Figure 104.1 Differential diagnosis of chronic constipation Figure 104.2 Diagnostic criteria for constipation Figure 104.3 Chronic constipation Figure 104.4 (a) A three-pronged approach is needed to manage functional constipation (b) Managing constipation
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Constipation
Constipation in children is a common complaint which presents many therapeutic challenges, depending on the age and presentation of the child. It can be associated with faecal soiling, and can happen at any age. The term ‘faecal impaction’ is also used to describe the condition.
In most cases it is functional (has a non-organic aetiology) and can be diagnosed with a careful history and thorough examination.
Criteria for a definition of functional constipation are mostly based on a variety of symptoms relating to reduced frequency, faecal incontinence and a change in consistency of the stools. A Paris Consensus on Childhood Constipation Terminology (PACCT) working group published a simplified terminology to standardize and define the diagnostic criteria (Figure 104.2).
There are many causes of functional constipation which can be interlinked and thereby make finding an obvious precipitating factor difficult. An understanding of normal bowel physiology that underpins the normal defecation process helps identify possible causes and helps direct appropriate treatment.
The constipated child
At the centre of childhood constipation is stool staying in the colon for longer than it should. This can happen for a variety of reasons and the cause and effect can be intertwined:
- Poor diet and/or low fluid intake
- Fear of pain – passing a hard stool in the past can lead to a delay in toileting or toilet avoidance
- Incomplete rectal evacuation
- Distraction – video games ‘finish this level’
- Embarrassment.
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