Constipation in children: Difference between revisions

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==Overview==
==Overview==


Constipation in childhood is the delay or difficulty in passing stool for more than two weeks. It is one of the most common pathologies that presents to a pediatrician. The diagnosis is based on history, physical exam and a constipation log. As a comparison normal average stooling patterns are detailed below:
[[Constipation]] in childhood is the delay or difficulty in passing stool for more than two weeks. It is one of the most common pathologies that presents to a pediatrician. The diagnosis is based on history, physical exam, and a constipation log. As a comparison, normal average stooling patterns are detailed below:
:* Newborns pass meconium within the first 24 hours of life.
 
:*Newborns pass [[meconium]] within the first 24 hours of life.
:*First week of life:  
:*First week of life:  
:**Infants pass up to four stools per day with breastfed babies developing bowel movements more slowly as the mother's milk is produced.
:**Infants pass up to four stools per day with breastfed babies developing bowel movements more slowly as the mother's milk is produced.
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==Historical Perspective==
==Historical Perspective==


*[Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
There is no historical perspective concerning constipation in children.
*In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
 
*In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
==Classification==
==Classification==
*Constipation in children may be classified according to [classification method] into two subtypes/groups:  
 
*Constipation in children may be classified according to the cause into two subtypes/groups:
 
:*Functional - This is the most common type of constipation in children where there is no anatomic or systemic cause. The predilection is for preschool-aged children. This is further classified according to duration:
:*Functional - This is the most common type of constipation in children where there is no anatomic or systemic cause. The predilection is for preschool-aged children. This is further classified according to duration:
:**Recent onset where symptoms are present within a two month period.
:**Recent onset where symptoms are present within a two month period.
:**Chronic duration is considered for patients with symptoms for three months or more.  
:**Chronic duration is considered for patients with symptoms for three months or more.
:*Organic - the most common causes being celiac disease, hypothyroidism and cow's milk protein allergy.
:*Organic - the most common causes being [[celiac disease]], [[hypothyroidism]], and cow's [[milk]] protein allergy.
:**Care must be taken to exclude urgent causes such as Hirschsprung's disease, cystic fibrosis, lead poisoning, infantile botulism, obstruction, and malformations of the spine. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref> <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>
:**Care must be taken to exclude urgent causes such as [[Hirschsprung's disease]], [[cystic fibrosis]], [[lead poisoning]], infantile [[botulism]], obstruction, and malformations of the spine. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref> <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>


==Pathophysiology==
==Pathophysiology==


*The pathogenesis of constipation in children is most often characterized by painful stools causing the child to withhold to avoid the pain developing a vicious cycle of constipation. Withholding behavior causes the rectum to absorb and retain water from the fecum further creating a harder stool. The eventual defecation of the fecum is difficult and can create anal fissures exacerbating withholding behavior. Repeated accumulation of the fecum can result in dilation of the colon with a loss of sensation leading to slow transit time. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*The pathogenesis of [[constipation]] in children is most often characterized by painful stools causing the child to withhold to avoid the pain developing a vicious cycle of constipation. Withholding behavior causes the rectum to absorb and retain water from the fecum further creating a harder stool. The eventual [[defecation]] of the fecum is difficult and can create anal [[Fissure|fissures]] exacerbating withholding behavior. Repeated accumulation of the fecum can result in dilation of the [[colon]] with a loss of sensation leading to a slow transit time. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


==Causes==
==Causes==
Constipation in children may be caused by functional or organic causes.
[[Constipation]] in children may be caused by functional or organic causes. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref> <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>
 
*Functional causes include:
*Functional causes include:<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
**Fecal [[retention]] to avoid a painful stool.
**Fecal retention to avoid a painful stool
**Developmental disorder component ie [[Attention-deficit hyperactivity disorder|ADHD]], [[Autism]].
**Developmental disorder component ie ADHD, Autism
**Psychological, as in the case of new [[toilet training]] or [[sexual abuse]].
**Psychological, as in the case of new toilet training or sexual abuse <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>
**[[Genetic predisposition]].
**Genetic predisposition
**Poor [[Dietary fiber|fiber]] intake, low fluid intake, or [[malnutrition]].
**Poor fiber intake, low fluid intake or malnutrition
**Introduction of formula or cow's [[milk]].
**Introduction of formula or cow's milk <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>


*Organic causes include:<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Organic causes include:
**Neuromuscular disorders such as congenital megacolon, cerebral palsy, neurofibromatosis
**Neuromuscular disorders such as congenital [[megacolon]], [[cerebral palsy]], [[neurofibromatosis]].
**Anatomic lesions such as gastroschisis
**Anatomic lesions such as [[gastroschisis]].
**Systemic diseases such as cystic fibrosis, diabetes mellitus, hyper or hypothyroidism, Down syndrome  
**Systemic diseases such as [[cystic fibrosis]], [[diabetes mellitus]], [[Hyperthyroid|hyper]] or [[hypothyroidism]], [[Down syndrome]].
**Drug exposure such as narcotics, codeine, antidepressants, and lead poisoning
**Drug exposure such as [[Narcotic|narcotics]], [[codeine]], [[antidepressants]], and [[lead poisoning]].
**Other causes such as cow's milk allergy or celiac disease
**Other causes such as cow's [[milk]] allergy or [[celiac disease]].


==Differentiating Constipation in Children from other Diseases==
==Differentiating Constipation in Children from other Diseases==


Constipation must be differentiated from infantile dischezia, Hirschsprung’s disease, and cystic fibrosis.  
Constipation must be differentiated from infantile dischezia, [[Hirschsprung’s disease]], and [[cystic fibrosis]].  


*Infantile dischezia is a pelvic floor dysfunction that results in diarrhea or constipation presenting in the neonatal period. It is caused by the child not being able to coordination the increased pressure in the abdomen with the relaxation of the pelvis. The disorder is self resolving as the child learns to muscle coordination and does not require any intervention. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Infantile dischezia is a [[pelvic floor]] dysfunction that results in [[diarrhea]] or [[constipation]] presenting in the [[neonatal]] period. It is caused by the child not being able to coordinate the increased pressure in the [[abdomen]] with the relaxation of the [[pelvis]]. The disorder is self resolving as the child learns muscle coordination and does not require any intervention. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Hirschsprung's disease can present with difficulties in passing stool in the neonatal period because of colonic agangliosis. However Hirschsprung's disease would also present with bilious vomiting, refusal to feed, and fever caused by severe enterocolitis. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref> On digital rectal examination, there would be "squirt sign" with relief of gas with stool. <ref name="pmid10985000">{{cite journal| author=Lall A, Gupta DK, Bajpai M| title=Neonatal Hirschsprung's disease. | journal=Indian J Pediatr | year= 2000 | volume= 67 | issue= 8 | pages= 583-8 | pmid=10985000 | doi=10.1007/BF02758486 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10985000  }} </ref>
*[[Hirschsprung's disease]] can present with difficulties in passing stool in the [[neonatal]] period because of colonic agangliosis. However, [[Hirschsprung's disease]] would also present with bilious [[vomiting]], refusal to feed, and a [[fever]] caused by severe [[enterocolitis]]. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref> On [[digital rectal examination]], there would be a "squirt sign" with relief of gas with stool. <ref name="pmid10985000">{{cite journal| author=Lall A, Gupta DK, Bajpai M| title=Neonatal Hirschsprung's disease. | journal=Indian J Pediatr | year= 2000 | volume= 67 | issue= 8 | pages= 583-8 | pmid=10985000 | doi=10.1007/BF02758486 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10985000  }} </ref>
*Cystic fibrosis patients will present with meconium ileus in the neonatal period as well as abdominal distention. These patients can present with constipation but would also have recurrent pulmonary infections and pancreatic insufficiency. <ref name="pmid16202780">{{cite journal| author=Accurso FJ, Sontag MK, Wagener JS| title=Complications associated with symptomatic diagnosis in infants with cystic fibrosis. | journal=J Pediatr | year= 2005 | volume= 147 | issue= 3 Suppl | pages= S37-41 | pmid=16202780 | doi=10.1016/j.jpeds.2005.08.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16202780  }} </ref>
*[[Cystic fibrosis]] patients will present with [[meconium ileus]] in the [[neonatal]] period as well as [[Abdominal distension|abdominal distention]]. These patients can present with [[constipation]] but would also have recurrent pulmonary infections and [[pancreatic insufficiency]]. <ref name="pmid16202780">{{cite journal| author=Accurso FJ, Sontag MK, Wagener JS| title=Complications associated with symptomatic diagnosis in infants with cystic fibrosis. | journal=J Pediatr | year= 2005 | volume= 147 | issue= 3 Suppl | pages= S37-41 | pmid=16202780 | doi=10.1016/j.jpeds.2005.08.034 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16202780  }} </ref>


==Epidemiology and Demographics==
==Epidemiology and Demographics==
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===Prevalence===
===Prevalence===


*The prevalence of constipation in children is between 10% and 23% in North and South America, with lower values of 0.7% to 12% in Europe. Asian populations have a prevalence between 0.5% and 29.6%. <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>
*The [[prevalence]] of [[constipation]] in children is between 10% and 23% in North and South America, with lower values of 0.7% to 12% in Europe. Asian populations have a [[prevalence]] of between 0.5% and 29.6%. <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>
 
===Age===
===Age===


*Constipation in children is more commonly observed among patients aged two to four years old because of the learning process of toilet training. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*[[Constipation]] in children is more commonly observed among patients aged two to four years old because of the learning process of [[toilet training]]. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


===Gender===
===Gender===


*Constipation in children affects boys and girls equally before the age of 5 with girls have more incidence after age 13. <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref>
*[[Constipation]] in children affects boys and girls equally before the age of 5 followed by girls having increased [[incidence]] after age 13. <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref>


===Race===
===Race===
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==Risk Factors==
==Risk Factors==


*Common risk factors in the development of constipation in children are low fiber intake, stressful events such as bullying and familial changes, cow's milk protein allergy, sedentary lifestyle, low birth weight and consumption of processed foods.<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Common risk factors in the development of constipation in children are low [[Dietary fiber|fiber]] intake, stressful events such as bullying and familial changes, cow's [[milk]] protein allergy, sedentary lifestyle, [[low birth weight]] and the consumption of processed foods.<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==


*If left untreated, constipation in children may progress to develop bowel bladder dysfunction, where the chronic constipation with withholding can lead to decreased voiding, causing recurrent urinary tract infections. <ref name="pmid11732126">{{cite journal| author=Feng WC, Churchill BM| title=Dysfunctional elimination syndrome in children without obvious spinal cord diseases. | journal=Pediatr Clin North Am | year= 2001 | volume= 48 | issue= 6 | pages= 1489-504 | pmid=11732126 | doi=10.1016/s0031-3955(05)70387-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11732126  }} </ref>
*If left untreated, [[constipation]] in children may progress to develop bowel bladder dysfunction, where the chronic [[constipation]] with withholding can lead to decreased voiding and recurrent [[Urinary tract infection|urinary tract infections]]. <ref name="pmid11732126">{{cite journal| author=Feng WC, Churchill BM| title=Dysfunctional elimination syndrome in children without obvious spinal cord diseases. | journal=Pediatr Clin North Am | year= 2001 | volume= 48 | issue= 6 | pages= 1489-504 | pmid=11732126 | doi=10.1016/s0031-3955(05)70387-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11732126  }} </ref>
*Common complications of constipation in children  include anal fissures, encoparesis, and withholding behavior. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Common complications of constipation in children  include [[Anal fissure|anal fissures]], encoparesis, and withholding behavior. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Prognosis is generally excellent for patients under five. Patients who don't do well are suspected to have noncompliance of medications. <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref>
*Prognosis is generally excellent for patients under five. Patients who don't do well are suspected to have noncompliance of medications. <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref>
*Prognosis for full recovery is 48%. Those with symptoms early in their life, family history of constipation and history of sexual abuse are associated with a poor prognosis. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Prognosis for full recovery is 48%. Those with symptoms early in their life, family history of [[constipation]] and a history of [[sexual abuse]] are associated with a poor prognosis. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
===Diagnostic Criteria===


*In the Paris Consensus Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met for more than 8 weeks: <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*In the Paris Consensus Criteria, the diagnosis of [[constipation]] in children is made when at least two of the following diagnostic criteria are met for more than 8 weeks: <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


:*Less than 3 bowel movements per week  
:*Less than 3 bowel movements per week.
:*More than one fecal leakage episode per week  
:*More than one fecal leakage episode per week.
:*Rectal obstruction caused by large diameter stools  
:*Rectal obstruction caused by large diameter stools.
:*Withholding behavior  
:*Withholding behavior.
:*Painful defecation  
:*Painful [[defecation]].


*In the Rome III Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met; with children over four years old requiring to have the symptoms for a minimum of two months: <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*In the Rome III Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met; with children over four years old requiring to have the symptoms for a minimum of two months: <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


:*Less than 2 bowel movements per week
:*Less than 2 bowel movements per week.
:*Fecal incontinence episode after achieving complete bowel control  
:*[[Fecal incontinence]] episode after achieving complete bowel control.
:*Rectal obstruction caused by large diameter stools  
:*Rectal obstruction caused by large diameter stools.
:*Withholding behavior  
:*Withholding behavior.
:*Painful defecation
:*Painful defecation.
:*Large fecal mass seen in digital rectal examination
:*Large [[fecal mass]] seen in [[digital rectal examination]].


===Symptoms===
===Symptoms===
Line 114: Line 114:
*Symptoms of constipation in children may include the following:<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Symptoms of constipation in children may include the following:<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


:*Straining
:*Straining.
:*Crying
:*Crying.
:*Bleeding per rectum  
:*[[Bleeding per rectum]].
:*Anal tears
:*Anal tears.
:*Withholding behavior
:*Withholding behavior.
:*Nocturnal fecal soiling in response to loss of sensation
:*Nocturnal fecal soiling in response to a loss of sensation.
:*Abdominal pain
:*[[Abdominal pain]].
:*Nausea
:*Nausea.
:*Decreased appetite
:*Decreased appetite.
:*Enuresis
:*[[Enuresis]].
:*Urinary tract infections because of hard fecum obstructing urinary flow
:*[[Urinary tract infection|Urinary tract infections]] because of hard fecum obstructing urinary flow.
:*Hard stools <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>
:*Hard stools. <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>


*Alarm symptoms point to an organic cause:<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Alarm symptoms point to an organic cause:<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


:*Ribbon stools
:*Ribbon stools.
:*Blood in stools without anal fissures
:*Blood in stools without anal [[Fissure|fissures]].
:*Fever
:*[[Fever]].
:*Bilious vomiting
:*Bilious [[vomiting]].
:*Failure to thrive
:*Failure to thrive.
:*More than 48 hours to pass meconium
:*More than 48 hours to pass [[meconium]].
:*Occult blood in stool
:*Occult [[blood in the stool]].
:*Fear when anus is being examined due to pain
:*Fear when the [[anus]] is being examined due to pain.
:*Sacral dimple, agenesis
:*[[Sacral dimple]], agenesis.
:*Perianal scars, fistula
:*Perianal scars, [[fistula]].
:*Pilonidal dimple with hair tuft
:*[[Pilonidal cyst|Pilonidal dimple]] with hair tuft.
:*Abnormal anus position
:*Abnormal [[anus]] position.
:*Thyroid gland abnormalities
:*[[Thyroid gland]] abnormalities.
:*Family history of Hirschsprung's disease
:*Family history of [[Hirschsprung's disease]].
:*Fecal mass with empty rectum
:*Fecal mass with an empty [[rectum]].
:*Air or fluid release on digital rectal examination
:*Air or fluid release on [[digital rectal examination]].
:*Absence of anal wink, anal reflex, cremasteric reflex
:*Absence of an anal wink, anal reflex, or cremasteric reflex.
:*Delayed lower extremity deep tendon reflexes
:*Delayed lower extremity deep tendon reflexes.
:*Decreased lower extremity tone, strength and sensation
:*Decreased lower extremity tone, strength, and sensation.


===Physical Examination===
===Physical Examination===


*Patients with constipation usually appear pale and fatigued. <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref>
*Patients with [[constipation]] usually appear [[Pallor|pale]] and fatigued.  
*Physical examination may be remarkable for: <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref>
*Physical examination may be remarkable for: <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref> <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume= | issue=  | pages= | pmid=30725722 | doi= | pmc= | url= }} </ref>


:*mouth ulcers
:*[[Oral ulcer|Mouth ulcers]].
:*blood or mucus in the stools
:*Blood or mucus in the stools.
:*perianal skin tags or fistulae
:*Perianal skin tags or [[Fistula|fistulae]].
:*hypotonia
:*[[Hypotonia]].
:*absent lower extremity reflexes
:*Absent lower extremity reflexes.
:*fever
:*[[Fever]].
:*exopthalmos and lid lad for hypothyroidism <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>
:*[[Exophthalmos|Exopthalmos]] and lid lag for [[hypothyroidism]].
:*abdominal distension or mass
:*[[Abdominal distension]] or mass.
:*lumbar abnormalities or hair tufts <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref>
:*[[Lumbar]] abnormalities or hair tufts.


*Digital rectal examinations are not routinely done but may assist in diagnosis for the following patients:<ref name="pmid24345831">{{cite journal| author=Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S | display-authors=etal| title=Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. | journal=J Pediatr Gastroenterol Nutr | year= 2014 | volume= 58 | issue= 2 | pages= 258-74 | pmid=24345831 | doi=10.1097/MPG.0000000000000266 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24345831  }} </ref>
*[[Digital rectal examinations]] are not routinely done but may assist in diagnosis for the following patients:<ref name="pmid24345831">{{cite journal| author=Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S | display-authors=etal| title=Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. | journal=J Pediatr Gastroenterol Nutr | year= 2014 | volume= 58 | issue= 2 | pages= 258-74 | pmid=24345831 | doi=10.1097/MPG.0000000000000266 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24345831  }} </ref>
:*Symptoms of constipation since infanthood
 
:*Alarm signs present suggesting organic causes
:*Symptoms of [[constipation]] since infanthood.
:*Patients not fully meeting the diagnostic criteria with continuance of symptoms
:*Alarm signs present suggesting organic causes.
:*Patients not fully meeting the diagnostic criteria with the continuance of symptoms.


===Laboratory Findings===
===Laboratory Findings===


*If the patient does not respond to initial treatment, testing must be done for celiac disease (IgA antibodies to tissue transglutaminase), lead levels, CBC, serum electrolytes and a thyroid function test, uranalysis, urine culture, sweat test, fecal occult blood test, allergy testing.  
*If the patient does not respond to initial treatment, testing must be done for [[celiac disease]] (IgA antibodies to tissue [[transglutaminase]]), lead levels, [[Complete blood count|CBC]], serum electrolytes, [[Thyroid function tests|thyroid function test]], [[urinalysis]], [[urine culture]], [[sweat test]], [[fecal occult blood test]], and [[allergy testing]].
*If lab results are negative with no response to treatment, organic causes must be further investigated through chest radiograph if there is difficulty to examine the patient, barium enema, anorectal manometry and rectal biopsy to exclude Hirschsprung's disease, and MRI of the lumbosacral spine. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*If lab results are negative with no response to treatment, organic causes must be further investigated through a radiograph, [[barium enema]], [[anorectal manometry]] and rectal biopsy to exclude Hirschsprung's disease, and a MRI of the [[lumbosacral spine]]. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


===Electrocardiogram===
===Electrocardiogram===
Line 178: Line 179:


===X-ray===
===X-ray===
An abdominal x-ray may be helpful in the diagnosis of constipation in children. Findings on an x-ray suggestive of constipation include retained stool. However, these are not routinely done and the diagnosis should be approached through history and physical examination primarily. A spinal radiograph can be considered if there are findings to suggest an organic cause with neurological impairment. <ref name="pmid24345831">{{cite journal| author=Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S | display-authors=etal| title=Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. | journal=J Pediatr Gastroenterol Nutr | year= 2014 | volume= 58 | issue= 2 | pages= 258-74 | pmid=24345831 | doi=10.1097/MPG.0000000000000266 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24345831  }} </ref>
An [[abdominal x-ray]] may be helpful in the diagnosis of [[constipation]] in children. Findings on an x-ray suggestive of [[constipation]] include retained stool. However, these are not routinely done and the diagnosis should be approached through history and physical examination primarily. A spinal radiograph can be considered if there are findings to suggest an organic cause with neurological impairment. <ref name="pmid24345831">{{cite journal| author=Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S | display-authors=etal| title=Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. | journal=J Pediatr Gastroenterol Nutr | year= 2014 | volume= 58 | issue= 2 | pages= 258-74 | pmid=24345831 | doi=10.1097/MPG.0000000000000266 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24345831  }} </ref>


===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===
Line 187: Line 188:


===MRI===
===MRI===
MRI may be helpful in the diagnosis of constipation in children. Findings on MRI suggestive of lumbosacral spine abnormalities may be helpful to identify neuropathic causes of dysfunction <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
MRI may be helpful in the diagnosis of constipation in children. Findings on MRI suggestive of [[lumbosacral spine]] abnormalities may be helpful to identify neuropathic causes of dysfunction <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>


===Other Imaging Findings===
===Other Imaging Findings===


A contrast enema may be helpful in excluding Hirschsprung's disease as the cause for constipation. <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref> This should be completed without measures to clean out the stool. Findings on an barium enema diagnostic of Hirschsprung's disease include a transition zone where the normal rectum transitions to a dilated portion that is aganglionic. This is always confirmed by a rectal biopsy. <ref name="pmid18679610">{{cite journal| author=Stranzinger E, DiPietro MA, Teitelbaum DH, Strouse PJ| title=Imaging of total colonic Hirschsprung disease. | journal=Pediatr Radiol | year= 2008 | volume= 38 | issue= 11 | pages= 1162-70 | pmid=18679610 | doi=10.1007/s00247-008-0952-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18679610  }} </ref>
A [[contrast enema]] may be helpful in excluding [[Hirschsprung's disease]] as the cause for [[constipation]]. <ref name="pmid30725722">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30725722 | doi= | pmc= | url= }} </ref> This should be completed without measures to clean out the stool. Findings on an [[Lower gastrointestinal series|barium enema]] diagnostic of [[Hirschsprung's disease]] include a transition zone where the normal [[rectum]] transitions to a dilated portion that is aganglionic. This is always confirmed by a rectal biopsy. <ref name="pmid18679610">{{cite journal| author=Stranzinger E, DiPietro MA, Teitelbaum DH, Strouse PJ| title=Imaging of total colonic Hirschsprung disease. | journal=Pediatr Radiol | year= 2008 | volume= 38 | issue= 11 | pages= 1162-70 | pmid=18679610 | doi=10.1007/s00247-008-0952-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18679610  }} </ref>


===Other Diagnostic Studies===
===Other Diagnostic Studies===


*Constipation in children can also be evaluated by parents giving a symptom and dietary history log including frequency of bowel movements, pain and description of the stool. <ref name="pmid12074527">{{cite journal| author=Arce DA, Ermocilla CA, Costa H| title=Evaluation of constipation. | journal=Am Fam Physician | year= 2002 | volume= 65 | issue= 11 | pages= 2283-90 | pmid=12074527 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12074527  }} </ref>
*[[Constipation]] in children can also be evaluated by parents giving a symptom and dietary history log including frequency of bowel movements, pain and description of the stool. <ref name="pmid12074527">{{cite journal| author=Arce DA, Ermocilla CA, Costa H| title=Evaluation of constipation. | journal=Am Fam Physician | year= 2002 | volume= 65 | issue= 11 | pages= 2283-90 | pmid=12074527 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12074527  }} </ref>
*Radiopaque marker studies can be considered in patients who are not responding to treatment with an unclear diagnosis. This is used primarily to diagnose slow transit constipation or outlet obstruction. <ref name="pmid27325615">{{cite journal| author=Benninga MA, Tabbers MM, van Rijn RR| title=How to use a plain abdominal radiograph in children with functional defecation disorders. | journal=Arch Dis Child Educ Pract Ed | year= 2016 | volume= 101 | issue= 4 | pages= 187-93 | pmid=27325615 | doi=10.1136/archdischild-2015-309140 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27325615  }} </ref>
*Radiopaque marker studies can be considered in patients who are not responding to treatment with an unclear diagnosis. This is used primarily to diagnose slow transit constipation or outlet obstruction. <ref name="pmid27325615">{{cite journal| author=Benninga MA, Tabbers MM, van Rijn RR| title=How to use a plain abdominal radiograph in children with functional defecation disorders. | journal=Arch Dis Child Educ Pract Ed | year= 2016 | volume= 101 | issue= 4 | pages= 187-93 | pmid=27325615 | doi=10.1136/archdischild-2015-309140 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27325615  }} </ref>


Line 202: Line 203:


*Treatment for constipation in children depends on the age group:<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
*Treatment for constipation in children depends on the age group:<ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref>
**Infants 3 months to 1 year are offered sorbitol containing juices diluted with water, trial of avoiding cow's milk, breastfed children with trial of the mother avoiding cow's milk. Glycerin suppositories and laxatives can be used for children 6 months and older if needed. Infants older than 6 months should also increase consumption of fruits and vegetables.
**Infants 3 months to 1 year are offered sorbitol containing juices diluted with water, a trial of avoiding cow's milk, breastfed children with a trial of the mother avoiding cow's milk. Glycerin suppositories and [[Laxative|laxatives]] can be used for children 6 months and older if needed. Infants older than 6 months should also increase the consumption of fruits and vegetables.
**In children treatment consists of three phases:
**In children treatment consists of three phases:
:#Disimpaction of hard fecum through osmotic laxatives (lactulose, bisacodyl suppository, magnesium citrate, magnesium hydroxide, paraffin oil, sorbital, senna, paraffin oil) for 1-3 days.
:#Restoring muscle tone through stool softeners for 2-6 months.
:#Restore normal bowel movements by increasing fiber and water intake and reducing laxative use gradually for 4-6 months.


*Treatment also includes behavior modification of re-toilet training with routine scheduled toilet visits. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref> Possible psychological issues must be addressed and a star reward system can be helpful in tracking improvement. <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref>
:#Disimpaction of the hard fecum through osmotic [[Laxative|laxatives]] ([[lactulose]], [[bisacodyl]] suppository, [[magnesium citrate]], [[magnesium hydroxide]], [[paraffin oil]], [[sorbitol]], or [[senna]]) for 1-3 days.
:#Restoring muscle tone through [[Stool softeners (patient information)|stool softeners]] for 2-6 months.
:#Restore normal bowel movements by increasing [[Dietary fiber|fiber]] and water intake and reducing [[laxative]] use gradually for 4-6 months.
 
*Treatment also includes behavior modification of re-[[toilet training]] with routine scheduled toilet visits. <ref name="pmid26435640">{{cite journal| author=Xinias I, Mavroudi A| title=Constipation in Childhood. An update on evaluation and management. | journal=Hippokratia | year= 2015 | volume= 19 | issue= 1 | pages= 11-9 | pmid=26435640 | doi= | pmc=4574579 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26435640  }} </ref> Possible psychological issues must be addressed and a star reward system can be helpful in tracking improvement. <ref name="pmid21668945">{{cite journal| author=Afzal NA, Tighe MP, Thomson MA| title=Constipation in children. | journal=Ital J Pediatr | year= 2011 | volume= 37 | issue=  | pages= 28 | pmid=21668945 | doi=10.1186/1824-7288-37-28 | pmc=3143086 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21668945  }} </ref>


===Surgery===
===Surgery===


*Patients who are refractory to medical management may require an anal sphincter release through myectomy. <ref name="pmid25775070">{{cite journal| author=Siminas S, Losty PD| title=Current Surgical Management of Pediatric Idiopathic Constipation: A Systematic Review of Published Studies. | journal=Ann Surg | year= 2015 | volume= 262 | issue= 6 | pages= 925-33 | pmid=25775070 | doi=10.1097/SLA.0000000000001191 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25775070  }} </ref>
*Patients who are refractory to medical management may require an anal sphincter release through [[myectomy]]. <ref name="pmid25775070">{{cite journal| author=Siminas S, Losty PD| title=Current Surgical Management of Pediatric Idiopathic Constipation: A Systematic Review of Published Studies. | journal=Ann Surg | year= 2015 | volume= 262 | issue= 6 | pages= 925-33 | pmid=25775070 | doi=10.1097/SLA.0000000000001191 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25775070  }} </ref>


===Prevention===
===Prevention===


*Effective measures for the primary prevention of constipation in children include anticipatory guidance with parents with respect to proper nutrition, diet and toilet training. Parents should be advised that children are likely to experience constipation in transition phases such as entering school, starting cow's milk or during toilet training. <ref name="pmid6737192">{{cite journal| author=Abrahamian FP, Lloyd-Still JD| title=Chronic constipation in childhood: a longitudinal study of 186 patients. | journal=J Pediatr Gastroenterol Nutr | year= 1984 | volume= 3 | issue= 3 | pages= 460-7 | pmid=6737192 | doi=10.1097/00005176-198406000-00027 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6737192  }} </ref> If parents are aware of forthcoming episodes they can quickly move to the treatment phase. Once children are introduced with solid foods, parents should be advised to also increase their fluid intake. Parents should also encourage routine use of the toilet after meals to begin toilet training measures while keeping a close monitor of their bowel habits. <ref name="pmid11063041">{{cite journal| author=Loening-Baucke V| title=Clinical approach to fecal soiling in children. | journal=Clin Pediatr (Phila) | year= 2000 | volume= 39 | issue= 10 | pages= 603-7 | pmid=11063041 | doi=10.1177/000992280003901005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11063041  }} </ref> Parents can be on the lookout for withholding behaviors, possible anal fissures exacerbating the withholding behavior, and over use of cow's milk. <ref name="pmid9770556">{{cite journal| author=Iacono G, Cavataio F, Montalto G, Florena A, Tumminello M, Soresi M | display-authors=etal| title=Intolerance of cow's milk and chronic constipation in children. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 16 | pages= 1100-4 | pmid=9770556 | doi=10.1056/NEJM199810153391602 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9770556  }} </ref>
*Effective measures for the primary prevention of [[constipation]] in children include anticipatory guidance with parents with respect to proper [[nutrition]], diet and [[toilet training]]. Parents should be advised that children are likely to experience constipation in transition phases such as entering school, starting cow's [[milk]] or during [[toilet training]]. <ref name="pmid6737192">{{cite journal| author=Abrahamian FP, Lloyd-Still JD| title=Chronic constipation in childhood: a longitudinal study of 186 patients. | journal=J Pediatr Gastroenterol Nutr | year= 1984 | volume= 3 | issue= 3 | pages= 460-7 | pmid=6737192 | doi=10.1097/00005176-198406000-00027 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6737192  }} </ref> If parents are aware of forthcoming episodes they can quickly move to the treatment phase. Once children are introduced with solid foods, parents should be advised to also increase their fluid intake. Parents should also encourage routine use of the toilet after meals to begin [[toilet training]] measures while keeping a close monitor of their bowel habits. <ref name="pmid11063041">{{cite journal| author=Loening-Baucke V| title=Clinical approach to fecal soiling in children. | journal=Clin Pediatr (Phila) | year= 2000 | volume= 39 | issue= 10 | pages= 603-7 | pmid=11063041 | doi=10.1177/000992280003901005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11063041  }} </ref> Parents can be on the lookout for withholding behaviors, possible anal fissures exacerbating the withholding behavior, and the overuse of cow's milk. <ref name="pmid9770556">{{cite journal| author=Iacono G, Cavataio F, Montalto G, Florena A, Tumminello M, Soresi M | display-authors=etal| title=Intolerance of cow's milk and chronic constipation in children. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 16 | pages= 1100-4 | pmid=9770556 | doi=10.1056/NEJM199810153391602 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9770556  }} </ref>
*Toilet training of children should begin when they display developmental, physical and behavioral signs of being ready though there are unclear age guidelines. Parents should indicate proper vocabulary for indicating the child has to go to the bathroom and encouragement to use a potty chair. Parents should not punish the child if accidents occur. A proper routine should be established according to the child's pace and understanding. <ref name="pmid10353954">{{cite journal| author=Stadtler AC, Gorski PA, Brazelton TB| title=Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics. | journal=Pediatrics | year= 1999 | volume= 103 | issue= 6 Pt 2 | pages= 1359-68 | pmid=10353954 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10353954  }} </ref>
*[[Toilet training]] of children should begin when they display developmental, physical, and behavioral signs of being ready. Parents should indicate proper vocabulary for the child to express having to go to the bathroom and encouragement to use a potty chair. Parents should not punish the child if accidents occur. A proper routine should be established according to the child's pace and understanding. <ref name="pmid10353954">{{cite journal| author=Stadtler AC, Gorski PA, Brazelton TB| title=Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics. | journal=Pediatrics | year= 1999 | volume= 103 | issue= 6 Pt 2 | pages= 1359-68 | pmid=10353954 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10353954  }} </ref>


==References==
==References==
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[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Primary care]]

Latest revision as of 21:01, 24 February 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dushka Riaz, MD

Synonyms and keywords: Constipation in kids

Overview

Constipation in childhood is the delay or difficulty in passing stool for more than two weeks. It is one of the most common pathologies that presents to a pediatrician. The diagnosis is based on history, physical exam, and a constipation log. As a comparison, normal average stooling patterns are detailed below:

  • Newborns pass meconium within the first 24 hours of life.
  • First week of life:
    • Infants pass up to four stools per day with breastfed babies developing bowel movements more slowly as the mother's milk is produced.
  • First 3 months of life:
    • Formula-fed infants passing two stools per day.
    • Breastfed infants passing three stools per day.
  • Toddlers at age two with under two stools per day.
  • Children under age four with 1-2 stools per day.

Historical Perspective

There is no historical perspective concerning constipation in children.

Classification

  • Constipation in children may be classified according to the cause into two subtypes/groups:
  • Functional - This is the most common type of constipation in children where there is no anatomic or systemic cause. The predilection is for preschool-aged children. This is further classified according to duration:
    • Recent onset where symptoms are present within a two month period.
    • Chronic duration is considered for patients with symptoms for three months or more.
  • Organic - the most common causes being celiac disease, hypothyroidism, and cow's milk protein allergy.

Pathophysiology

  • The pathogenesis of constipation in children is most often characterized by painful stools causing the child to withhold to avoid the pain developing a vicious cycle of constipation. Withholding behavior causes the rectum to absorb and retain water from the fecum further creating a harder stool. The eventual defecation of the fecum is difficult and can create anal fissures exacerbating withholding behavior. Repeated accumulation of the fecum can result in dilation of the colon with a loss of sensation leading to a slow transit time. [1]

Causes

Constipation in children may be caused by functional or organic causes. [1] [2]

Differentiating Constipation in Children from other Diseases

Constipation must be differentiated from infantile dischezia, Hirschsprung’s disease, and cystic fibrosis.

Epidemiology and Demographics

Prevalence

  • The prevalence of constipation in children is between 10% and 23% in North and South America, with lower values of 0.7% to 12% in Europe. Asian populations have a prevalence of between 0.5% and 29.6%. [2]

Age

Gender

  • Constipation in children affects boys and girls equally before the age of 5 followed by girls having increased incidence after age 13. [5]

Race

  • There is no racial predilection for constipation.

Risk Factors

  • Common risk factors in the development of constipation in children are low fiber intake, stressful events such as bullying and familial changes, cow's milk protein allergy, sedentary lifestyle, low birth weight and the consumption of processed foods.[1]

Natural History, Complications and Prognosis

  • If left untreated, constipation in children may progress to develop bowel bladder dysfunction, where the chronic constipation with withholding can lead to decreased voiding and recurrent urinary tract infections. [6]
  • Common complications of constipation in children include anal fissures, encoparesis, and withholding behavior. [1]
  • Prognosis is generally excellent for patients under five. Patients who don't do well are suspected to have noncompliance of medications. [5]
  • Prognosis for full recovery is 48%. Those with symptoms early in their life, family history of constipation and a history of sexual abuse are associated with a poor prognosis. [1]

Diagnosis

Diagnostic Criteria

  • In the Paris Consensus Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met for more than 8 weeks: [1]
  • Less than 3 bowel movements per week.
  • More than one fecal leakage episode per week.
  • Rectal obstruction caused by large diameter stools.
  • Withholding behavior.
  • Painful defecation.
  • In the Rome III Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met; with children over four years old requiring to have the symptoms for a minimum of two months: [1]

Symptoms

  • Symptoms of constipation in children may include the following:[1]
  • Alarm symptoms point to an organic cause:[1]

Physical Examination

  • Patients with constipation usually appear pale and fatigued.
  • Physical examination may be remarkable for: [5] [2]
  • Symptoms of constipation since infanthood.
  • Alarm signs present suggesting organic causes.
  • Patients not fully meeting the diagnostic criteria with the continuance of symptoms.

Laboratory Findings

Electrocardiogram

There are no ECG findings associated with constipation in children.

X-ray

An abdominal x-ray may be helpful in the diagnosis of constipation in children. Findings on an x-ray suggestive of constipation include retained stool. However, these are not routinely done and the diagnosis should be approached through history and physical examination primarily. A spinal radiograph can be considered if there are findings to suggest an organic cause with neurological impairment. [7]

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with constipation in children.

CT scan

There are no CT scan findings associated with constipation in children.

MRI

MRI may be helpful in the diagnosis of constipation in children. Findings on MRI suggestive of lumbosacral spine abnormalities may be helpful to identify neuropathic causes of dysfunction [1]

Other Imaging Findings

A contrast enema may be helpful in excluding Hirschsprung's disease as the cause for constipation. [2] This should be completed without measures to clean out the stool. Findings on an barium enema diagnostic of Hirschsprung's disease include a transition zone where the normal rectum transitions to a dilated portion that is aganglionic. This is always confirmed by a rectal biopsy. [8]

Other Diagnostic Studies

  • Constipation in children can also be evaluated by parents giving a symptom and dietary history log including frequency of bowel movements, pain and description of the stool. [9]
  • Radiopaque marker studies can be considered in patients who are not responding to treatment with an unclear diagnosis. This is used primarily to diagnose slow transit constipation or outlet obstruction. [10]

Treatment

Medical Therapy

  • Treatment for constipation in children depends on the age group:[1]
    • Infants 3 months to 1 year are offered sorbitol containing juices diluted with water, a trial of avoiding cow's milk, breastfed children with a trial of the mother avoiding cow's milk. Glycerin suppositories and laxatives can be used for children 6 months and older if needed. Infants older than 6 months should also increase the consumption of fruits and vegetables.
    • In children treatment consists of three phases:
  1. Disimpaction of the hard fecum through osmotic laxatives (lactulose, bisacodyl suppository, magnesium citrate, magnesium hydroxide, paraffin oil, sorbitol, or senna) for 1-3 days.
  2. Restoring muscle tone through stool softeners for 2-6 months.
  3. Restore normal bowel movements by increasing fiber and water intake and reducing laxative use gradually for 4-6 months.
  • Treatment also includes behavior modification of re-toilet training with routine scheduled toilet visits. [1] Possible psychological issues must be addressed and a star reward system can be helpful in tracking improvement. [5]

Surgery

  • Patients who are refractory to medical management may require an anal sphincter release through myectomy. [11]

Prevention

  • Effective measures for the primary prevention of constipation in children include anticipatory guidance with parents with respect to proper nutrition, diet and toilet training. Parents should be advised that children are likely to experience constipation in transition phases such as entering school, starting cow's milk or during toilet training. [12] If parents are aware of forthcoming episodes they can quickly move to the treatment phase. Once children are introduced with solid foods, parents should be advised to also increase their fluid intake. Parents should also encourage routine use of the toilet after meals to begin toilet training measures while keeping a close monitor of their bowel habits. [13] Parents can be on the lookout for withholding behaviors, possible anal fissures exacerbating the withholding behavior, and the overuse of cow's milk. [14]
  • Toilet training of children should begin when they display developmental, physical, and behavioral signs of being ready. Parents should indicate proper vocabulary for the child to express having to go to the bathroom and encouragement to use a potty chair. Parents should not punish the child if accidents occur. A proper routine should be established according to the child's pace and understanding. [15]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 Xinias I, Mavroudi A (2015). "Constipation in Childhood. An update on evaluation and management". Hippokratia. 19 (1): 11–9. PMC 4574579. PMID 26435640.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 "StatPearls". 2020. PMID 30725722.
  3. ↑ Lall A, Gupta DK, Bajpai M (2000). "Neonatal Hirschsprung's disease". Indian J Pediatr. 67 (8): 583–8. doi:10.1007/BF02758486. PMID 10985000.
  4. ↑ Accurso FJ, Sontag MK, Wagener JS (2005). "Complications associated with symptomatic diagnosis in infants with cystic fibrosis". J Pediatr. 147 (3 Suppl): S37–41. doi:10.1016/j.jpeds.2005.08.034. PMID 16202780.
  5. ↑ 5.0 5.1 5.2 5.3 Afzal NA, Tighe MP, Thomson MA (2011). "Constipation in children". Ital J Pediatr. 37: 28. doi:10.1186/1824-7288-37-28. PMC 3143086. PMID 21668945.
  6. ↑ Feng WC, Churchill BM (2001). "Dysfunctional elimination syndrome in children without obvious spinal cord diseases". Pediatr Clin North Am. 48 (6): 1489–504. doi:10.1016/s0031-3955(05)70387-4. PMID 11732126.
  7. ↑ 7.0 7.1 Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S; et al. (2014). "Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN". J Pediatr Gastroenterol Nutr. 58 (2): 258–74. doi:10.1097/MPG.0000000000000266. PMID 24345831.
  8. ↑ Stranzinger E, DiPietro MA, Teitelbaum DH, Strouse PJ (2008). "Imaging of total colonic Hirschsprung disease". Pediatr Radiol. 38 (11): 1162–70. doi:10.1007/s00247-008-0952-4. PMID 18679610.
  9. ↑ Arce DA, Ermocilla CA, Costa H (2002). "Evaluation of constipation". Am Fam Physician. 65 (11): 2283–90. PMID 12074527.
  10. ↑ Benninga MA, Tabbers MM, van Rijn RR (2016). "How to use a plain abdominal radiograph in children with functional defecation disorders". Arch Dis Child Educ Pract Ed. 101 (4): 187–93. doi:10.1136/archdischild-2015-309140. PMID 27325615.
  11. ↑ Siminas S, Losty PD (2015). "Current Surgical Management of Pediatric Idiopathic Constipation: A Systematic Review of Published Studies". Ann Surg. 262 (6): 925–33. doi:10.1097/SLA.0000000000001191. PMID 25775070.
  12. ↑ Abrahamian FP, Lloyd-Still JD (1984). "Chronic constipation in childhood: a longitudinal study of 186 patients". J Pediatr Gastroenterol Nutr. 3 (3): 460–7. doi:10.1097/00005176-198406000-00027. PMID 6737192.
  13. ↑ Loening-Baucke V (2000). "Clinical approach to fecal soiling in children". Clin Pediatr (Phila). 39 (10): 603–7. doi:10.1177/000992280003901005. PMID 11063041.
  14. ↑ Iacono G, Cavataio F, Montalto G, Florena A, Tumminello M, Soresi M; et al. (1998). "Intolerance of cow's milk and chronic constipation in children". N Engl J Med. 339 (16): 1100–4. doi:10.1056/NEJM199810153391602. PMID 9770556.
  15. ↑ Stadtler AC, Gorski PA, Brazelton TB (1999). "Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics". Pediatrics. 103 (6 Pt 2): 1359–68. PMID 10353954.
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