Functional Constipation

Children with functional constipation (FC) often present to the ED with impaction or colicky abdominal pain. The prevalence of FC  in infants and toddlers is approximately 20%. While organic causes are responsible for less than 5% of constipation in children, FC  may mimic surgical causes of abdominal pain, such as appendicitis, intussusception and bowel obstruction, thus a careful  assessment is required before making this diagnosis.

• The Rome IV Criteria¹ are validated clinical criteria used to diagnose FC and include features such as ≤2 bowel movements (BMs) per week, stool retention, painful/hard BMs, large diameter BMs +/- toilet obstruction, presence of a large fecal  mass in the rectum and fecal incontinence.
• While the Rome IV Criteria require symptoms to be present for at least one month, FC may be diagnosed in the ED with a  shorter duration of symptoms.
• Use the Bristol Stool Chart² to help young patients/caregivers describe the consistency of stool.
• Consider infantile dyschezia in infants under 6 months. This is a benign, self-limited condition due to temporary  uncoordinated defecation that is characterized by painful straining and crying before passing soft stools.
• Confirm the absence of red flags that would suggest another cause of constipation (see below).

• Routine investigations, including screening for celiac and hypothyroidism, are not recommended unless indicated by red flag  features identified on history or physical examination.³
• Abdominal radiographs should not be performed. Their use is associated with misdiagnosis and unnecessary radiation  exposure.⁴
• Chronic constipation is associated with urinary tract infections (UTIs) and voiding dysfunction in children. Consider testing for UTI in infants/children with constipation and fever without a source.⁵

• FC is a chronic, relapsing and remitting condition that requires long term management, and may require repeated disimpaction and maintenance phases of treatment.
• Acute and symptomatic impaction of stool requires disimpaction followed by maintenance therapy for AT LEAST 2 months to retrain the bowel.
• Disimpaction is achieved with a high dose osmotic laxative (e.g., PEG 3350, first line) and a stimulant (e.g., bisacodyl, senna) may be added for 1 to 3 days, if needed.
• Maintenance is achieved with a lower dose osmotic laxative (e.g., PEG 3350, first line).
• Enemas may be considered if oral disimpaction fails, but are generally avoided as they are invasive, can cause pain and  discomfort, and carry a small risk of electrolyte disturbances.

Step 1: Prior to labelling with refractory constipation, confirm/consider:

1. 1. Successful disimpaction has been achieved (rectal exam may be indicated at this stage)
   2. Adequate PEG 3350 dose and adherence for 2 months
   3. Toileting routine and adherence (scheduled post-meal toilet sits)
   4. Diet and hydration are appropriate
   5. Behavioral issues (stool withholding, fear) are addressed
   6. Absence of any new red flag symptoms/signs (see Page 1)
   7. Potential diagnosis of irritable bowel syndrome, subtype with constipation, if abdominal pain is the predominant symptom

Step 2: Add adjunct osmotic laxative (e.g., milk of magnesia, lactulose) and change the stimulant laxative (e.g., switch from bisacodyl to pico-salax); for dosing information refer to TREKK’s Functional Constipation Medication Dosing Recommendations.

Step 3: If the above steps fail, consider referring to Pediatrics/Pediatric GI/Pediatric Referral Centre and/or other Health Care Provider with experience in managing refractory constipation (e.g., dietitian, psychologist, physiotherapist).

• For more information: NASPGHAN/ESPGHAN Algorithm for evaluation and treatment of FC in infants and children.
• CHEO Constipation handouts for parents and families in English and French.
• McMaster Children’s Hospital (MCH) GoPoop Program is available in English only. Some MCH doses may vary from doses in  this TREKK resource; use either resource as appropriate.
• ECHO-KT and ARCHE Constipation infographic and video for parents and families in English.

Thank you to the following content experts who led the development of the Constipation Bottom Line Recommendations:

Mohamed Eltorki, MBChB, MSc, FRCPC, Assistant Clinical Professor, Division of Emergency Medicine, McMaster University.

Paige Landy, MBChB, FRCPC (PEM), Assistant Clinical Professor, Department of Pediatrics, McMaster University.

Thank you to the TREKK Editorial Committee, editors Drs. Sarah Reid (CHEO) and Sey Shwetz (University of Saskatchewan), who provided editorial support and expertise in the development of this resource. Thank you as well to TREKK Project Manager Megan Bale-Nick and TREKK Research Coordinator Jessica Meza Resillas, (University of Manitoba) who coordinated the review and update process.

1. NICE. Bristol Stool Chart. National Institute for Health and Care Excellence. 2013.
2. Hyams JS, Di Lorezo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood Functional Gastrointestinal Disorders:  Child/Adolescent. Gastroenterology. 2016;150(6):1456-68.e2.
3. Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children:  Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-74.
4. Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant  misdiagnoses. J Pediatr. 2014;164(1):83-8.e2.
5. Shaikh N, Hoberman A, Keren R, et al. Recurrent urinary tract infections in children with bladder and bowel dysfunction.  Pediatrics. 2016;137(1):e20152982.
6. Bekkali NL, van den Berg MM, Dijkgraaf MG, et al. Rectal fecal impaction treatment in childhood constipation: Enemas  versus high doses oral peg. Pediatrics. 2009;124(6):e1108-15.
7. MCH. MCH GoPoop PROGRAM. McMaster Children’s Hospital. 2021.
8. CHEO. WHAT YOU NEED TO KNOW: CONSTIPATION. Children’s Hospital of Eastern Ontario. 2020.
9. CHEO. CE QU’IL FAUT SAVOIR : LA CONSTIPATION. Children’s Hospital of Eastern Ontario. 2020.
10. CHU Sainte-Justine. Constipation fonctionnelle et encoprésie. CHU Sainte-Justine. 2023.

For a complete list of the evidence that informed the creation of the Constipation Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use