What is constipation in children?

• Constipation is generally defined as infrequent defecation, painful defecation, or both. In most cases, parents are worried that their child's stools are too large, too hard, not frequent enough, and/or painful to pass. The North American Society of Gastroenterology, Hepatology, and Nutrition (NASPGHAN) defines constipation as "a delay or difficulty in defecation, present for 2 weeks or more, and sufficient to cause significant distress to the patient. The Paris Consensus on Childhood Constipation Terminology (PACCT) defines constipation as "a period of 8 weeks with at least 2 of the following symptoms: defecation frequency less than 3 times per week, fecal incontinence frequency greater than once per week, passage of large stools that clog the toilet, palpable abdominal or rectal fecal mass, stool withholding behavior, or painful defecation.

What causes childhood constipation?

• Most children suffering from constipation have no underlying medical condition. They are often labeled as having functional constipation or acquired megacolon. In most cases, childhood constipation develops when the child begins to associate pain with defecation. Once pain is associated with the passage of bowel movements, the child begins to withhold stools in an attempt to avoid discomfort. However certain children have correctable surgical causes like Hirschsprung Disease. Constipation occurs in all pediatric age groups from infancy to young adulthood. Typically, childhood constipation develops during 3 stages of childhood: in infants during weaning, in toddlers during toilet training, and in school-aged children.

 How it is diagnosed?

• History and physical examination including rectal examination is useful for diagnosis. Sacral dimples, pits, anal fissures, fistula, hemorrjoids and even anorectal malformations can be diagnosed. For practical purposes, in an otherwise healthy child, the differential diagnosis of chronic constipation is Hirschsprung disease and functional constipation.

What investigations  are needed for diagnosis?

• Plain X-ray Abdomen

• Contrast enema

• Anorectal manometry

• Rectal biopsy- definitive

How is is treated?

• The basic components of therapy include evacuation of the colon, elimination of pain with defecation, establishing regular bowel habits and dietary modifications. If the child has anal fissures, using Xylocaine ointment or hydrocortisone suppositories for a short time period to provide symptomatic relief may be helpful. It is generally recommended that the child be encouraged to attend the toilet twice daily for 5-10 minutes, preferably after breakfast and after supper to take advantage of the gastrocolic reflex. Dietary changes, such as increasing the child's intake of fluids and carbohydrates, are commonly recommended as part of the treatment of constipation. Balanced diet that includes whole grains, fruits, vegetables, and an abundance of fluids seems appropriate. In infants and young children, consider removing cow-milk protein from the diet for a period, because chronic constipation may be precipitated by ingestion of cow-milk proteins.

Severe Pediatric constipation

• Constipation which require more aggressive treatments, and surgery can be labelled as severe Pediatric Constipation. Most  of these children have functional (idiopathic) constipation, which has a wide spectrum of severity. A small number of patients have very severe bowel dysmotility . Apart from these, patients who have undergone surgery for anorectal malformations (ARMs), as well as those with Hirschsprung disease  can suffer from severe constipation and incontinence. Many of these children are managed by Bowel Management Program. The two surgical procedures described for these children management are colonic resection and access for antegrade enemas (Malone). Patients with internal anal sphincter achalasia benefit from injection of botulinum toxin into the internal sphincter. Patients with pelvic floor dyssynergia may benefit from biofeedback alone or a combination of biofeedback and botulinum toxin.