Constipation

Rome IV Criteria

• Infants (≤4 years): ≥2 symptoms for 1 month

• Children (>4 years): ≥2 symptoms for 2 months

  • ≤2 bowel motions per week

  • Stool withholding or straining >25% of defecations

  • Painful or hard stools >25% of defecations

  • Large stools clogging the toilet >25% of defecations

  • Palpable rectal faecal mass or need for manual stool evacuation

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Organic Causes

• Endocrine/Metabolic: Hypothyroidism, hypercalcaemia

• Gastrointestinal: Hirschsprung's disease, coeliac disease, cow's milk intolerance

• Neurological: Spina bifida, tethered cord syndrome

• Other: Anal fissures, anorectal malformations

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History (Red Flags)

Stool Characteristics

• Blood or mucus (suggests fissures, inflammatory bowel disease)

Red Flags

• Delayed passage of meconium (>24 hours)

• Bilious vomiting (suggests bowel obstruction)

• Poor weight gain or failure to thrive

• Abdominal mass (consider Hirschsprung’s disease, neoplasm)

• Neurological signs (e.g., lower limb weakness, sacral dimple—suggests spina bifida)

Other Important History

• Stool withholding behaviours, painful defecation

• Feeding type (breastfed vs formula-fed, dietary intake)

• Family history of coeliac disease, hypothyroidism, or chronic constipation

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Examination

Abdominal Examination

• Palpable left lower quadrant (LLQ) faecal mass

Neurological Examination

• Inspect the back and lower limbs for signs of spina bifida or tethered cord (sacral dimple, hair tuft, asymmetry)

Perianal Examination

• Fissures, inflammation, skin tags (suggestive of inflammatory bowel disease)

Rectal Examination

• Rarely needed

• Consider only if red flags present (e.g., suspicion of Hirschsprung’s disease, abnormal perianal findings)

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Management

Behavioural Strategies

• Toileting routine: Sit on the toilet for 5 minutes after meals to utilise the gastrocolic reflex

• Posture: Use a footstool to ensure knees are above hips, aiding defecation

• Positive reinforcement: Reward systems and charts to encourage compliance

Dietary and Medical Management

• Dietary changes: Increase fibre intake (fruits, vegetables, whole grains) and fluid intake

• Laxatives:

  • First-line: Osmotic agents (lactulose, Movicol, Osmolax)

  • Alternative: Paraffin oil (stool softener)

  • Continue for 3–6 months post-resolution to prevent relapse

• Avoid enemas unless severe impaction or refractory cases

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Notes

• Investigate red flags promptly to rule out organic causes

• Elderly patients: Encourage mobilisation, use commodes, and track bowel habits

• Digital rectal examination (DRE) may be required in persistent or unclear cases