Chronic Functional Constipation in Infants and Children

Constipation: A Pristine Universal Pediatric Health Delinquent

Constipation suffered by children is a global public health problem. Functional constipation (FC) brings about deteriorating effects in the children's lives who suffer from it. The risk factors for the development of constipation include the consumption of a diet low in fiber and high in calories (such as the consumption of fast food), a sedentary lifestyle with a lack of exercise, a family history of constipation, and emotional and psychological stress endured by children in their families. It is one of the most common causes of stomachaches in children. FC may lead to fecal incontinence (FI), anal fissures, recurrent urinary tract infections (RUTI), and enuresis in children. Severe constipation may result in stool becoming rock-hard and inflexible in the rectum, which is clinically identified as fecal impaction. It is imperative to perform clinical evaluation and treatment, including pharmacological (the use of stimulant and osmotic laxatives) and non-pharmacological (education, changes in diet, intervention to promote positive behavior and address any emotional issues, toilet training, and physiotherapy for the pelvic floor) interventions. In the case of refractory patients, neuromodulation, the irrigation of the anal canal, and surgical management may be needed. It is essential to lead a healthy, stress-free lifestyle with plenty of exercise and a balanced diet rich in fiber (such as fruits and vegetables) so children can have regular bowel habits and thrive.

A narrative review on the diagnosis and management of constipation in infants

INTRODUCTION

Functional constipation is one of the common disorders of gut-brain interaction in infancy, and decreases the quality of life of infants and parents.

AREAS COVERED

Relevant articles up to November 2022 were reviewed. We searched in PubMed, Google Scholar, and MEDLINE for guidelines, position papers, reviews, and randomized controlled trials on infant constipation.

EXPERT OPINION

Randomized controlled trials in this specific age group are mostly limited to trials with infant formula. The prevalence of infant constipation in formula-fed infants is decreasing, and can be associated with adaptations in formula composition. While the supplementation of infant formula with pro-, pre- and/or synbiotics decreases the prevalence of constipation, their efficacy in constipated infants is disappointing. There is limited evidence to support the addition of magnesium to infant formula to treat constipation. The evidence for the efficacy and safety of polyethylene glycol in children < 2 years has expanded over the past years. The administration of lactulose or polyethylene glycol is the preferred medical management, in case nutritional management does result in insufficient improvement.

Functional constipation: A common and often overlooked cause for abdominal pain in children

The most common causes for chronic pain abdomen in pediatric practice are functional abdominal pain disorders, a subgroup of functional gastrointestinal disorders under the Rome IV classification. Constipation is usually associated with painful defecation, but abdominal pain as a predominant or presenting symptom of functional constipation (FC) is not very well recognized. We conducted this study to ascertain the prevalence of FC in chronic pain abdomen and proportion of FC children presenting with predominant complaints of pain abdomen. Prevalence of FC and functional abdominal pain was ascertained separately over a 1-year in children > 4 years of age in our hospital. The number of children with FC presenting with abdominal pain was noted. Abdominal pain site and duration were noted in the FC group and were compared with those in the functional abdominal pain group to find out any significance. Diagnosis was based on Rome IV criteria, but relevant investigations to rule out organic pathology were done whenever clinically indicated. The prevalence of abdominal pain was 22% in our gastroenterology service and that of FC was 27%. Among the children presenting with chronic abdominal pain, FC was seen in 10% of the patients and functional abdominal pain disorders in 34%. Among children presenting with constipation, 12% had pain as the sole complaint. However, some form of pain or pain as one of the symptoms was seen in 47.5%.  FC is a major cause for abdomen pain in children and is often overlooked. Not attributing pain to constipation may delay the diagnosis, which may have poor prognosis.