Childhood constipation: Current status, challenges, and future perspectives

Table 1 Rome IV diagnostic criterial for constipation in children

Diagnostic criteria must include at least 2 of the following features of constipation in a child with a development age of at least 4 yr with insufficient criteria to diagnose irritable bowel syndrome
Two or fever defecations in the toilet per week
History of retentive posturing or excessive volitional stool retention
History of painful or hard bowel motion
Presence of a large fecal mass in the rectum
History of large diameter stools which may obstruct the toilet
After appropriate evaluation, the fecal incontinence cannot be explained by another medical condition

Table 2 Clinical history-taking

Component and subcomponents
Onset of symptoms and duration of the disease
Bowel habits
Frequency of stools
Nature of the stools
Fecal incontinence
Blood in stools
Passage of meconium
Other associated symptoms
Withholding behavior
Somatic symptoms
Past medical and surgical history
Bowel surgeries
Medications
Neuromuscular diseases
Dietary history
Fiber continent in the diet
Frequency of junk food
Family history
Psychological history
Developmental history

Table 3 Physical examination

Component and subcomponents
General examination
Assessment of growth
Assessment of development
Abdominal examination
Abdominal distension
Surgical scars
Palpable fecal masses
Perianal observation
Position of the anus
Perianal excoriation and dermatitis
Scars, fissures, and tags
Patulous anus
Neurological evaluation
Spine
Lower limb neurological assessment

Table 4 Red flag features and their clinical relevance

Features and subfeatures
Hirschsprung disease
Delayed passage of meconium
Positive family history
Ribbon like stools
Significant abdominal distension
Child sexual abuse
Extreme fear of anal examination
Scars in the perianal region
Fissures in children > 2 yr of age
Neurological abnormalities
Hair tuft/hemangioma/scars on spine
Abnormal anal and cremasteric reflex
Deficiencies in lower limb neurology
Developmental delay
Other organic disorders
Bilious vomiting
Blood in stools
Failure to thrive
Malposition of the thyroid gland

Table 5 Factors negatively affect the prognosis of functional constipation

Factor
Constipation during the 1st yr of life
Longer duration of symptoms before presentation
Low defecation frequency at presentation
Presence of fecal incontinence
Large diameter stools
Stool withholding
Nighttime urinary incontinence
Presence of fecal mass in abdomen/rectum
Prolonged colonic transit > 100 h
Failed balloon expulsion test