Functional constipation is a common issue in pediatric patients, affecting up to 30% of children and causing significant morbidity. The condition is characterized by infrequent or painful bowel movements and can arise from withholding behavior and various developmental stages such as dietary changes and toilet training. Management includes education, dietary modifications, and in some cases, probiotic treatments to improve symptoms.

1. Functional Constipation
Infants & Children
Material For Healthcare Professionals Only
BREASTFEEDING IS BEST FOR BABIES
Dr. Hooria Rehman
Assistant Professor
(Pediatrician, Pediatric Gastroenterologist)
Lahore General Hospital

2. Which of the following is the most common organic
cause of constipation in pediatric patients?
A. Hirschsprung disease
B. Hypokalaemia
C. Imperforate anus
D. Occult spina bifida

3. Which of the following is the most common organic
cause of constipation in pediatric patients?
A. Hirschsprung disease
B. Hypokalaemia
C. Imperforate anus
D. Occult spina bifida

4. Definition
Infrequent, difficult, painful or incomplete evacuation of hard
stools
Functional constipation describes all children in whom
constipation does not have an organic etiology.
Commonly the result of withholding of feces in a child who
wants to avoid painful defecation.
Frequently, children will also experience recurrent episodes of
fecal incontinence due to overflow caused by fecal impaction
(known as encopresis).

5. STAGES OF CONSTIPATION
Three
periods
during which
the infant/
child are
particularly
prone to
develop
functional
constipation.
1st: : after the introduction of cereals
and solid food into the infant's diet
2nd : with toilet training
3rd: during the start of school
https://www.physio-pedia.com/Pediatric_Functional_Constipation

6. Functional Constipation
• Constipation affects up to 30 percent of children
• Nearly 10% of all pediatric hospital visits can be attributable to constipation
• Functional constipation is responsible for more than 95 percent of cases of constipation in healthy
children one year and older and is particularly common among preschool-age children.
• It causes morbidity on both a physical and psychological level
https://pjmhsonline.com/index.php/pjmhs/article/view/4983/4927
https://ferozsons-labs.com/functional-constipation/

7. Prevalence of Constipation in Different Ages
https://www.becares.in/Scientific_Articles/modulating-the-gut-microbiome-to-manage-pediatric-functional-constipation

8. Diagnostic Criteria, Rome IV for Functional Constipation
Infants and toddlers up to 4 years old Children and adolescents age >4 years
At least 2 of the following present for at least 1 month At least 2 of the following present at least once per
week for at least 1 month
 2 or fewer defecations per week
 History of excessive stool retention
 History of painful or hard bowel movements
 History of large diameter stools
 Presence of large fecal mass in the rectum
*In toilet trained children
 At least 1 episode/week of incontinence
 History of large diameter stools that may obstruct the
toilet
 2 or fewer defecations per week
 At least 1 episode/week of incontinence
 History of retentive posturing or excessive volitional
stool retention
 History of painful or hard bowel movements
 Presence of large fecal mass in the rectum
 History of large diameter stools that may obstruct the
toilet
 Symptoms cannot be explained by another medical
condition

9. POTENTIAL ALARM FEATURES in Constipation

10. CONSEQUENCES
1: http://www.cps.ca/documents/position/functional-constipation
2:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042216/
Approximately 30% of affected children will continue to have symptoms beyond puberty contrary to the common belief
that children outgrow constipation
Abdominal Pain Appetite Suppression Fecal Incontinence
Lowered self-esteem Social Isolation Family Disruption

11. How to Approach Functional Constipation
Medical History Physical Exam
Digital Rectal Exam Lab Tests
Abdominal Imaging
Anorectal
Manometry
https://www.physio-pedia.com/Pediatric_Functional_Constipation

12. Medical History & Physical Exam
HISTORY
• Age of onset
• Passage of first meconium
• Frequency and consistency of stools
• Abdominal pain, Vomiting , Weight loss
• Fecal incontinence,
• Withholding behavior
• Dietary history
• Stressful life events
• Neurodevelopmental delay
• positive family history for gastrointestinal
disease
EXAMINATION
 Growth Parameters
 Abdominal Exam
 Inspection :Perianal Region
 Inspection : Lumbosacral Region
 Digital Rectal Exam
https://www.physio-pedia.com/Pediatric_Functional_Constipation

13. Management
Education
Fecal Disimpaction
Behavioral Modification
Dietary Modification
Maintenance Therapy

14. Management
Education
• Mechanism of
functional constipation
• Toilet learning
• physical &
psychological
components of
chronic constipation,
• the role of diet
Fecal
Disimpaction
•Achieved via oral /
rectal meds
Behavioral
Management
• Establishing proper
feeding time including
meals and snacks
• Establish regular toilet
routine
Dietary
Management
•Balanced diet that
includes whole grains,
fruits, and vegetables
• Fiber
• Adequate hydration
• Eliminating Cows milk
Maintenance
Therapy
•Laxatives
•Probiotics
•Lactose
•Magnesium
Nelson Textbook of Pediatrics, 21st Edition 2020

15. Can The Gut Microbiome Be
Modulated to Tackle
Functional Constipation?
Gut microbiological
imbalance is an
important factor
associated with
functional
constipation.

16. EMERGING ROLE OF PROBIOTICS
• Administration of Bifidobacterium or Lactobacillus has also
been shown to improve colonic transit times in
constipated patients
• The administration of L reuteri (DSM 17938) in infants
with functional chronic constipation has a positive effect
on bowel frequency.
• Because of their safety profile, probiotics may be an
attractive option in the treatment of functional
constipation.
https://www.uptodate.com/contents/chronic-functional-constipation-and-fecal-incontinence-in-infants-children-and-adolescents-
treatment?search=management%20of%20functional%20constipation%20in%20toddlers&source=search_result&selectedTitle=1~30&usage_type=default&display_rank=1#H4
Coccorullo P et al” Lactobacillus reuteri (DSM 17938) in infants with functional chronic constipation: a double-blind, randomized, placebo-controlled study; J Pediatr. 2010 Oct;157(4):598-602.

17. EMERGING ROLE OF PROBIOTICS
• One RCT involved 44 infants aged ≥6 months
with functional constipation according to the
Rome III criteria who were randomly assigned to
receive L. reuteri DSM 17938
(Limosilactobacillus reuteri)- or placebo for
8 weeks.
• Compared with the placebo group, infants in the
L. reuteri group had a significantly higher
frequency of bowel movements at week 2
(P = 0.042), week 4 (P = 0.008), and week 8
(P = 0.027).
Magdalena Urbańska and Hania Szajewska ;” The efficacy of Lactobacillus reuteri DSM 17938 in
infants and children: a review of the current evidence”: Eur J Pediatr. 2014; 173(10): 1327–1337.

18. EMERGING ROLE OF PROBIOTICS
Paola Coccorullo et al”Lactobacillus reuteri (DSM 17938) in Infants with Functional Chronic Constipation: A Double-Blind, Randomized, Placebo-Controlled Study ; The Journal of
Pediatrics;Volume 157, Issue 4, October 2010, Pages 598–602

19. EMERGING ROLE OF LACTOSE
It has prebiotic effects in that it is not completely absorbed in
young infants
It stimulates the development of bifidogenic flora, which in turn
bring the stools of formula-fed infants closer to the stools of
breast-fed infants
Non-hydrolyzed lactose reaches the colon, where it is
metabolized by anaerobic microorganisms, producing an osmotic
laxative
Oscar O Segarra et al ‘ Modification of stool’s water content in constipated infants: management with an adapted infant formula” Infante et al. Nutrition Journal 2011, 10:55
http://www.nutritionj.com/content/10/1/55

20. EMERGING ROLE OF MAGNESIUM
• Magnesium has an osmotic effect which draws water into gut,
thus increase intestinal motility
Oscar O Segarra et al ‘ Modification of stool’s water content in constipated infants: management with an adapted infant formula” Infante et al. Nutrition Journal 2011, 10:55
http://www.nutritionj.com/content/10/1/55
Magnesium
Osmotic
effect
Intestinal
Motility

21. A 4-month-old male infant is brought to the emergency department by his grandmother because he has had
constipation, irritability, and weakness and has been feeding poorly during the past 4 days. The grandmother
has custody of the patient. She says she has been introducing many new foods to the infant on a weekly basis.
On physical examination, ptosis is noted, and the patient has a weak cry. Based on these findings, which of the
following is the most appropriate next step in management?
A. Barium enema
B. Measurement of blood lead level
C. Referral for genetic testing
D. Test of the stool for botulinum toxin

22. Test of the stool for botulinum toxin. This patient has constipation in addition to other symptoms that are indicative of infant
botulism, which could result from his caregiver feeding him honey before the appropriate age. Choice A is an appropriate
test only if Hirschsprung disease were suspected. Choice B is an appropriate next step if lead poisoning were suspected.
Choice C is an appropriate test if cystic fibrosis were suspected.
A 4-month-old male infant is brought to the emergency department by his grandmother because he has had
constipation, irritability, and weakness and has been feeding poorly during the past 4 days. The grandmother
has custody of the patient. She says she has been introducing many new foods to the infant on a weekly basis.
On physical examination, ptosis is noted, and the patient has a weak cry. Based on these findings, which of the
following is the most appropriate next step in management?
A. Barium enema
B. Measurement of blood lead level
C. Referral for genetic testing
D. Test of the stool for botulinum toxin
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26. THANK YOU
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