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 Table of Contents  
Year : 2023  |  Volume : 11  |  Issue : 1  |  Page : 48-54

Prevalence and profile of functional constipation among children aged 1–12 years at a tertiary care center

1 Department of General Medicine, SVS Medical College, Mahbubnagar, Telangana, India
2 Department of Pediatrics, SVS Medical College, Mahbubnagar, Telangana, India

Date of Submission29-Jun-2022
Date of Decision21-Aug-2022
Date of Acceptance29-Aug-2022
Date of Web Publication02-Dec-2022

Correspondence Address:
Sumanth Reddy Musali
Department of General Medicine, SVS Medical College, Mahbubnagar, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjhs.mjhs_29_22

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Background: Constipation not only bothers children but also their parents. Even then, it remains neglected and leads to delayed medical care. It leads to physical as well as psychological morbidity. It affects the quality of life of children. Lack of timely medical care compounds the problem. The child may lose his/her self-esteem. About 1%–3% of children may develop impaction of the feces and may lead to soiling with fecal matter.
Objective: The objective was to study the prevalence and clinicopsychological profile of functional constipation (FC) among children aged 1–12 years.
Materials and Methods: This was a hospital-based cross-sectional study carried out among 156 children aged 1–12 years attending the tertiary care center for 1 year. During the study, 911 children aged 1–12 years attended the hospital. We applied Rome IV criteria for the diagnosis of FC. Using these criteria, 156 children were found to have FC, and all of them were included in the present study.
Results: The prevalence of FC among the children was 17.1%. It was more in the toddler group (43.6%) with a slight female preponderance (51.3%). It was more in urban resident children (69.2%) and children belonging to the low socioeconomic group (33.3%). Painful defecation was the most common presenting complaint (81.4%). Most of the children passed Bristol Type II stool <three times a week. Majority of children were taking low-fiber diet, had poor physical activity, and aversion to school.
Conclusion: The prevalence FC among children was high at 17.1%. Low-fiber diet, poor physical activity, and aversion to school were common in children with FC.

Keywords: Fecal soiling, functional constipation, painful defecation, withholding behavior

How to cite this article:
Musali SR, Damireddy AR. Prevalence and profile of functional constipation among children aged 1–12 years at a tertiary care center. MRIMS J Health Sci 2023;11:48-54

How to cite this URL:
Musali SR, Damireddy AR. Prevalence and profile of functional constipation among children aged 1–12 years at a tertiary care center. MRIMS J Health Sci [serial online] 2023 [cited 2023 Mar 30];11:48-54. Available from: http://www.mrimsjournal.com/text.asp?2023/11/1/48/362528

  Introduction Top

Contrary to the common belief that constipation is a problem of adults or the elderly, it is also a common health issue in children. Among all the hospital visits among children, almost 10% can be attributed to constipation. Constipation can be seen irrespective of socioeconomic status. It not only bothers the child but also their parents. Even then, it remains neglected and leads to delayed medical care. It leads to physical as well as psychological morbidity. It affects the quality of life of children. Lack of timely medical care compounds the problem. The child may lose his/her self-esteem. About 1%–3% of children may develop impaction of the feces and may lead to soiling with the fecal matter if the problem is not treated properly. Hence, it is necessary that the problem of constipation should be immediately diagnosed and managed appropriately. Constipation also leads to a variety of gastrointestinal problems like pain in the abdomen, bleeding from the rectum, nausea, anorexia, etc. It has been said that the most common cause of constipation in more than 90% of the cases is functional and not organic. About 30% of children, vising the pediatric gastroenterologist, are found to be suffering from functional constipation (FC).[1]

It is a common practice to rule out the organic causes of constipation before commenting on the final word of FC. If any organic cause is not found, then only we label that constipation as FC. There is a lack of sufficient literature on FC among children. The commonly associated risk factors of FC among children are many. Some important of them are stress, rearing by the parents, low-fiber diet, junk foods, reduction in the activity, obesity, etc.[2]

Constipation is defined as, “a delay or difficulty in defecation sufficient to cause significant distress to the patient.” In “acute constipation” duration of complaints will be <4 weeks, and duration will be more in “chronic constipation.” The Rome IV criteria provide a symptom-based diagnostic tool for functional gastrointestinal disorders in children and adolescents.[3],[4]

With this background, the present study was carried out to study the prevalence and clinical and psychological profiles of FC among children aged 1–12 years.

  Materials and Methods Top

This was a hospital-based cross-sectional study carried out among 156 children aged 1–12 years attending the tertiary care center. Children attending outpatient clinics at the Department of Pediatrics, SVS Medical College, from January 2021 to December 2021, were included in the study.

A total of 911 children aged 1–12 years attended the outpatient department (OPD) of pediatrics at this hospital during the study. Using Rome IV criteria, 156 children were found to have FC. All these children were included in the present study.

The Institutional Ethics Committee permission was obtained. Child assent was obtained from the parents. All children with FC were managed as per the standard guidelines and appropriate protocol.

Children aged 1–12 years of either gender attending OPD during the study and those fulfilling the criteria for Rome IV FC in the past 1 month were included in the present study. Children with potential red-flag signs suggestive of organic causes of constipation, those already on treatment for constipation, those with Rome IV IBS-C constipation variant, and those using drugs or having illness which may modify bowel movements were excluded.

Out of 911 children who attended OPD during the study, 156 children fulfilling the inclusion criteria and having given the assent were included in the study. A detailed pre-structured pro forma regarding the demographic profile, socioeconomic status, details about bowel pattern, frequency, shape according to Bristol chart, presenting complaints onset and duration, any relevant history, developmental issues, details regarding toilet training, psychosocial aspects, diet pattern, and physical activity was given to the parents or primary caretakers to be filled under supervision of a single investigator to minimize subjective bias. Relevant investigations were done to rule out organic pathologies when suspected. All the data obtained were analyzed. Categorical data were expressed as absolute counts and percentages.

Diagnosis of FC was made using the Rome IV criteria.[5] For infants and toddlers: the presence of any two symptoms for at least one month such as excessive retention of stools, pain while passing stools or hard stools, passing motions only less than or equal to two every week on an average, stool with more diameter, and rectum shows more mass of feces. If the child is trained in toilet, we can ask for two more criteria such as stools with more diameter, which is able to block the toilet, and incontinence at least once a week. For older children, the diagnosis of FC using Rome IV criteria should have any two symptoms lasting for one month such as weekly passing only two or lesser defecation, incontinence minimum once a week, pain while passing stools or movement of the bowel is hard, stools with more diameter, which is able to block the toilet, and rectum shows more mass of feces. The above symptoms should not be associated with any other health problem.[5]

  Results Top

FC ratio was slightly more in female in the ratio of 1:1.05. When compared between age groups, FC was more prevalent in toddlers, especially among boys. The average age of onset of constipation is 52.36 ± 28.24 in months. Of 156 children who were included in the study, 76 were male and 80 were female [Table 1].
Table 1: Distribution of study participants as per age and sex (n=156)

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Most of the children belonged to the lower middle class 52 (33.2%), followed by the upper middle class 44 (28.2%), upper lower class 35 (22.8%), lower class 15 (9.6%), and upper class 10 (6.2%) [Figure 1].
Figure 1: Distribution of study participants as per socioeconomic status

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Most of the children belonged to urban areas 108 (69.2%) rather than rural areas 48 (30.8%). Most of the children with FC were using outdoor toilets. In children using indoor toilets, usage of Western type was more [Table 2].
Table 2: Distribution of study participants as per residence and type of toilet

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Most of the children had painful defecation, 127 (81.4%), as a major presenting complaint. Children resent to squat/sit or postpone to go to toilet due to the fear of pain, further leading to hardening of stool and difficulty in passing. Fecal impaction, 103 (66.02%), in the form of the loaded rectum and palpable fecolith, was seen in 78 (50%) and 46 (29.5%) children, respectively [Table 3].
Table 3: Distribution as per clinical presentation (n=156)

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Most of the children with FC were passing stool <three times in a week, 79 (50.6%), while 37 (23.75%) children were passing 3–6 times in a week, and 40 (25.6%) children were passing more than or equal to seven times in a week. The type of stool passed in the past 2 weeks was recorded. Most of the children were passing stool similar to Bristol Type II, 75 (48.07%), while the least number of children were passing Type IV, 10 (6.41%) [Table 4].
Table 4: Average stool frequency and type of stool

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Most of the children in the study had normal body mass index (BMI)–87 (55.8%) [Figure 2].
Figure 2: BMI among children with functional constipation. BMI: Body mass index

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In the present study, about 37 children had <3 meals/day, especially skipping breakfast. Consumption of junk food daily was reported by 18 (11.54%) children, while no junk food was reported by only 14 (9%) children. Consuming milk of more than 500 ml/day (especially replacing a major meal with milk) was seen in 87 (55.6%) children. An adequate fiber diet in the form of vegetables and fruits was taken in more than half of the children. Consuming vegetables and fruits every day is reported by 53 children (34%), while the poor intake was seen in 35 (22.43%) children. Having physical activity for about 45 min in a day was reported by 75 (48.08%) children, while poor physical activity was reported by 39 (25%) children [Table 5].
Table 5: Dietary pattern and physical activity among children with functional constipation (n=156)

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Aversion to use school toilets was expressed in 56 (35.89%) children. Temper tantrum, hyperactive behavior, and oppositional behavior were noted in 30.13%, 25%, and 21.15% of children, respectively, while school phobia was reported in 19.87% of children. Marital disharmony including the death of a parent, single parent, and domestic violence was noted in 19.23% of families of children with FC [Table 6].
Table 6: Psychosocial factors among children with functional constipation

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  Discussion Top

In the present study, applying the Rome IV criteria, we have observed the prevalence of 17% FC among the children attending OPD. Similar prevalence of 19% and 18.8% was observed in Bangladesh study[6] and China study,[7] respectively. A study done by Makhwana et al.[8] in Indian children applying Rome IV criteria reported a prevalence of 5.6%, while another Indian study done by Kondapalli and Gullapalli.[9] applying Rome III criteria reported a prevalence of 30.88%. A South African study[10] reported a worldwide prevalence of 0.7%–29%, with a median of 12%.

The mean age of constipation in the present study was 52.36 ± 28.24 months, and the prevalence of FC was more in toddler and preschool children (2–6 years) rather than school-age children (6–12 years). The present study findings are in correlation with previous Indian studies.[8],[9]

We have found a slight female preponderance of 1: 1.05 when compared in all age groups; however, in the toddler age group, boys were more constipated. Studies made by Chu et al.[7] and Olaru et al.[11] had similar observations. Study made by Benzamin et al.[6] noted a much higher female preponderance of FC, 1:1.78, while a study made by Rezaianzadeh et al.[12] noted more prevalence in boys, 50.6%. No gender difference was observed by Bansal et al.[13]

We have observed that children from lower economic strata (65.6%), especially the lower middle class (33.2%), were more constipated. The difference may be as a result of differences in dietary habits, cultural differences in toilet training, differences in rearing up the child, and perhaps other social determinants unknown to us. Further, children from urban areas (69.2%) and those using outdoor toilet (53.2%) were found to be more suffering from FC. Bytzer FC et al.[14] and Peppas et al.[15] too have noted a higher prevalence of FC in lower economic strata. A higher prevalence of FC in urban areas was noted by Walter et al.[16] and Mazumder et al.[17] in their studies. Benzamin et al.[6] found that FC is more prevalent in low income and slum areas and rural areas, while a Bihar study[18] reported that children using outdoor toilets and those from rural areas are more constipated.

In the present study, the common presenting complaint was painful defecation in 81.4% of the children with FC. Pain during defecation leads to postponing the urge to defecate, excessive self-control, and withholding behavior in children, which further leads to hard stool due to absorption of water in the large intestine, and aggravates the pain, thereby perpetuating the vicious cycle of FC. Similar observations were made in previous studies.[6],[8],[12],[13],[19] Khanna et al.[20] and Aydoğdu et al.[21] reported a lesser frequency of painful bowel movements, while Walter et al.[16] reported a very higher frequency of bowel movements (94%). We have noted anorexia in 38.9% of children similar to Dehghani et al.[22] (38%), but more than that reported by Oswari et al.[23] (29.7%) and Mazumder et al.[17] (24.02%). Fecal impaction in the form of loaded rectum or palpable fecolith per abdomen was seen in 66.02% of children similar to the previous studies,[8],[12],[13],[18],[20],[24] but higher than Walter et al.[16] (31%). We have noted a higher rate of abdominal pain (65.4%) compared to previous studies (15%–30%).[8],[9],[13],[20]

Abnormal posturing in the form of withholding and retentive behavior is more common in toddler and preschool children, which leads to further aggravation of constipation. We have noted such behavior in 54.5% of children similar to Kondapalli and Gullapalli,[9] and Vishal et al.[8] This is higher than that observed by Benzamin et al.[6] (9%), Makhwana et al.[8] (24.1%), and Khanna et al.[20] (27.4%). Abdominal distention was noted in 26.3% of children due to the pooling of gases and stool. Khanna et al.[20] and Bansal et al.[13] noted abdominal distention in 5.1% and 10.26% of children, respectively. Large-diameter stool obstructing toilet, which is one of the Rome IV criteria, was reported in 25.6% of cases similar to Walter AW et al., but much higher cases were reported in Srilankan study[16] – 66%, Iran study[12] – 76.2%, and Bangladesh study[6] – 92.3%.

Local lesions in the form of anal fissures, perianal tags, erythema, cellulitis, etc., was noted in 25% of children similar to Bansal et al.[13] Aydoğdu et al.[21] Dehghani et al.[22] noted perianal lesions in the form of fissures in 7.2% and perianal erythema in 13.1%. Recurrent urinary tract infection (UTI) was noted in 25%. Straining due to constipation leads to the aggravation of vesical ureteral reflux in predisposed children, especially in toddler and preschool children. Further loaded rectum leads to urinary retention, which predisposes to UTIs. Loening-Baucke.[25] reported recurrent UTIs in 11% of children. Similarly, voiding difficulties in the form of urinary retention, incontinence was reported in 14% of children, whereas Loening-Baucke.[25] reported urinary incontinence in 29% of children. Makhwana et al.[8] noted urinary symptoms in 10.35% of children.

Fecal incontinence was seen in 24.35% of children similar to previous studies.[12],[13] Chang et al.[24] 16% and Benzamin et al.[6] 2.6% reported much lower rates of fecal soiling, while Voskuijl et al.[26] 84% and Kokkonen et al.[27] 62% reported much higher cases. Fecal soiling usually indicates chronic or severe constipation and seen more commonly in school-aged children. Blood in stool was seen in 21.79% of children, similar to Khanna et al.[20] and Bansal et al.[13] Some of the previous studies reported lower rates 9%–13%.[8],[9]

We have observed that 50.6% of children were passing <3 times a day in similar to that by Bansal et al.[13] Based on normal stool frequency of >1/day in Indian children of older than 2 years, physicians should be guided more by the stool consistency and other features of FC rather than stool frequency. Stool frequency of ≤2/week as defined in Western guidelines may not be necessarily applicable in Indian children and may miss a substantial number of children with constipation if this criterion is taken in isolation.[1] Some of the studies[12],[23] reported around 65% in their studies passing <2–3 times a day, while some[16],[24] reported below 35%. Most of the children with FC passing more than seven times a day were passing small pellet-like stools similar to Bristol Type I. We have observed that passing hard stool was reported in 66.6% (Bristol Type I and II) similar to some previous studies,[23],[24] while Bansal et al.[13] reported still higher numbers 85.26%.

Most of the children in the present study have normal BMI. 27% were underweight, while 11.5% were overweight and 5.8% were obese. While Vishal et al.,[8] Mazumder et al.,[17] and Chang et al.[24] has a good correlation with the findings of the present study, Olaru et al.[11] reported 29.49% to be overweight among the FC group. Walter et al.[16] stated that obesity/overweight does not seem to be a risk factor for FC, but those children who were underweight have a tendency toward FC due to the possibility of abnormalities in transit and anorectal function.

Taking irregular meals or <3 meals/day was noted in 23.7%, similar to Mazumder et al.[17] Chang et al.[24] stated that only 69% of children have sufficient meals, while Kondapalli and Gullapalli.[9] stated that 14.5% have irregular breakfast. Excess junk food was consumed by 57.05%. Some of the previous studies[6],[17],[24] reported that 27%–33% of children were having junk food daily. Kondapalli and Gullapalli.[9] noted that junk food in the form of baked and fried items was preferred in 68.3% and 46.03%, respectively. Almost 55.6% of children with FC agreed to consume >500 ml of milk/day similar to a study made by Benzamin et al.[6] Olaru et al.[11] stated that children in FC group consumed 200–1000 ml of milk as per against the control group consuming <500 ml/day. Mazumder et al.[17] and Andyran et al.[28] noted cow's milk consumption in 30%–33% of children, and further stated that cow's milk protein allergy, or intolerance or associated allergic colitis forming sticky feces might contribute to constipation. Olaru et al.[11] stated that cow's milk intake was a risk factor for FC. We have observed low-fiber intake and low intake of vegetables and fruits in 22.43% of children in the present study similar to Kondapalli and Gullapalli.,[9] and de Araújo Sant'Anna and Calçado.[29] Dietary fiber is beneficial in constipation by increasing mass of fecal bolus and gas, retaining water, and increasing colonic bacteria, thereby increasing colon transit.[30] Mazumder et al.,[17] in their study, mentioned that 72.3% of children with FC take a diet low in fiber.

We have noted that 48.08% of children with FC had a poor physical activity, which correlates with the studies by Olaru et al.[11] and Benzamin et al.[6] Hormonal changes and reduction in colonic transit time that occur during exercise influence the frequency of bowel movements.[31] Southwell et al.[32] and Chien et al.[33] have put forward no relation between constipation and exercise, particularly in teenagers.

Aversion to use school toilet was expressed by 35.89%, school phobia by 19.87%, and temper tantrums in 30.13%, similar to previous studies.[7],[8] Benzamin et al.[6] stated that school-related factors such as long periods of school, unhygienic toilets, inadequate number of toilets, and government versus private schools have significant effects on constipation in children by increasing the withholding behavior. Lundblad and Hellstorm.[34] observed that 63% of children do not use toilets at school. Marital disharmony was noted in 19.3% of parents of children similar to the study reported by Kondapalli and Gullapalli.[9] Olaru et al.[11] stated in their study that most of the children from a single-parent houses with fear of insecurity and psychological stress suffer from constipation. Walter et al.[16] stated that home-related stress does not seem to affect constipation in young children, probably to the immaturity of the brain-gut axis.

  Conclusion Top

FC constitutes 17% of pediatric OPD visits. It is more common in the toddler age group. As the age increases, it is more common in girls. FC is more in lower socioeconomic groups, urban areas, and those using outdoor toilets. Rather than frequency alone, gastrointestinal complaints are more common by the time child seeks medical advice. Painful defecation is the most common complaint. Painful defecation leads to withholding behavior and fecal impaction, which are the next common presentations. Fecal soiling is more common in older children, while abnormal posturing is more common in toddler and preschool children. Most of the children with FC pass hard to very hard stool less than three bowel movements per week. Those with more frequency pass pellet-like stools and incomplete emptying. Underweight children rather than overweight children are associated with FC. Irregular meals, skipping breakfast, taking less fiber, less vegetables and fruits, milk-predominant diet, and poor physical activity are some of the common associations in children with FC. Aversion to using school toilets, family disharmony, and temper tantrums are some of the psychosocial factors associated with FC.

Constipation is one of the problems where there is much delay in seeking medical care. Most of the parents prefer to use home remedies or disimpaction methods rather than continuous medication to regularize bowel movements. In the present study, using recent Rome IV criteria and collecting information under the supervision of a single investigator are the main strengths of the study. However, being a single-center study and recall bias by parents are some of the drawbacks of the study. Further larger studies comparing children from various localities may lead to standard guidelines for physicians to address the issue both pharmacologically as well as behavioral counseling.

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  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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