Constipation in Children

GP Connect Clinical Feature by Alison Wroth APAM, MACP, Pelvic Health Physiotherapist, Director/Principal Physiotherapist, Hillview Women’s and Men’s Health Physiotherapy

Chronic constipation is the most common bowel dysfunction in children, with an estimated prevalence of around 10 per cent, worldwide. Whilst constipation can be attributed to organic causes such as neurological dysfunction or sphincter abnormality, by far the majority of cases of constipation in children can be attributed to functional causes.

Functional constipation is a significant problem in children, comprising three to five per cent of all paediatric outpatient referrals and 10 per cent of gastroenterology referrals. Wait lists can be anything from several weeks to many months, and so the distress of symptoms is ongoing and progressive for children. Pelvic health physiotherapy offers comprehensive assessment and ongoing management, and is an underutilised community resource in the management of childhood bowel (and bladder) dysfunction.

The pathophysiology of functional constipation in children is thought to be multifactorial. Stool with-holding behaviour is the most commonly encountered etiological factor. Such behaviour may arise from a single trigger event such as an episode of painful bowel evacuation, or an experience of being afraid whilst in the toilet. In adults, research evidence shows that the pelvic floor muscles, which are integrally involved in evacuation of faeces, are the first area in the body to tense when an individual is feeling unsafe.

For a child who has experienced pain or fear on bowel evacuation, pelvic floor muscle tension can become their conditioned response with each new toilet visit. As such, a cascade of dyssynergic defaecation, incomplete evacuation and subsequent faecal impaction with overflow faecal incontinence develops.

Notwithstanding physical symptoms, the psychological and emotional burden for children is enormous. Functional constipation has been associated with reduced quality of life, diminished academic performance and psychological problems (Mill et al 2019). Waitlists for psychologists with expertise in this field are often lengthy.

Experienced practitioners will observe and feel the parent-child dyad, which also informs management. This non-invasive, therapeutic approach is well upheld in the literature, since invasive assessments should be reserved for resistant cases, to prevent trauma to the child.

Management strategies are targeted towards assessment findings, and include education, defaecation dynamics, dietary and fluid modifications, toilet training, pelvic floor biofeedback, postural/general exercise, and small group therapy as appropriate. Some practitioners also utilise neuromodulation for management of slow transit constipation – an innovative therapy which is showing great promise in the literature.

Pelvic health physiotherapy offers targeted management for children and families dealing with the complex physical, social and emotional problem of functional constipation.

See also the recently published “Constipation in Children” HealthPathway.