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Functional constipation in infants and children: Clinical features and differential diagnosis

Manu R Sood, FRCPCH, MD
Section Editor
Deputy Editor
Alison G Hoppin, MD


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 [1]. Although it is common, the complaint should not be ignored because children with functional constipation will benefit from prompt and thorough treatment interventions. Delayed or inadequate intervention may result in stool withholding behavior with worsening constipation and psychosocial consequences.

The clinician also has an important role in identifying the small fraction of children with organic causes of constipation. Organic causes of constipation are more likely among young infants, and among infants and children presenting with atypical features or "alarm signs" (table 1).

The clinical features that are typical for functional constipation are described in this topic review, and features of specific organic causes of constipation are summarized briefly. Other aspects of managing the infant or child with constipation are discussed in the following topic reviews:

(See "Constipation in infants and children: Evaluation".)

(See "Functional fecal incontinence in infants and children: Definition, clinical manifestations and evaluation".)

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Literature review current through: Sep 2017. | This topic last updated: Sep 28, 2017.
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  1. Loening-Baucke V. Prevalence, symptoms and outcome of constipation in infants and toddlers. J Pediatr 2005; 146:359.
  2. Thompson WG, Longstreth GF, Drossman DA, et al. Functional bowel disorders and functional abdominal pain. Gut 1999; 45 Suppl 2:II43.
  3. Benninga MA, Faure C, Hyman PE, et al. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016.
  4. Hyams JS, Di Lorenzo C, Saps M, et al. Functional Disorders: Children and Adolescents. Gastroenterology 2016.
  5. Di Lorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am 2001; 30:269.
  6. Fontana M, Bianchi C, Cataldo F, et al. Bowel frequency in healthy children. Acta Paediatr Scand 1989; 78:682.
  7. Hyams JS, Treem WR, Etienne NL, et al. Effect of infant formula on stool characteristics of young infants. Pediatrics 1995; 95:50.
  8. den Hertog J, van Leengoed E, Kolk F, et al. The defecation pattern of healthy term infants up to the age of 3 months. Arch Dis Child Fetal Neonatal Ed 2012; 97:F465.
  9. Peeters B, Noens I, Philips EM, et al. Autism spectrum disorders in children with functional defecation disorders. J Pediatr 2013; 163:873.
  10. McKeown C, Hisle-Gorman E, Eide M, et al. Association of constipation and fecal incontinence with attention-deficit/hyperactivity disorder. Pediatrics 2013; 132:e1210.
  11. Di Lorenzo C. Childhood constipation: finally some hard data about hard stools! J Pediatr 2000; 136:4.
  12. Giorgio V, Borrelli O, Smith VV, et al. High-resolution colonic manometry accurately predicts colonic neuromuscular pathological phenotype in pediatric slow transit constipation. Neurogastroenterol Motil 2013; 25:70.
  13. Partin JC, Hamill SK, Fischel JE, Partin JS. Painful defecation and fecal soiling in children. Pediatrics 1992; 89:1007.
  14. American Academy of Pediatrics. Guide to Toilet Training, Elk Grove Village, IL 2003.
  15. Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics. Pediatrics 1999; 103:1359.
  16. Hyams JS. Diet and gastrointestinal disease. Curr Opin Pediatr 2002; 14:567.
  17. Roma E, Adamidis D, Nikolara R, et al. Diet and chronic constipation in children: the role of fiber. J Pediatr Gastroenterol Nutr 1999; 28:169.
  18. 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; 58:258.
  19. Heine RG, Elsayed S, Hosking CS, Hill DJ. Cow's milk allergy in infancy. Curr Opin Allergy Clin Immunol 2002; 2:217.
  20. Irastorza I, Ibañez B, Delgado-Sanzonetti L, et al. Cow's-milk-free diet as a therapeutic option in childhood chronic constipation. J Pediatr Gastroenterol Nutr 2010; 51:171.
  21. Abrahamian FP, Lloyd-Still JD. Chronic constipation in childhood: a longitudinal study of 186 patients. J Pediatr Gastroenterol Nutr 1984; 3:460.
  22. Chan AO, Hui WM, Lam KF, et al. Familial aggregation in constipated subjects in a tertiary referral center. Am J Gastroenterol 2007; 102:149.
  23. Ostwani W, Dolan J, Elitsur Y. Familial clustering of habitual constipation: a prospective study in children from West Virginia. J Pediatr Gastroenterol Nutr 2010; 50:287.
  24. van Ginkel R, Reitsma JB, Büller HA, et al. Childhood constipation: longitudinal follow-up beyond puberty. Gastroenterology 2003; 125:357.
  25. Thiessen PN. Recurrent abdominal pain. Pediatr Rev 2002; 23:39.
  26. van Tilburg MA, Squires M, Blois-Martin N, et al. Test of the child/adolescent Rome III criteria: agreement with physician diagnosis and daily symptoms. Neurogastroenterol Motil 2013; 25:302.
  27. Kramer EA, den Hertog-Kuijl JH, van den Broek LM, et al. Defecation patterns in infants: a prospective cohort study. Arch Dis Child 2015; 100:533.
  28. Lewis NA, Levitt MA, Zallen GS, et al. Diagnosing Hirschsprung's disease: increasing the odds of a positive rectal biopsy result. J Pediatr Surg 2003; 38:412.
  29. Iacono G, Cavataio F, Montalto G, et al. Intolerance of cow's milk and chronic constipation in children. N Engl J Med 1998; 339:1100.
  30. Magazzù G, Scoglio R. Gastrointestinal manifestations of cow's milk allergy. Ann Allergy Asthma Immunol 2002; 89:65.
  31. Turunen S, Karttunen TJ, Kokkonen J. Lymphoid nodular hyperplasia and cow's milk hypersensitivity in children with chronic constipation. J Pediatr 2004; 145:606.
  32. Benninga MA, Büller HA, Tytgat GN, et al. Colonic transit time in constipated children: does pediatric slow-transit constipation exist? J Pediatr Gastroenterol Nutr 1996; 23:241.
  33. Hutson JM, McNamara J, Gibb S, Shin YM. Slow transit constipation in children. J Paediatr Child Health 2001; 37:426.
  34. de Lorijn F, van Wijk MP, Reitsma JB, et al. Prognosis of constipation: clinical factors and colonic transit time. Arch Dis Child 2004; 89:723.
  35. Hendren WH. Pediatric rectal and perineal problems. Pediatr Clin North Am 1998; 45:1353.
  36. Hendren WH. Constipation caused by anterior location of the anus and its surgical correction. J Pediatr Surg 1978; 13:505.
  37. Leape LL, Ramenofsky ML. Anterior ectopic anus: a common cause of constipation in children. J Pediatr Surg 1978; 13:627.
  38. Herek O, Polat A. Incidence of anterior displacement of the anus and its relationship to constipation in children. Surg Today 2004; 34:190.
  39. Genç A, Taneli C, Tansuğ N, et al. Evaluation of the location of the anus by a modified technique in the neonate. J Pediatr Surg 2002; 37:80.
  40. Davari HA, Hosseinpour M. The anal position index: a simple method to define the normal position of the anus in neonate. Acta Paediatr 2006; 95:877.
  41. Heneyke S, Smith VV, Spitz L, Milla PJ. Chronic intestinal pseudo-obstruction: treatment and long term follow up of 44 patients. Arch Dis Child 1999; 81:21.
  42. Hussain SZ, Di Lorenzo C. Motility disorders. Diagnosis and treatment for the pediatric patient. Pediatr Clin North Am 2002; 49:27.
  43. Mousa H, Hyman PE, Cocjin J, et al. Long-term outcome of congenital intestinal pseudoobstruction. Dig Dis Sci 2002; 47:2298.
  44. Cucchiara S, Borrelli O, Salvia G, et al. A normal gastrointestinal motility excludes chronic intestinal pseudoobstruction in children. Dig Dis Sci 2000; 45:258.
  45. Staiano A, Del Giudice E. Colonic transit and anorectal manometry in children with severe brain damage. Pediatrics 1994; 94:169.
  46. Cunningham C, Taylor HG, Minich NM, Hack M. Constipation in very-low-birth-weight children at 10 to 14 years of age. J Pediatr Gastroenterol Nutr 2001; 33:23.
  47. Cohen MS, Phay JE, Albinson C, et al. Gastrointestinal manifestations of multiple endocrine neoplasia type 2. Ann Surg 2002; 235:648.
  48. Gfroerer S, Theilen TM, Fiegel H, et al. Identification of intestinal ganglioneuromatosis leads to early diagnosis of MEN2B: role of rectal biopsy. J Pediatr Surg 2017; 52:1161.
  49. Schäppi MG, Staiano A, Milla PJ, et al. A practical guide for the diagnosis of primary enteric nervous system disorders. J Pediatr Gastroenterol Nutr 2013; 57:677.
  50. Schimpl G, Uray E, Ratschek M, Höllwarth ME. Constipation and intestinal neuronal dysplasia type B: a clinical follow-up study. J Pediatr Gastroenterol Nutr 2004; 38:308.
  51. Koletzko S, Jesch I, Faus-Kebetaler T, et al. Rectal biopsy for diagnosis of intestinal neuronal dysplasia in children: a prospective multicentre study on interobserver variation and clinical outcome. Gut 1999; 44:853.