Constipation is defined as having fewer than 3 stools per week and most stools are hard and either pebble like or large and painful. Often constipation is accompanied by stool incontinence in children or abdominal pain.
Most breastfed infants under 3 months of age have 3 stools per day and formula fed infants 2 stools per day. As children reach age 12 months stool frequency decreases slightly and continues to decrease until over age 3 years 1 stool per day is the typical frequency. Infants without stools for up to 7 days are not unusual.
In the newborn period, delayed stool passage greater than 48 hours suggests an organic problem such as Hirschsprung’s Disease. Overall, newborn constipation issues suggest an organic or structural cause and constipation under age 12 months is usually dietary related. The onset of constipation after 18-24 months suggests behavioral causes and usually is functional. Constipation is considered to be functional if no organic cause is present. Acute constipation suggests an organic cause and chronic constipation suggests functional causes.
Common symptoms associated with constipation include diffuse colicky intermittent abdominal pain and rectal pain with defecation. Children with constipation will often be fidgety and uncomfortable and perform a “stool dance” when they feel this colicky pain. The child may clench teeth, cross legs, wiggle and squeeze the buttocks together and turn red in the face while trying to hold the bowel movement in to avoid discomfort.
Anal fissures are also common as is a small amount of bright red blood on the surface of stool that is passed. Rectal prolapse is much less common but can occur with chronic constipation and extended periods of “pushing” to have a bowel movement.
A family history of constipation is important as is a history of celiac disease, cystic fibrosis, thyroid disease or Hirschsprung’s Disease. A history of recent family or social-emotional stressors is also common as well as a history of developmental delay or special needs.
If there is a history of infrequent hard, large and painful stools as well as stool withholding behaviors (”stool dance”) and a normal physical examination then the cause is usually functional. If stools are small in caliber, associated with bloody diarrhea or bilious vomiting, weight loss, fever or persistent abdominal pain then organic causes need to be pursued. In cases of malabsorption constipation is common. This is seen in cystic fibrosis and celiac disease. As always a thorough history and physical examination will determine whether a functional or organic cause needs to be pursued.
Your child’s examination will include a growth evaluation with height and weight measurements as well as a general physical examination including an abdominal examination for distension, liver or spleen enlargement, abdominal masses including stool mass and an inspection of the anus. A rectal examination is common unless refused by a child. The rectal examination provides information about the anal sphincter tone and the amount of retained stool in the rectum. Stool can also be tested for blood. A neurologic examination including an inspection of the low back for any signs of spinal abnormalities such as sinus tracts or hair tufts or general asymmetry is performed and reflexes in the lower extremities will be checked to assess possible spinal cord abnormalities including a tethered spinal cord.
Laboratory and radiographic evaluations will be performed if medically indicated based on history and the examination. An abdominal x-ray may be obtained if a rectal examination is not done. This allows the amount of stool in the rectum and colon to be assessed.