Paeds · gastroenterology-hepatology-and-nutrition
Constipation and faecal incontinence
Also known as Functional constipation · Childhood constipation · Faecal soiling · Encopresis · Overflow incontinence · Non-retentive faecal incontinence · Chronic idiopathic constipation
Fellowship guide to childhood constipation and faecal incontinence: the Rome IV diagnosis of functional constipation, the withholding vicious cycle that drives megarectum and overflow soiling, the red flags that flag Hirschsprung disease and other organic causes, and the disimpaction-then-maintenance polyethylene glycol regimen with behavioural support that underpins evidence-based management.
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Red flags
- Failure to pass meconium within 48 hours of birth
- Constipation from the first weeks of life or ribbon stools
- Weight loss, growth faltering, or delayed puberty
- Abdominal distension with bilious vomiting
- Abnormal anus, sacral dimple, hair tuft, or flat buttocks
- Lower limb neurology, absent anal wink, or abnormal reflexes
- Faecal incontinence with distress, bruising, or disclosure suggesting abuse
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- Diagnoses functional constipation positively using the Rome IV criteria
- Recognises the red flags that suggest Hirschsprung disease or other organic causes
- Explains the withholding cycle and overflow soiling to families
- Prescribes an evidence-based disimpaction and maintenance regimen
- Integrates behavioural, dietary, and pharmacological therapy over a long timeframe
- Manages refractory constipation and refers appropriately
- Differentiates functional constipation from organic causes
- Justifies polyethylene glycol disimpaction and maintenance dosing
- Outlines the stepwise management of constipation and faecal incontinence
- Takes a focused bowel and soiling history without shaming the child
- Counsels a family on the chronic, relapsing nature of treatment
- Negotiates a toileting and maintenance plan with family and school
- Stage 1: Recognition of constipation and its red flags
- Stage 2: Positive functional diagnosis and disimpaction-maintenance therapy
- Level 3: Management of refractory constipation and non-retentive incontinence
- Rome IV criteria for functional constipation across age groups
- Pathophysiology of stool withholding, megarectum, and overflow soiling
- Evidence for polyethylene glycol and behavioural treatment
- History and examination that elicit red flags and neurological signs
- Abdominal and perianal assessment in a soiling child
- Structured explanation of the withholding cycle to a family
- NASPGHAN approach to constipation and faecal incontinence
- Disimpaction and maintenance with osmotic laxatives
- Behavioural and family-centred management of encopresis
- Positive diagnosis of functional constipation with limited testing
- Family education on adherence and relapse prevention
- Recognition and referral of organic red flags
- Canadian approach to constipation and overflow soiling
- Coordinated primary care and gastroenterology follow-up
- Function-focused, non-punitive management of faecal incontinence
Overview & Definition
A toddler who screams and clenches on the potty, a preschooler who stains their underwear several times a day, and a school-aged child who has not opened their bowels for a week and now has a palpable abdominal mass are all showing the same condition from different angles. Constipation in childhood is common, distressing, and in the great majority of children has no underlying disease. Most of these children have functional constipation, a positive Rome IV diagnosis rather than a label of exclusion. [1]
Constipation means infrequent or painful passage of hard stool, and the child may also have large-diameter stools, withholding behaviour, and a palpable rectal or abdominal faecal mass. Faecal incontinence is the involuntary passage of stool in a child old enough to be toilet trained, usually beyond four years of age. In most children the two problems are linked, because retained stool overflows around a rectal impaction, but a minority soil without any constipation at all. [2]
The core clinical skill is to make a confident functional diagnosis, treat early and adequately, and stay alert for the small number of children whose constipation signals organic disease such as Hirschsprung disease. Early, effective treatment matters because an established withholding cycle with a stretched rectum is far harder to reverse than a new problem. Families need to understand from the outset that treatment is measured in months, not days. [1]
References11ShowHide
- [1]Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr, 2014.PMID 24345831
- [2]Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M Functional Disorders: Children and Adolescents. Gastroenterology, 2016.PMID 27144632
- [3]Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology, 2016.PMID 27144631
- [4]Gordon M, MacDonald JK, Parker CE, Akobeng AK, Thomas AG Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database Syst Rev, 2016.PMID 27531591
- [5]Bekkali NL, van den Berg MM, Dijkgraaf MG, van Wijk MP, Bongers ME, Liem O, Benninga MA Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG. Pediatrics, 2009.PMID 19948614
- [6]Mugie SM, Benninga MA, Di Lorenzo C Epidemiology of constipation in children and adults: a systematic review. Best Pract Res Clin Gastroenterol, 2011.PMID 21382575
- [7]Nurko S, Youssef NN, Sabri M, Langseder A, McGowan J, Cleveland M, Di Lorenzo C PEG3350 in the treatment of childhood constipation: a multicenter, double-blinded, placebo-controlled trial. J Pediatr, 2008.PMID 18534221
- [8]Bongers ME, van Wijk MP, Reitsma JB, Benninga MA Long-term prognosis for childhood constipation: clinical outcomes in adulthood. Pediatrics, 2010.PMID 20530072
- [9]van Mill MJ, Koppen IJN, Benninga MA Controversies in the Management of Functional Constipation in Children. Curr Gastroenterol Rep, 2019.PMID 31025225
- [10]Koppen IJN, Vriesman MH, Saps M, Rajindrajith S, Shi X, van Etten-Jamaludin FS, Di Lorenzo C, Benninga MA, Tabbers MM Prevalence of Functional Defecation Disorders in Children: A Systematic Review and Meta-Analysis. J Pediatr, 2018.PMID 29656863
- [11]Rajindrajith S, Hathagoda W, Devanarayana NM, Benninga M Non-retentive fecal incontinence in children: current perspectives and future directions. Expert Rev Gastroenterol Hepatol, 2026.PMID 42090001