination(squirtsignorblastsign),whichmay
relievetheobstructiontemporarily.Inaddition,infantswithHirschsprungdiseaseoftenhavegrossdistentionof
theabdomenandfailuretothrive.(See"Congenitalaganglionicmegacolon(Hirschsprungdisease)"and
"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon
'Hirschsprungdisease'.)
Findingssuggestiveoffunctionalconstipationareadistendedrectumthatisfullofstool.However,lackof
stooldoesnotexcludethepossibilityoffunctionalconstipation.
Testingofthestoolforoccultblood(guaiactesting,eg,Hemoccult),shouldbeperformedinmostcasesifstool
isavailablefromthedigitalrectalexaminationordiaper.Thisisparticularlyimportantininfantswith
constipation,inwhomsubclinicalmilkproteinintolerance(orotherfoodproteinintolerance)maypresentas
constipation(see"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",
sectionon'Cow'smilkintolerance').Ininfantsandchildrenwithmarkedabdominaldistensionorwhoareill
appearing,stoolswithvisibleoroccultbloodmayindicateenterocolitis,andthepatientrequiresurgentfurther
evaluation.(See"EmergencycomplicationsofHirschsprungdisease",sectionon'Enterocolitis'and
"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon
'Hirschsprungdisease'.)
DIAGNOSISOFFUNCTIONALCONSTIPATION
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

3/24

17/2/2016

Constipationininfantsandchildren:Evaluation

DiagnosticcriteriaAMultinationalWorkingTeamdevelopedcriteriaforfunctionalgastrointestinaldisorders
knownastheRomeIIIcriteria[13,14].Forchildrenwithdevelopmentalageoffouryearsorolder,functional
constipationisdefinedbythepresenceofatleasttwoofthefollowingsymptomsoccurringforatleasttwo
months(table6):

Twoorfewerdefecationsperweek
Atleastoneepisodeoffecalincontinenceperweek
Historyofretentiveposturingorexcessivevolitionalstoolretention(stoolwithholding)
Historyofpainfulorhardbowelmovements
Presenceofalargefecalmassintherectum
Historyoflargediameterstoolsthatmayobstructthetoilet

Forinfantsandtoddlers,thecriteriaaremodifiedtoonemonthdurationofsymptomsandtoreflectage
appropriatetoiletingskills.
ExclusionoforganiccausesThediagnosisoffunctionalconstipationalsorequiresexclusionoforganic
causesofthesymptom.Organiccausesareresponsibleforfewerthan5percentofchildrenwithconstipation
[11,15],butaremorecommonamongyounginfants,andamonginfantsandchildrenpresentingwithatypical
featuresoralarmsigns(table3)(see'Alarmsigns'above).Themaincausesarelistedinthetable(table2)
anddetailedinaseparatetopicreview.(See"Functionalconstipationininfantsandchildren:Clinicalfeatures
anddifferentialdiagnosis",sectionon'Differentialdiagnosis'.)
Particularattentionshouldbepaidtothefollowingcauses,whicharerelativelycommonorrequireurgent
diagnosis:
CommonorganiccausesCowsmilk(orotherdietaryprotein)intoleranceceliacdisease
Urgentcauses
InfantsHirschsprungdisease,spinaldysraphism,sacralteratoma,infantilebotulism
AllagesCysticfibrosis,leadpoisoning,intestinalobstruction
FURTHERTESTINGInmostcases,organiccausesofconstipationcanbeexcludedonthebasisofa
carefulhistoryandphysicalexamination.Ifwarningsignsofpossibleorganicconstipationarepresent,focused
laboratoryandradiographictestingshouldbeperformed.Inaddition,thesetestsmaybeappropriateforpatients
whofailtorespondtoawellconceivedandcarefullyadministeredinterventionprogram,includingdisimpaction,
frequentandeffectiveuseoflaxatives,andbehavioralmanagement.(See"Chronicfunctionalconstipationand
fecalincontinenceininfantsandchildren:Treatment".)
Imaging
AbdominalradiographAplainabdominalradiographisnotindicatedfortheroutineevaluationof
functionalconstipation[7].However,itcanbehelpfultodocumentretainedstoolwhenthereis
inadequatehistoricalinformationtodetermineifthepatienthasconstipationorifthephysicalexamination
islimitedbypatientcooperation,obesity,orisdeferredforpsychologicalconsiderations.Itshouldbe
recognizedthatabdominalradiographsareinconsistentlyinterpretedbydifferentobservers,arenot
particularlyspecificforconstipation,andrarelyaddtothediagnosisiftherectalexaminationrevealsa
largeamountofretainedstool[7,16,17].Thus,theyarenotanessentialpartoftheevaluationof
constipationandshouldnotbeusedasasubstituteforathoroughhistoryandphysicalexamination.
BariumenemaAbariumenemaprovidessupportiveevidenceforHirschsprungdiseaseinchildrenwith
featuressuggestiveofthisdisorder,suchasearlyonsetconstipationfromtheneonatalperiod,especially
withdelayedpassageofmeconium,orsuggestivefindingsonanorectalexamination.Thestudyshould
beperformed"unprepped",ie,withoutmeasurestoremovestoolfromtherectum(image1AB).Some
providersuseanorectalmanometryastheinitialinvestigationorproceeddirectlytorectalbiopsy.Invery
younginfants,thebariumenemamaybenormalandthediagnosismustbeestablishedbyrectalbiopsy.
(See"Congenitalaganglionicmegacolon(Hirschsprungdisease)"and"Functionalconstipationininfants
andchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon'Hirschsprungdisease'.)
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

4/24

17/2/2016

Constipationininfantsandchildren:Evaluation

SpineradiographsPlainfilmsofthelumbosacralspineshouldbeperformedforchildrenwithevidence
ofspinaldysraphismorneurologicalimpairmentoftheperianalareaorlowerextremities.Ifthereisahigh
suspicionofneurologicdysfunction,magneticresonanceimaging(MRI)shouldbeconsideredto
investigatethepossibilityoftetheredcordandspinalcordtumors[7,18,19].(See"Closedspinal
dysraphism:Clinicalmanifestations,diagnosis,andmanagement".)
LaboratorytestsWesuggestlaboratorytestingatthetimeoftheinitialevaluationinpatientswithsignsor
symptomssuggestiveofanorganiccauseofconstipation,suchasthefollowingclinicalsituations:
CeliacscreeningForchildrenwithfailuretothriveorrecurrentabdominalpain,performacomplete
bloodcountandserologicscreeningforceliacdisease(usuallyIgAantibodiestotissue
transglutaminase).Thesymptomsofceliacdiseasemaybesubtle.Therefore,wehavealowthreshold
forperformingceliacscreeninginchildrenwithconstipation,despitelimitedinformationaboutitsclinical
utilityinthispopulation.(See"Epidemiology,pathogenesis,andclinicalmanifestationsofceliacdisease
inchildren"and"Diagnosisofceliacdiseaseinchildren".)
UrineanalysisandcultureForchildrenwithahistoryofrectosigmoidimpaction,especiallyin
associationwithencopresis[2022],performaurineanalysisandurineculture.Thisisbecausefecal
impactionmaypredisposetourinarytractinfectionsduetothemechanicaleffectsofthedistended
rectumcompressingthebladder.
ThyroidstimulatinghormoneForchildrenwithimpairedlineargrowthanddepressedreflexes,or
thosewithahistoryofcentralnervoussystemdisease,wesuggestscreeningforhypothyroidism.A
growthvelocitylessthan5cm/year(1.6inches/year)suggeststhepossibilityofgrowthfailurein
prepubertalchildren.Ifcentralhypothyroidismissuspected,thescreenshouldincludemeasurementof
freethyroxine(T4)aswellasthyroidstimulatinghormone(TSH).(See"Acquiredhypothyroidismin
childhoodandadolescence".)
ElectrolytesandcalciumForchildrenatriskforelectrolytedisturbances(eg,thosewithmetabolic
abnormalitiesorinabilitytotolerateadequatefluids),wesuggestmeasuringserumconcentrationsof
electrolytesandcalcium.
BloodleadlevelScreeningforleadtoxicityshouldbeperformedinchildrenwithriskfactors.
Screeningrecommendationsvarybycommunity.Childrenatparticularriskincludethosewithpica,
developmentaldisabilities,orafamilyhistoryofleadpoisoninginasibling,orthoselivinginhousingbuilt
before1950orhousingthatrecentlyhasbeenrenovated.(See"Childhoodleadpoisoning:Clinical
manifestationsanddiagnosis"and"Screeningtestsinchildrenandadolescents",sectionon'Lead
poisoning'.)
Thislistisnotexhaustiveandspecificlaboratorytestingmaybeconsideredinanypatientwithanatypical
presentation.
MotilitytestingMotilitytestingistypicallyconsideredinpatientswhohavenoobviousorganiccauseof
constipationandwhofailtorespondtovigoroustreatmentoffunctionalconstipation.
ColontransitstudiesAcolonictransitstudyisnothelpfulfortheroutineevaluationofachildwith
constipationbecausetheresultsrarelyaltermanagement[7].Thesestudieshelptoidentifysubsetofchildren
withintractableconstipationthathasabnormallyslowmovementoffoodresiduethroughthecolon,acondition
referredtoas"slowtransit"constipation.Slowtransitconstipationisaclinicaldescriptionratherthanadisease
becauseitremainsunclearwhetherthisgroupofchildrenisdistinctfromthosewithfunctionalconstipation,
manyofwhomhaverelativelydelayedcolonictransit.Acolonictransitstudyisgenerallyreservedforthe
secondaryevaluationofselectedpatientsinwhomthediagnosisisuncleardespiteathoroughinitialevaluation
andtrialsoftreatment.Inparticular,itmaybeusefultohelpdistinguishbetweenretentive(constipation
associated)fecalincontinenceandnonretentivefecalincontinence[7].Onesmallstudyreportedthatchildren
withnormalcolontransitalsohaveanormalcolonmanometrystudy[23].Therefore,acolontransitstudy(eg,
Sitzmarkstudy)mayhelptoscreenforpatientswhomayrequirefurtherevaluationwithcolonmanometry.
Somechildrenwithconstipationandslowcolontransitdevelopchronicintractablediseaseandhaveapoor
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

5/24

17/2/2016

Constipationininfantsandchildren:Evaluation

outcome.Thisismorelikelyinchildrenwithonsetofsymptomsbeforethreeyearsofage,severesymptoms
(passinglessthanonestoolaweek),andlackofresponsetooptimalstandardtherapywithlaxativesand
behavioralintervention.Wesuggestearlyreferraltoagastroenterologistforpatientswiththisprofile.These
patientscanbenefitfromevaluationofcolontransittimeandmotilitystudiestoassessforacolon
neuromuscularabnormality.(See"Chronicfunctionalconstipationandfecalincontinenceininfantsand
children:Treatment",sectionon'Treatmentfailure'.)
Colonictransitstudiescanbeperformedusingavarietyofprotocols[24,25].Oneoftheeasiesttechniquesis
tohavethechildswallowacapsulecontaining24radiopaquemarkers(Sitzmarkcapsules)onceadayforthree
days.Plainradiographsaretakenonthefourthday(andsometimesalsoontheseventhday),andanalyzedfor
thenumberandlocationofretainedmarkers[25].Ideally,anyfecalimpactionshouldberelieved,andlaxatives
shouldbediscontinuedseveraldayspriortoperformingthestudy.
Thecolonictransittime(CTT)canthenbecalculatedwiththefollowingformula:
Fortheday4films:
Colonictransittime(hours)=#markersremainingx1.0
(where1.0=72hours/72markersingested)
Fortheday7films:
Colonictransittime(hours)=#markersremainingx2.3
(where2.3=168hours/72markersingested)
Ifcapsulescontaining20(ratherthan24)radiopaquemarkersareused,theconstant1.2isusedfortheday4
calculation,and2.8fortheday7calculation.Ifthecapsulescontainingradiopaquemarkersarenotavailable,
segmentsofnumber10radiopaquenasogastrictubecutinto1cmlengthscanbeusedasmarkers,andthe
constantadjustedaccordingtothenumberofmarkersingested.Transittimealsomaybeanalyzedbycolonic
segment,usingsimilarcalculations.
Inonestudyofadolescents,CTTwas58.3forthosewithconstipationand30.2hoursforthosewithout
constipation[25].PediatricslowtransitconstipationisgenerallydefinedasCTT>100hours[26].Mostchildren
withslowtransitconstipationhavenoidentifiableunderlyingdisease.Typicalfeaturesofchildrenwithslow
transitconstipationaredelayedpassageofthefirstmeconiumstoolbeyond24hoursofage,symptomsof
severeconstipationwithinayear,ortreatmentresistantencopresisattwotothreeyearsofage,andsoft
stoolsdespiteinfrequentbowelactions[26,27].Theyaremanagedinthesamewayasotherchildrenwith
functionalconstipation,buttheyhaveaworseprognosisforpromptrecovery[28].Suchchildrenmayrequire
furtherevaluationandmayrespondtostimulantlaxatives.Afewhavedisordersassociatedwithcolonic
dysmotility,whichincludeintestinalneuronaldysplasiaandintestinalneuronaldysplasiatypeB.(See
"Functionalconstipationininfantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon'Other
causes'.)
Thisstudyalsomayhelptoidentifypatientswithoutletobstruction,manifestedbyaccumulationofmarkersin
therectosigmoidarea.PatientswithoutletobstructionmayrequireabiopsytoevaluateforHirschsprung
diseaseorotherneuromusculardisorders[11].However,thispatternalsomaybeseeninpatientswithfecal
impactionandinthosewithabnormalresponsesofthepelvicfloormusclesduringdefecation.(See"Etiology
andevaluationofchronicconstipationinadults",sectionon'Outletdelay'and"Functionalconstipationin
infantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon'Differentialdiagnosis'.)
AnorectalmanometryAnorectalmanometryinvolvesplacementofacathetercontainingpressure
transducingsensorsintotherectum,therebypermittingmeasurementofneuromuscularfunctionofthe
anorectum.Theprocedureincludesmeasurementsoftherectoanalinhibitoryreflex(whichisabsentin
Hirschsprungdisease),rectalsensationandcompliance,andsqueezepressures.Thetestisperformedmainly
inchildrenwithintractableconstipationthatrestrictstheirlifestyle,orwhenthereissuspicionofinternalanal
sphincterachalasia,orHirschsprungdisease[11,20,2931].Anorectalmanometryalsocanidentifypatients
withdyssynergicdefecation,whichisafunctionaldisordercharacterizedbytheincompleteevacuationoffecal
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

6/24

17/2/2016

Constipationininfantsandchildren:Evaluation

materialfromtherectumduetoparadoxicalcontractionorfailuretorelaxpelvicfloormuscleswhenstrainingto
defecate.Thechancesofartifactduetocathetermovement(whichcanmimicrectoanalinhibitoryresponse)
arehigherinchildrenlessthansixmonthsofage.DefinitivediagnosisofHirschsprungdiseaseismadeby
rectalbiopsy.(See"Congenitalaganglionicmegacolon(Hirschsprungdisease)"and"Functionalconstipationin
infantsandchildren:Clinicalfeaturesanddifferentialdiagnosis",sectionon'Differentialdiagnosis'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasics
andBeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Constipationinchildren(TheBasics)"and"Patientinformation:
Hirschsprungdisease(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Constipationininfantsandchildren(Beyondthe
Basics)")
SUMMARYANDRECOMMENDATIONSThefollowingrecommendationsareconsistentwithguidelines
developedbytheNorthAmericanSocietyforPediatricGastroenterology,Hepatology,andNutrition
(NASPGHAN)andendorsedbytheAmericanAcademyofPediatrics(AAP)(availableat:www.naspghan.org)
[7].
Functionalconstipationisresponsibleformorethan95percentofcasesofconstipationinhealthy
childrenoneyearandolder,Itisdefinedbythepresenceofatleasttwoofsixcriteriadescribingstool
frequency,hardness,size,fecalincontinence,orvolitionalstoolretention(table6).Thesymptomsmust
bepresentforonemonthininfantsandtoddlers,andtwomonthsinolderchildren.Thediagnosisalso
requiresexclusionoforganiccausesofthesymptoms.Functionalconstipationusuallycanbediagnosed
baseduponthehistoryandphysicalexamination.Keyelementsofthehistoryandphysicalexamination
areoutlinedinthetable(table1).(See'Diagnosisoffunctionalconstipation'above.)
Organiccausesareresponsibleforfewerthan5percentofchildrenwithconstipation(table2),butare
morecommonamongyounginfants.Particularattentionshouldbegiventopatientswithalarmsigns
(table3)orotherelementsofthehistoryandphysicalexaminationthatraisesuspicionforanorganic
cause(table3).(See'Alarmsigns'above.)
SignsandsymptomssuggestiveofHirschsprungdiseaseincludedelayedpassageofmeconium
(after48hoursoflife),failuretothriveordelayedgrowth,vomiting,abdominaldistension,atight
analcanalwithanemptyampulla,oranexplosiveexpulsionofstoolafterthedigitalexamination
(squirtsign).Hirschsprungdiseaseshouldbeparticularlyconsideredforinfantspresentingwith
constipationduringtheneonatalperiod.Othercausesofconstipationordelayedpassageof
meconiumintheearlyneonatalperiodarelistedinthetable(table4).(See"Congenitalaganglionic
megacolon(Hirschsprungdisease)".)
Cow'smilkmaycauseconstipationininfantsandyoungchildren.Thediagnosisissuggestedby
onsetofsymptomsthatcoincidewithanincreaseincow'smilkinthedietandisgenerally
confirmedandtreatedbysubstitutionofsoyorhydrolyzedproteinintheformula.(See
'Psychosocialandenvironmentalfactors'aboveand"Functionalconstipationininfantsandchildren:
Clinicalfeaturesanddifferentialdiagnosis",sectionon'Cow'smilkintolerance'.)
Celiacdiseaseiscommonandoccasionallyisassociatedwithconstipation.Asaresult,wehavea
lowthresholdforperformingceliacscreeninginchildrenwithconstipation,bymeasuringceliac
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

7/24

17/2/2016

Constipationininfantsandchildren:Evaluation

specificantibodies(usuallyIgAantibodiestotissuetransglutaminase).(See'Laboratorytests'
above.)
Laboratoryandradiographictestingshouldbeselectivelyperformedbaseduponthehistoryandphysical
examination.Forthemajorityofchildrenwhosepresentationistypicaloffunctionalconstipation,
laboratorytestingispursuedonlyifthepatientfailstorespondtoawellconceivedandcarefully
administeredinterventionprogram,includingdisimpaction,frequentandeffectiveuseoflaxatives,and
behavioralmanagement.Incontrast,laboratorytestingshouldbeperformedearlyinpatientswithsignsor
symptomssuggestiveofanorganiccauseofconstipation.(See'Furthertesting'above.)
ACKNOWLEDGMENTTheeditorialstaffatUpToDatewouldliketoacknowledgeGeorgeDFerry,MD,
whocontributedtoanearlierversionofthistopicreview.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.vandenBergMM,BenningaMA,DiLorenzoC.Epidemiologyofchildhoodconstipation:asystematic
review.AmJGastroenterol2006101:2401.
2.RubinGP.Childhoodconstipation.AmFamPhysician200367:1041.
3.LoeningBauckeV.Chronicconstipationinchildren.Gastroenterology1993105:1557.
4.LoeningBauckeV.Prevalence,symptomsandoutcomeofconstipationininfantsandtoddlers.JPediatr
2005146:359.
5.ProcterE,LoaderP.A6yearfollowupstudyofchronicconstipationandsoilinginaspecialistpaediatric
service.ChildCareHealthDev200329:103.
6.LeungAK,ChanPY,ChoHY.Constipationinchildren.AmFamPhysician199654:611.
7.TabbersMM,DiLorenzoC,BergerMY,etal.Evaluationandtreatmentoffunctionalconstipationin
infantsandchildren:evidencebasedrecommendationsfromESPGHANandNASPGHAN.JPediatr
GastroenterolNutr201458:258.
8.ArceDA,ErmocillaCA,CostaH.Evaluationofconstipation.AmFamPhysician200265:2283.
9.BurgersRE,MugieSM,ChaseJ,etal.Managementoffunctionalconstipationinchildrenwithlower
urinarytractsymptoms:reportfromtheStandardizationCommitteeoftheInternationalChildren's
ContinenceSociety.JUrol2013190:29.
10.FengWC,ChurchillBM.Dysfunctionaleliminationsyndromeinchildrenwithoutobviousspinalcord
diseases.PediatrClinNorthAm200148:1489.
11.DiLorenzoC.Pediatricanorectaldisorders.GastroenterolClinNorthAm200130:269.
12.HendrenWH.Pediatricrectalandperinealproblems.PediatrClinNorthAm199845:1353.
13.RasquinA,DiLorenzoC,ForbesD,etal.Childhoodfunctionalgastrointestinaldisorders:
child/adolescent.Gastroenterology2006130:1527.
14.HymanPE,MillaPJ,BenningaMA,etal.Childhoodfunctionalgastrointestinaldisorders:
neonate/toddler.Gastroenterology2006130:1519.
15.ThiessenPN.Recurrentabdominalpain.PediatrRev200223:39.
16.PensabeneL,BuonomoC,FishmanL,etal.Lackofutilityofabdominalxraysintheevaluationof
childrenwithconstipation:comparisonofdifferentscoringmethods.JPediatrGastroenterolNutr2010
51:155.
17.BergerMY,TabbersMM,KurverMJ,etal.Valueofabdominalradiography,colonictransittime,and
rectalultrasoundscanninginthediagnosisofidiopathicconstipationinchildren:asystematicreview.J
Pediatr2012161:44.
18.RosenR,BuonomoC,AndradeR,NurkoS.Incidenceofspinalcordlesionsinpatientswithintractable
constipation.JPediatr2004145:409.
19.SiddiquiA,RosenR,NurkoS.Anorectalmanometrymayidentifychildrenwithspinalcordlesions.J
PediatrGastroenterolNutr201153:507.
20.AbiHannaA,LakeAM.Constipationandencopresisinchildhood.PediatrRev199819:23.
21.HellersteinS,LinebargerJS.Voidingdysfunctioninpediatricpatients.ClinPediatr(Phila)200342:43.
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

8/24

17/2/2016

Constipationininfantsandchildren:Evaluation

22.LoeningBauckeV.Urinaryincontinenceandurinarytractinfectionandtheirresolutionwithtreatmentof
chronicconstipationofchildhood.Pediatrics1997100:228.
23.TipnisNA,ElChammasKI,RudolphCD,etal.Dooroanaltransitmarkerspredictwhichchildrenwould
benefitfromcolonicmanometrystudies?JPediatrGastroenterolNutr201254:258.
24.LoeningBaucke,V.Constipationandencopresis.In:PediatricGastroenterologyandNutritioninClinical
Practice.LifschitzCH(Ed),MarcelDekker,NewYork2001.p.551.
25.ZaslavskyC,daSilveiraTR,MaguilnikI.Totalandsegmentalcolonictransittimewithradioopaque
markersinadolescentswithfunctionalconstipation.JPediatrGastroenterolNutr199827:138.
26.BenningaMA,BllerHA,TytgatGN,etal.Colonictransittimeinconstipatedchildren:doespediatric
slowtransitconstipationexist?JPediatrGastroenterolNutr199623:241.
27.HutsonJM,McNamaraJ,GibbS,ShinYM.Slowtransitconstipationinchildren.JPaediatrChildHealth
200137:426.
28.deLorijnF,vanWijkMP,ReitsmaJB,etal.Prognosisofconstipation:clinicalfactorsandcolonictransit
time.ArchDisChild200489:723.
29.HussainSZ,DiLorenzoC.Motilitydisorders.Diagnosisandtreatmentforthepediatricpatient.Pediatr
ClinNorthAm200249:27.
30.OsatakulS,PatrapinyokulS,OsatakulN.Thediagnosticvalueofanorectalmanometryasascreening
testforHirschsprung'sdisease.JMedAssocThai199982:1100.
31.PensabeneL,YoussefNN,GriffithsJM,DiLorenzoC.Colonicmanometryinchildrenwithdefecatory
disorders.roleindiagnosisandmanagement.AmJGastroenterol200398:1052.
Topic5906Version30.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&so...

9/24

17/2/2016

Constipationininfantsandchildren:Evaluation

GRAPHICS
Evaluationofaninfantorchildwithconstipation
History

Implications

Wastheredelayed

SuggestsHirschsprungdisease

passageofmeconium
(ie,firstmeconiumafter
48hoursoflife)?
Onsetofconstipation:
Wasconstipation

Morelikelytobeanorganiccause(eg,Hirschsprungdisease)

presentfrombirthor
earlyinfancy?
Wastherea

Suggestsfunctionalconstipation

precedingchangein
dietordiarrheal
illness?
Wastheonset

Suggestsfunctionalconstipation

aroundthetimeof
toilettraining,or
aroundaprecipitating
event?
Werethereproblems
withtoilettraining?
(eg,childresistance,

Suggestsfunctionalconstipation

fearorlatemastery)
Stoolqualityand
appearance:

Isdefecationpainful?

Suggestsfunctionalconstipation

Arethestoolshardor
soft?

Softstoolssuggestscauseotherthanconstipation(eg,dyscheziain
aninfant)

Doesthestoolform

Supportsdiagnosisoffunctionalconstipation

pelletsinthediaper
ortoilet?Dothey
clogthetoilet?
Istherebloodonthe
stool?

Possibleanalfissure,whichcancauseorresultfromfunctional
constipation

Ifthechildistoilet

Indicatesfecalincontinence,whichisusuallyduetofunctional

trained,doesheorshe
have"accidents"inthe

constipationandwithholding,leadingtofecalimpaction

underwear?
Doesthechildhave
stoolwithholding
behavior?("dance",hide

Suggestsfunctionalconstipation,withstoolwithholding

orappeartobetrying
nottohaveabowel
movement)

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

10/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Dietaryissues:
Isthedietunusual?

Lowfluidintakeoccasionallycontributestoconstipation

Aretheresourcesof
fiber?Isthere
adequatefluid?
Didtheconstipation
coincidewitha
changeindiet?(eg,

Suggestsfunctionalconstipation,possiblycow'smilkprotein
intolerance

transitiontosolid
foodsininfants,orto
milk)
Arethereunderlying

Considerneurogeniccausesofconstipationsomecongenital

medicalproblems,
congenitalanomalies,
abnormalgrowth,or

syndromesareassociatedwithHirschsprungdisease(eg,
Downsyndrome).Congenitalmalformations,suchaskidneyand
urinarytractanomalies,alsoraiseconcernsforanorectal,sacraland

developmentaldelay?

spinalabnormalities,whichcaninterferewithdefecation.

Whattreatmentshave
beentried,andwhat

Informsclinicalmanagement

wastheresponse?
Isthereafamilyhistory
offunctional
constipation,

Eachofthesecauseshassomefamilialpatterns

Hirschsprungdisease,or
celiacdisease?

Physical
examination

Abdominaldistension

Severedistensionraisesconcernfororganicdisease

Palpablestoolmass

Consistentwithconstipationfromanycause,butlackofpalpable
stooldoesnotruleoutconstipation

Massinsuprapubicarea

Commonfindinginpatientswithrectalstoolimpaction,butcanalso
suggestsacralteratoma

Cutaneouschangesin
thelumbosacralarea
(dimple,hairtuft,
lipoma,ordeviationof
theglutealcleft)

Suggestsspinaldysraphism

Soiledunderwear(fecal
incontinence)

Inthepresenceofrectalstoolimpaction,suggestsoverflow
incontinenceandfunctionalconstipation

Absentanalwinkor

Suggestsneurologicdysfunction

cremastericreflex,
decreasedlower
extremitytoneor
strength
Analfissureorscarring

Analfissuresmaybeacauseoraconsequenceoffunctional
constipation

Anteriorlydisplaced

Suggestsanorectalanomaly

anus,orperianal
fistula
http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

11/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Digitalrectal
examination:

Analsphinctertone

IncreasedtonesuggestsHirschsprungdisease,lowtonesuggest
neurogenicconstipation

Sizeofrectalvault

Largevaultisconsistentwithchronicfunctionalconstipation

Impactedstool(hard
orsoft)

Softstoolsuggestspossibilityofanorectaldysfunction,including
Hirschsprungdisease

Explosiveexpulsionof
stoolafterthe
examination(squirt
sign)

SuggestsHirschsprungdisease

Graphic79830Version4.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

12/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Causesofconstipationinchildren
Physiologiccausesofconstipation
Functionalconstipation*(mayhavedietaryorbehavioraltriggers,exacerbatedbypainful
defecationandstoolwithholding)
Cow'smilkorotherdietaryproteinintolerance*
Lowdietaryfiber*
Inadequatefluidintake(fever,hotweather)
Immobility
Anorexianervosa
Starvation

Neurogeniccauses
Hirschsprungdisease
Cerebralpalsy
Myelomeningocele
Spinalcordinjury
Closedspinaldysraphism (eg,tetheredcord,sacralagenesis,splitspinalcord
malformation[diastematomyelia])
Sacralteratoma
Neurofibromatosis
Muscularweakness(maybegeneralized,asinDownsyndrome,orduetoabnormal
abdominalmusculature, asinprunebellysyndromeorgastroschisis)
Infantilebotulism (constipationanearlycomplaint,facialandocularpalsies,poorsuck
andhypotoniaareotherfeatures)
Pseudoobstruction(eg,visceralneuropathies,myopathies,mitochondrialdisorders)
Intestinalneuronaldysplasia
Familialoracquireddysautonomia

Endocrineandmetaboliccauses
Cysticfibrosis (withmeconiumileusinneonates, ordistalintestinalobstructionsyndrome
inolderchildren)
Hypokalemia
Leadpoisoning
VitaminDintoxication
Hypoorhypercalcemia
Hypothyroidism
Diabetesmellitus
Pheochromocytoma
Multipleendocrineneoplasiatype2B(MEN2B)
Polyuria(leadingtodehydration)

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

13/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Juvenilesystemicsclerosis(scleroderma)ormixedconnectivetissuedisease
Acuteintermittentporphyria

Anatomiccauses
Anorectalanomalies(imperforateanus, anteriorlydisplacedanus)
Intestinalobstruction (inneonates,consideratresia,websorvolvulus)
Smallleftcolonsyndrome

Othercauses
Celiacdisease*
Drugs(opiates,anticholinergics,antidepressants,chemotherapy,aluminumcontaining
antacids)
*Relativelycommoncause.
Promptdiagnosisisimportanttotheoutcome.
Generallypresentsduringinfancy.
RefertoUpToDatetopicreviewsonclosedspinaldysraphism(spinabifidaocculta).
SimilarfindingsmayoccurininfantswithHirschsprungdisease.
Datafrom:
1.TunnessenWJ.Constipationandfecalretention.In:SignsandSymptomsinPediatrics,3rded,
Lippincott,Williams&Wilkins,Philadelphia1999.p.518.
2.TabbersMM,DilorenzoC,BergerMY,etal.EvaluationandTreatmentofFunctional
ConstipationinInfantsandChildren:EvidenceBasedRecommendationsFromESPGHANand
NASPGHAN.JPediatrGastroenterolNutr201458:265.
Graphic94998Version3.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

14/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Alarmsignsorphysicalfindingsthatsuggestanorganiccauseof
constipationinchildren
Symptomsorhistory
Acutesigns

Physicalfindings
Severeabdominaldistension

Delayedpassageofmeconium(after48
hoursoflife)

Pelvicmass(eg,sacralteratoma)

Fever,vomiting,ordiarrhea

Lumbosacraldimple,hairtuftorlipoma,or
deviationoftheglutealcleft

Rectalbleeding(unlessattributabletoan
analfissure)
Severeabdominaldistension
Chronicsigns
Constipationpresentfrombirthorearly
infancy
Ribbonstools(verynarrowindiameter)

Lowerspineabnormalities

Analscars
Anteriorlydisplacedanus
Patulousanus
Perianalfistula
Tightanalcanalwithemptyrectum

Urinaryincontinenceorbladderdisease

Explosiveexpulsionofstoolafterdigital
examinationoftherectum

Weightlossorpoorweightgain

Absentanalwink

Delayedgrowth(eg,decreasingheight
percentiles)

Absentcremastericreflex

Extraintestinalsymptoms(especially
neurologicdeficits)
Congenitalanomaliesorsyndrome
associatedwithHirschsprungdisease(eg,
Downsyndrome)
FamilyhistoryofHirschsprungdisease

Decreasedlowerextremitytoneor
strength
Abnormallowerextremitydeeptendon
reflex:absenceofdelayinrelaxation
phase
Abnormalthyroidgland
Extremefearduringtheanalinspection

BasedoninformationinTabbersMM,DilorenzoC,BergerMY,etal.EvaluationandTreatmentof
FunctionalConstipationinInfantsandChildren:EvidenceBasedRecommendationsFromESPGHAN
andNASPGHAN.JPediatrGastroenterolNutr201458:265.
Graphic94989Version3.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

15/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Diagnosestoconsiderininfantsandchildrenwithdelayed
passageofmeconium
Condition

Comments

Hirschsprung

Abdominaldistensionandvomitingarecommon.Ondigitalexamination,

disease

typicalfindingsareatightanalcanalwithemptyrectum,oftenwithan
explosive"squirt"ofsoftstoolwhenthefingeriswithdrawn.Oncontrast
enema,atransitionzonemaybeseen,butoftenisnotvisibleinnewborns.

Intestinal

Consideratresia,webs,orvolvulus.Obstructionmaybepresentevenin

obstruction

infantswhopassmeconium.

Meconiumileus

Symptomsoftenbeginonseconddayoflife.Mostpatientswithmeconium
ileushavecysticfibrosis.

Meconiumplug
syndrome

Causedbycolonicdysmotilityorabnormalmeconiumconsistency,

Functionalileus

Occursinsettingofprematurity,sepsis,respiratorydistress,pneumonia,or

leadingtoobstipationinthenewborn.Acontrastenemaisboth
diagnosticandtherapeutic.Somepatientswithmeconiumplug
syndromehaveHirschsprungdisease.
electrolytedisturbances.

Smallleft
colon*

Bariumenemashowssmallcaliberleftcolon.Increasedincidencewith
maternaldiabetes.

Drugs
administeredto
motherbefore
delivery

Magnesiumsulfate(MgSO4),opiates,organglionicblockingagents.

Hypothyroidism

Infantswithhypothyroidismalsomayhaveprolongedjaundice,lethargy,and
lowbodytemperature.

*SimilarfindingsmayoccurininfantswithHirschsprungdisease(HD),soaffectedinfantsshouldbe
observedcloselyandevaluatedforHDifappropriate.
Datafrom:TunnessenWJ.Constipationandfecalretention.In:SignsandSymptomsinPediatrics,
3rded,Lippincott,Williams&Wilkins,Philadelphia1999.p.518.
Graphic82181Version6.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

16/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Causesofvoluntarystoolwithholdingininfantsandchildren
Painfuldefecation
Analfissure
Perianalirritation
Sexualabuse
Hemorrhoids

Changeofenviroment
Newschool,traveling,orotherchangeinroutine
Familystress

Impropertoilettraining
Emotionaldisturbance
Severementalretardation
Depression
Datafrom:TunnessenWJ.Constipationandfecalretention.In:SignsandSymptomsinPediatrics,
3rded,Lippincott,Williams&Wilkins,Philadelphia1999.p.518.
Graphic55786Version4.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

17/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Spectrumofanorectalanatomyinthefemale

A)Normalanatomywithanusinnormallocationandperinealbodybetween
anusandvagina.B)Severeanomalywithrectumendinghighinthevagina.
Arrowheadsmarknormalanallocation.C)Lowanomalywithrectoperineal
fistula(fourchetteectopicanus),anteriortonormalanallocation.D)
Intermediatepositionofanalopeningintheperineum.
Reproducedwithpermissionfrom:HendrenWH.Pediatricrectalandperineal
problems.PediatrClinNorthAm199845:1353.Copyright1998Elsevier.
Graphic78404Version2.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

18/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Rectalshelfinathreemontholdgirlwithan
intermediateanorectalanomaly

A)Theanalopeningisexcentricallylocatedinpigmentedskinof
perineum.Theopeningisnotstenotic.B)Todemonstratethe
posteriorshelf,asurgicalclampisinsertedintotheanalopening,
pullingoutwardontheposteriorlipofanorectalcanal.
Reproducedwithpermissionfrom:HendrenWH.Pediatricrectalandperineal
problems.PediatrClinNorthAm199845:1353.Copyright1998Elsevier.
Graphic62573Version3.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

19/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Nineteenyearoldwomanwithlifelonghistoryof
severeconstipation

A)Inthis19yearoldwomanwithalifelonghistoryofconstipation,
theanusisclearlyanteriorlylocated,withashortperinealbody.
Normally,theanusshouldbelocatedintheshinypigmentedskin,
whichisposteriortoanalopeninginthispatient.B)Bariumenemain
thesamepatient.Thereismarkeddilatationofrectum,extendingto
theanus.Thisisthetypicalappearanceofsocalled"habit
constipation"or"psychogenic"constipation.However,someofthese
casesareprobablycausedbyunrecognizedslightanorectal
malformation,asinthiscase.Afteranoplasty,thispatientdeveloped
normaldefecationpatterns.
Reproducedwithpermissionfrom:HendrenWH.Pediatricrectalandperineal
problems.PediatrClinNorthAm199845:1353.Copyright1998Elsevier.
Graphic65755Version3.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

20/24

17/2/2016

Constipationininfantsandchildren:Evaluation

RomeIIIcriteriaforthediagnosisoffunctionalconstipationin
children
Infantsandtoddlers
Atleasttwoofthefollowingpresentforatleast
onemonth
Twoorfewerdefecationsperweek
Atleastoneepisodeofincontinenceafterthe
acquisitionoftoiletingskills
Historyofexcessivestoolretention
Historyofpainfulorhardbowelmovements
Presenceofalargefecalmassintherectum
Historyoflargediameterstoolsthatmay
obstructthetoilet

Childrenwithdevelopmental
age4to18years
Atleasttwoofthefollowingpresentforat
leasttwomonths*
Twoorfewerdefecationsperweek
Atleastoneepisodeoffecalincontinence
perweek
Historyofretentiveposturingorexcessive
volitionalstoolretention
Historyofpainfulorhardbowelmovements
Presenceofalargefecalmassintherectum
Historyoflargediameterstoolsthatmay
obstructthetoilet

*Inaddition,thesymptomsareinsufficienttofulfillthediagnosticcriteriaofirritablebowel
syndrome.
Datafrom:
1.HymanPE,MillaPJ,BenningaMA,etal.Childhoodfunctionalgastrointestinaldisorders:
Neonate/toddler.Gastroenterology2006130:1519
2.RasquinA,DiLorenzoC,ForbesD,etal.Childhoodfunctionalgastrointestinaldisorders:
child/adolescent.Gastroenterology2006130:1527
Graphic57882Version3.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

21/24

17/2/2016

Constipationininfantsandchildren:Evaluation

BariumenemainHirschsprungdisease

BariumenemaofaninfantwithHirschsprungdisease,showingthe
transitionzone(arrow)betweentheloweraganglionicbowelandthe
normalcolonabove.
CourtesyofGeorgeDFerry,MD.
Graphic59877Version4.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

22/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Functionalconstipation

Thisunpreppedbariumenemaiscompatiblewithfunctional
constipation.Therectumismildlydilatedwithstoolandthereisno
evidenceofobstruction.
CourtesyofGeorgeDFerry,MD.
Graphic58657Version2.0

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

23/24

17/2/2016

Constipationininfantsandchildren:Evaluation

Disclosures
Disclosures:ManuRSood,FRCPCH,MDConsultant/AdvisoryBoards[Malabsorption(Sacrosidase)].EquityOwnership/Stock
Options(spouse/partner):AbbVieAbbott.Employment(spouse/partner):AbbVieNorelevantconflictontopic.BUKLi,MDNothing
todisclose.AlisonGHoppin,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvetting
throughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriately
referencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

http://aplicacionesbiblioteca.udea.edu.co:4560/contents/constipationininfantsandchildrenevaluation?topicKey=PEDS%2F5906&elapsedTimeMs=1&s...

24/24