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Constipation is a common problem encountered by the general pediatrician. Most cases are functional in nature and children respond well to dietary and laxative regimens; however, constipation may become chronic in nature and is associated with a decrease in quality of life. Consequently, timely comprehensive evaluation and treatment is important.
Illustrative Case
The patient is a 5-year-old boy who presents to your office for an initial evaluation of abdominal pain for the past 2 months. He describes the character of the pain as dull throughout the periumbilical area with periodic sharp pains in the left upper and lower quadrants. He states the pain is worse after a meal, but the pain does not seem to be related to any particular food groups or time of day. Associated symptoms include a decreased appetite, early satiety, and mild nausea after breakfast. The patient's mother reports his behavior has also been a bit more challenging lately. He denies vomiting, dysphagia, blood in stool, melena, diarrhea, or fecal incontinence, and he has not had any weight loss.
The patient has no other medical conditions and has never had surgery. His mother reports no family history for inflammatory bowel disease, celiac disease, or thyroid conditions. She reports that her son was born at 38 weeks gestation and that he passed meconium stool in the newborn nursery. He was breast-fed for 6 months, and during this time he often had no bowel movement (BM) for 4 to 7 days at a time. She was told this pattern can be normal for breast-fed babies. The patient started formula and baby food at 6 months and his stools became pasty and infrequent.
At age 1 year, he switched to whole milk and his stools were occasionally hard and formed. His mother remembers a few longer intervals of 6 to 7 days between BMs and her son crying during defecation. He was prescribed polyethylene glycol (PEG) on an as-needed basis at age 18 months, and his mother recalls giving him an occasional suppository during his toddler years if he was having trouble passing a stool. She states that he succeeded with toilet training at age 2.5 years for urine, but he was not fully trained for stool until age 3.5 years.
He started full-day...