Functional constipation accounts for 95% of cases of childhood constipation. With a combination of lifestyle changes focusing on diet, physical activity, toilet habits and use of laxatives if needed, 75% of children with functional constipation will achieve remission within 6 months. However, 50% may experience relapse within a year of stopping treatment. Evaluation of history and examination is important to identify red flags and rule out the 5% of cases that are caused by organic disease.

2. Introduction
• Frequency of defecation reduces gradually
from > 4 times/day in first year to about 1
time/day by age 4 y.
• From 5 yrs of age, children pass stools like
adult pattern.
4 X 1 then 1 X 4
Range from
3 times/day upto 3 times/week

3. Fecal continence
• is maintained by :
• Internal anal sphincter is
Involuntary muscle
• The external anal
sphincter is under
voluntary control

4. Defecation reflex

5. Child who does not want to defecate

6. Definition
• Any definition of constipation is relative and
depends on :
Stool frequency
Stool consistency
Difficulty in passing the stool with pain
Duration of condition

7. Definition
• So Constipation is considered in children
when :
• Stool frequency < 3 times/week
• Hard stool
• Passed with difficulty sufficient to cause
significant pain to the patient.
• Persist for > 4 weeks
Acute < 8 weeks > chronic

8. Is Constipation common ?
• About 30 % of children
• 5 % of the visits to general pediatrics
• 25% of the visits to Gastroenterologists
• School age  Boys > Girls ratio = 3 : 1
• After puberty  females > males ratio = 3 : 1

9. Is Constipation Serious ?
• Constipation is a symptom not a disease.
• it may be the only present symptom of a
serious underlying disorder.

10. Mechanism

11. Classification
FunctionalOrganic
95 %5 %Incidence
No
But with
Genetic predisposition
Environmental Life changes
Contributing Factors
ABCD
YesApparent Cause
TTT of the Contributing Factors
ABCD
TTT of the causeTTT

12. Causes of Organic constipation
Intestinal nerve/muscle disorder: HSD,
neuronal dysplasia, pseudo-obstruction
Intestinal:CMPA,Celiac,CF / IBD,IB$
Anorectal:anteriorly placed anus,anal stenosis,pelvic mass
Spinal Cord Anomalies:myelomeningocoele,Sacral Agenesis
,teethered cord,Cauda equina $
Neurological: CP,MR
Psycho-social: autism, child abuse
Endocrinal:hypothyroid, hypercalcemia / D.I,D.M
Renal : CRF
Drugs: opiates,codeine,phenobarbitone,anticholinergic/
diuretics /antacids,sucralfate/ vincristine,
lead,iron,vit D toxicity

13. Functional constipation
• Common during period of changes :
Weaning (change type of foods)
Toilet training (change defecation position)
School entry (change surrounding environment)
Travel , stress (change routine)

14. Contributing factors for
Functional constipation
• Lack of physical Activity : more likely for
obese with sedentary life.

15. Contributing factors for
Functional constipation
• Behavioral factors : ignore the urge to defaecate
• Infants :
 to not to stop a play activity
 negative feelings and fear toward public toilets
 Peri anal irritation (Fissure – Parasites)
 stressful events (sibling birth , parental divorce, nursery
entry)
• Children < 5 y : as a way of asserting independence.
• School aged children : because they feel shy about using a
school, camp, or public toilets.
• Toilet training Position : start toilet training too early 
child may refuse and withhold stool.

16. Contributing factors for
Functional constipation
• Diet : less Fluid and less Fiber intake

17. FunctionalOrganic
Usually after 1 yr of agesince birthOnset of constipation
NoCommonH/O of delayed meconium
UncommonCommonAbdominal distension
NoCommonFTT
NopossibleMalnutrition
NopossibleEnterocolitis
defective emptyingdefective fillingMechanism
Ampulla is filled with stoolAmpulla is emptyPR
NoYesFecal mass above rectum

18. FunctionalOrganic
YesNoPassage of large stool
YesNoPassage of flatus
YesNoFissure
YesNoPainful defecation
CommonNoneWithholding
CommonNoneFaecal incontinence
NormalNormalAnal tone
Rectal Distension
Int sphincter relaxation
No Rectal Distension
No int sphincter relaxation
Anorectal manometry
Massive amounts of stool,
No transition zone
Delayed evacuation ,
Transition zone
Barium enema
NormalDiagnosticRectal biopsy

19. History
• Family’s definition of constipation
• Age of onset
• Timing of meconium passage after birth (< 48hr)
• Stool freqequency
• Stool consistency
• Duration of condition
• Toilet Pain , difficulty
• Toilet training
• Toilet refusal and withholding behavior
• Faecal incontinence
• Urinary incontinence

20. • Weight loss or Weight gain
• Loss of appetite
• Rectal blood loss
• Dietary history
• Medication history
• Developmental history
• Psychosocial history
• Family’s history of constipation : due to shared
genetic or environmental factors.

21. Red flags on history
• Age of onset < 1 y (first few weeks)
• Delayed passage of meconium (> 48hr)
• Absence of withholding
• Absence of Faecal incontinence
• Presence of Urinary incontinence
• FTT
• No response to conventional therapy > 6 m

22. Examination
• Height and weight ( FTT)
• Abdomen : palpable faecal masses
• Spine : absent sacrum , deep sacral cleft or
tuft of hair
• Neurology : assessment of L.L tone & power
• Anal area : visually examine for site , fissures ,
piles , signs of sexual abuse + P.R 

23. P.R Examination
• It is the most important part of the physical examination.
• Perform P.R in any child with chronic constipation > 8 weeks ,
regardless of age.
• Upon P.R examination, note :
• Anal site
• Anal canal and Rectal size
• Anal tone
• Presence of anal wink
• Perianal sensation
• Perianal irritation
• Intrarectal masses
• the rectum is empty or filled with stool
• the consistency of the stool

24. Red flags on examination
• FTT
• Pilonidal sinus , dimple , tuft of hair
• Midline pigmentary abnormalities
• Lack of lumbosacral curve
• Flat buttocks
• Abdominal distension
• Absent cremastric reflex , L.L weakness
• Anteriorly placed anus,Patulous anus, Absent anal wink.
• Empty rectum on P.R

25. Investigations
• ESPGHAN and NASPGHAN not recommended
routine investigations to screen for organic
cause of constipation in absence of Red flags.

26. Lab Investigations
• Free T4/TSH
• Serum electrolyte (Na, K, Ca)
• TTG IgA in difficult to treat
• Sweet Cl chronic constipation with FTT

27. Rad Investigations
• Spinal cord problems (spine imaging x ray-MRI)
• Barium enema
• Rectal manometry when Red flags seen
• Rectal biopsy Suspecting HSD

28. Complications• Intestinal :
• Recurrent abdominal colics
• Abdominal distension
• Vomiting
• Decreased appetite
• Anal fissures, piles , prolapse
• Fecal incontinence
• Extra Intestinal :
• Urinary incontinence
• Recurrent UTIs
• FTT
• Low self-esteem, depression

29. ESPGHAN/NASPGHAN Guidelines
Red flags on History & examination
Yes
Investigate for
Organic cause
No
Functional constipation
(By Exclusion)
Clinical Diagnosis
A B C D

30. Physical Activity & Weight
• Regular physical activity helps to stimulate
normal bowel function.
• Weight reduction

31. Behaviour modifications
• Allow enough time to have a bowel movement , do
not get in a hurry & do not ignore the urge to have a
bowel movement.
• Praise child for sitting on toilet, keep toileting a
positive experience.
• Toilet chart – to reinforce positive behaviour and
record frequency of bowel actions.
• Delay toilet training attempts until child is painlessly
passing soft stool.
• Toilet sits for 10 minutes after each meal to benefit
from Gastrocolic reflex.

32. Good Position (Footstool)

33. Diet
• GIT Motility is stimulated by :
• ↑ Fibers , ↑ Carbohydrates intake
• GIT Motility is inhibited by :
• ↑ Fat , ↑ Ptn intake
Advice
• No processed foods , meat
• No junk foods: Wafers, Chips, Ruffles , …. etc
• No fried, pasta, burgers, pizza , noodles , ... Etc
• No sweets
Breakfast is a Must

34. Fibers
• Fiber is nondigestable substance that resists enzymatic
digestion  reaches the colon unchanged  fermented by
colonic bacteria → retains water  softening stool 
prokinetic effect
• Fiber that is not fermented →increases stool bulk → osmotic
effect
• Increase the amount of fiber consumed daily  increased
stool bulk , softness  ease evacuation.
• Normal fiber intake 10 g/day
Advice
• excess fibers
• to determine fiber intake in gm/day  use the rule of :
15 gm/1000 kcals/day OR age in Y + 5

35. Foods Rich in Fibers
• Fresh Fruits ,Vegetables = 1 gm/serving
• Whole grains Breads = 1 gm/serving
• Cereals = 2 gm/serving
• Legumes like Beans , Chickpeas , Lentils = 2
gm/serving
• Sorbitol containing juices as apple, pear, prune
= 2 gm/serving
• 3 good sources of fiber that kids are happy to
eat are PopCorn , Corn flakes , trail mix (dried
fruits , nuts , chocolate) = 2 gm/serving

36. Fluids
• Child should drink plenty of non-caffeinated
fluids daily.
• Water requirements throughout the day :
• Limit Sugary drinks to
100 ml/day in infants
200 ml/day in children
0.5 L/10 kg
Water is the best

37. Milk & Milk products
• Can slow intestinal motility (↑ Fat , Ptn) and
satiates the child by decreasing the intake of
other fluids and foods that promote soft
stools.
• No excessive cows milk intake (max 500
ml/day)
• Limited amounts of Processed milk like cheese
• But Foods containing probiotics, like yogurt,
can also promote good digestive health.

38. Trade name in MarketActive ingradient5 Groups
Mechanism (↑ peristalsis )
Benefiber Powders
Bran Tab
----
Agiocur Granules
Synthetic as Methylcellulose
Natural as
Bran
 Agar
Psyllium
1- Bulk forming
similar to natural fiber
nondigestable substance
↑ stool bulk
Epicogel Sy– Maalox Sy – Epimag Sach
Laxel Sach– Fleet Enema
1. Salts : (Na or Mg)
Mg salts (sulfate, hydroxide,citrate)
Na po4
2- Osmotics
nonabsorpable substance
↑ stool bulk
Lactulose Sy
Sorbitol Sach
2.Sugars :
Lactulose (disaccharide)
Sorbitol (monosaccharide)
Movicol Sach - Laxo Sach3. PEG
Glycerine Supp – Laxolene Supp4. Glycerin
Norgalax EnemaDocusate salts (Na or Ca)
3- Softeners (Emollients)
incorporation of fat into the stool
Paraffin OilParaffin oil
4- Lubricants (Mineral Oil)
↓ water absorption from GIT
Castor oilSmall bowel : Castor oil5- Stimulants (Irritants)
↑ salt and water secretion into GIT
Pico Drops – Skilax DropsLarge bowel : Na So4
Laxocodyl Supp – TabBisacodyl
Purgaton TabSenna

39. Rectal Disimpaction
• < 2 y : Glycerine supp
OR Rectal stimulation with lubricated thermometer
• > 2 y : Enemas
• It is a mechanical stimulation
• used to remove impacted stool from the rectum
• useful only for stool in the rectum, not in the rest of
GIT.
• used occasionally and should not be used frequently
because tolerance may develop & infants become
behaviorally conditioned to depend upon rectal
stimulation to initiate stooling.
• In addition, glycerin may irritate the anus or rectal
mucosa.

40. Laxative options
• < 6 m  Glycerine supp
• > 6 m 
 in acute constipation < 8 weeks  Lactulose
 in chronic constipation > 8 weeks  PEG
• Because with long term use, lactulose loses its efficacy
due to change in gut flora but PEG does not.
• So PEG more effective than lactulose in chronic cases.
• If no improvement after 1 m  add Mineral oil
“Paraffin oil”
• If still no improvement after another 1 m  add
stimulants “Castor oil” or Pico drops or Laxocodyl supp

41. Laxative options
• Stimulant laxatives are used in refractory
cases as a rescue therapy for a short course
(transient or intermittent periods)
• In children : we can use all
• In infants : Avoid mineral oil , stimulants

42. 2 Common Mistakes
1- not using an enough dose
2- stopping it too early after child’s first normal-
looking bowel movement.
• These 2 common mistakes lead to recurrence.

43. 2 Common Misconcepts
1-The bowel movement daily is necessary.
2- The wastes stored in the body are absorbed
and are dangerous to health or shorten the
life span.
• These 2 common misconcepts lead to a
marked overuse and abuse of laxatives 

44. Laxative abuse $ = Lazy bowel $
• This delay reinforces the need for more
laxatives doses to maintain bowel.
• To avoid this $  The dose of laxative should
be adjusted ↑ or ↓ gradually to have 1 – 2
soft stools/day.

45. Other Laxatives side effects
• Loss of water , lytes (Na , K)
• Poor absorption of vitamins and minerals
• Damage GIT epithelium

46. treatment effective
Yes
Gradual weaning
Relapse
No
Stop medication
Follow up
Yes
yes
No
Check ABCD
↑Dose
add other medication
Organic etiology ?
Specific inv

47. Referral
• Children with constipation need to be
referred to a Gastroenterologist & surgeon
when :
• Red flags for organic disease
• Intractable constipation = No response to
adequate therapy after 6 months
• Fecal incontinence
• Behavior abnormalities: depression , low self
esteem

48. Gastroenterologists
• New Medical therapies :
• Serotonin agonists (cisapride, tegaserod ,
Prucalopride) : selective, high affinity to 5HT4
receptor.
• Lubiprostone (Amitiza) : which opens Cl
channels in the GIT  stimulates intestinal
fluid secretion and shortens GIT transit time.

49. Gastroenterologists
• New Medical interventions :
• Sacral nerve modulation non relaxing
• Botulinum toxin A (Botox) sphincter

50. Surgeons
• have Surgical interventions as :
• Recto/Sigmoid Resection : in Resistent cases
if hugely dilated megacolon.

51. Results
• Medications only  remission within 6 m
• Combination of ABCD together is the best
results  remission within 3 months
• Ideal dose for 3 months with adjustment
↑or↓
• Gradual weaning from laxatives  3 months

52. Follow up
• Initial F/U should be monthly till a regular
bowel movement is achieved.
• then every 3 months for 2 years
• then yearly.

53. Prognosis
• about 75 % of all children with functional
constipation recover and are taken off
medication within 6 months
• Recurrence of constipation after initial
Recovery is common (50% may Relapse within
a year of stopping therapy) but they Respond
well to Retreatment
• but about 25 % continues to experience
symptoms at adult age

54. Summary
• Constipation is a common problem in 30 %
• Majority of childhood constipation is
functional 95%
• Majority of childhood constipation will
recover 75%
• 50 % can relapse
• Clinical diagnosis with detailed History,
Examination is important to exclude presence
of Red flags of Organic disease.
• Investigations have limited value except in
Organic disease.

55. • Proper care of diet & eating habits.
• Early initiation for therapy to prevent withholding
• Recovery is slow , Requires prolonged therapy and
follow-up, No quick solution , No miracles to be
expected.
• Early referral if needed
• Non-response despite adequate treatment and good
compliance suggests need for further investigation
and think in organic causes.

56. Thank You