Constipation and encopresis in children

• Childhood functional constipation is common: a pooled prevalence of about 9.5% in children worldwide, and at least 80% of faecal incontinence in children arises from it.^[3][4]
• Most constipation is functional. It usually starts after a painful or difficult stool, when an anal fissure, an illness, or a change in routine sets up withholding; retained stool then stretches the rectum and produces soiling.
• A child with red flag features (constipation from birth, delay passing meconium beyond 48 hours as a term infant, ribbon stools, poor growth, abdominal distension with vomiting, or abnormal legs or spine) should not simply be treated for constipation. They should be referred urgently.^[1]
• If a child is faecally impacted, disimpaction comes first: an escalating oral macrogol regimen is first-line. Daily laxative therapy then runs for months, not days. ^[1]
• PEG for disimpaction is conventionally 1 to 1.5 g per kg per day for 3 to 6 days; maintenance doses commonly run 0.2 to 0.8 g per kg per day, adjusted to the child's stools.^[2]
• Laxatives plus simple behavioural and dietary support work better than diet alone. Continue treatment until the bowel habit has been normal for weeks to months, then reduce slowly.

By the end of this page you should be able to:

1. Distinguish functional constipation from organic disease, using the red flags in the NICE history table.^[1]
2. Apply current Rome IV diagnostic criteria for functional constipation and for non-retentive faecal incontinence.^[3][4]
3. Assess a child for faecal impaction and plan oral disimpaction, including when to add a stimulant and when to use rectal measures.^[1]
4. Prescribe evidence-based maintenance laxative therapy, including doses, additions, duration and how to stop.
5. Outline the assessment and management of encopresis, and separate retentive from non-retentive incontinence.
6. Recognise Hirschsprung disease as an important underlying cause and know what to do next.
7. Adapt management to low-resource settings and to special groups such as infants, adolescents and anxious children.

Constipation is not a disease in itself; it is the final common pathway of a handful of mechanisms, of which functional withholding is by far the commonest. Constipation in a child is identified when two or more of the NICE history items are present: fewer than three complete stools per week, hard or rabbit-pellet stools, overflow soiling, straining, retentive posturing, abdominal discomfort that improves after a stool, or a history pointing to difficult defecation.^[1]

Chronic constipation is constipation lasting longer than 8 weeks.^[1]

Encopresis is repeated passage of stool into clothing or another inappropriate place in a child with a developmental age of at least 4 years. In Rome IV terminology this is split into two groups: constipated children with overflow (retentive faecal incontinence), which is the majority, and children who are not constipated (non-retentive faecal incontinence).^[4]

A useful bedside classification is by mechanism:

• Functional constipation with retention. The child withholds stool. The rectum stretches and loses sensation, so stool leaks around a hard mass. This accounts for at least 80% of faecal incontinence in children.^[4]
• Non-retentive faecal incontinence (Rome IV). A child of developmental age at least 4 years with at least a one-month history of defecation in inappropriate places, no evidence of faecal retention, and no other medical explanation; such children usually have normal stool frequency and normal colonic transit. (DSM-5 criteria for encopresis instead require at least one such event each month for at least three months.)^[4]
• Functional constipation without incontinence. Constipation alone, of short or long duration.
• Secondary constipation. Caused by another condition or by a drug. Examples include Hirschsprung disease, anorectal malformation, spinal or sacral anomalies, hypothyroidism, coeliac disease, cystic fibrosis, cerebral palsy, a drug effect (opiates, anticholinergics, iron), or a neurological disorder. These are excluded by red flags and examination before calling the constipation idiopathic.^[1]

Constipation is one of the commonest reasons children present to primary care. A pooled world prevalence of functional constipation is about 9.5% in children, and it carries a substantial burden on families and services.^[3] Children who soil after the age of 4 years are reported at 1.6 to 4.4% in most series, and boys are affected more often than girls.^[4]

Peak incidence is around the age of toilet training. Constipation starting in the first month of life, or constipation present from birth, should never be assumed functional.^[1]

Functional constipation starts with a single unpleasant stool. The child learns that defecation hurts, and the response is voluntary withholding: tightening the external sphincter and gluteal muscles, hiding, dancing on the toes, arching the back. The longer stool stays in the rectum, the more water is absorbed and the harder it becomes.

Common precipitants and risk factors include an acute anal fissure after a hard stool, dehydration or poor fluid intake, fever or intercurrent infection, a change in diet including weaning or a change in milk formula, toilet training before the child is ready, stress such as starting nursery or school, lack of time or fear of school toilets in older children, family clustering of slow bowel habit, and psychological and behavioural conditions, which are a particularly important driver in non-retentive incontinence.^[4]

There is no single modifiable cause to fix; the aim is to break the withholding cycle and remould the rectum.

Liquid stool from higher up bypasses a hard faecal mass in an over-stretched rectum and leaks out of the anus without the child being aware of it. That is overflow soiling. It is not laziness or bad behaviour, and it should be explained to parents in exactly those terms, because misunderstanding fuels shame and punishment.

The rectum adapts to prolonged distension by tolerating larger volumes before signalling urgency. Sensation of filling is blunted, so the child may not feel the urge until it is too late. Retentive posturing (standing on tiptoe, squatting, crossing the legs, hiding behind furniture) is the child's conscious attempt to suppress defecation.

History is the single most useful tool.

Symptoms in the child's own or the parent's words:

• Infrequent, hard or painful stools; 'rabbit droppings' or large stools that block the toilet.^[1]
• Straining, withholding, or retentive posturing.
• Overflow soiling: loose, smelly, often unnoticed stool in the underwear, sometimes described as 'diarrhoea' by parents. Soiling is typically during the day and rarely during sleep.
• Abdominal pain, which often improves when a large stool is passed, and a poor appetite that improves with defecation.^[1]
• Irritability, painful defecation, and blood on the stool or on the paper from an anal fissure.
• In infants: straining and crying with hard stools, or passing small hard stools.

In the parent's history, establish the onset, the toilet-training story, the diet and fluids, and the bowel-habit pattern. Ask how often the child stools, what the stools look like on a stool chart, whether there is night-time soiling, and whether meconium was passed normally as a newborn.

On examination:

• Growth: plot height and weight. Faltering growth moves the child out of the functional category and into referral.^[1]
• Abdomen: distension, visible bowel loops, and a palpable left iliac fossa or pelvi-rectal faecal mass. A mass extending above the umbilicus suggests severe impaction.
• Perianal area: anal position, fissures, skin tags, soil, bruising or scars. Pain on inspection itself is informative.
• Neurological examination of the legs and back: tone, power, reflexes, anal and cremasteric reflexes, and the lumbosacral skin (dimple, tuft, flat buttocks, deviation of the gluteal cleft).
• Digital rectal examination where indicated, performed by a clinician competent in children: anal canal, tone, the rectal vault size, and whether a hard load of stool is present.

The differential diagnosis falls into three questions.

First, is it constipation at all? Diarrhoea from infection or poor absorption can be mistaken for soiling. Infection usually lasts days and the child is unwell.

Second, is it functional or organic? The NICE red flag table below settles most cases. Organic causes include Hirschsprung disease, anorectal malformation, spinal lesions, hypothyroidism, coeliac disease and cystic fibrosis. A child with only 'amber' features (normal growth but an unclear picture) may still have idiopathic constipation and can be treated, with reassessment if nothing improves.

Third, is soiling retentive or non-retentive? The child with a loaded rectum and hard infrequent stools has overflow. The child with normal stool frequency, no mass, and normal transit has non-retentive incontinence, which needs a different pathway.

Hirschsprung disease is the organic cause that everything else must not be mistaken for. It is absent ganglion cells in a segment of distal bowel, so that segment cannot relax and the colon above it dilates. The take-home points for a medical student:

• It usually declares itself in the neonatal period, but some children present later with severe chronic constipation.
• Delayed passage of meconium is the classic clue. Almost all healthy term neonates pass meconium within 48 hours, but some children with Hirschsprung disease also pass meconium within that time, so a normal first meconium does not exclude the diagnosis.
• Later features include marked abdominal distension, vomiting (sometimes bile-stained), ribbon stools and growth failure, and reluctance to feed.
• Digital rectal examination in Hirschsprung disease classically shows an empty rectum and a tight anal canal, sometimes followed by explosive release of stool when the finger is withdrawn.
• Definitive diagnosis is histological: rectal suction biopsy showing absent ganglion cells. This is arranged by paediatric surgical teams, not by the generalist.

Because the exact biopsy and imaging pathway is decided by paediatric surgical teams, this page does not give it. The important bedside action is to spot the red flags, refer, and not to start empirical disimpaction in a suspected case.^[1]

Functional constipation is a clinical diagnosis. When no alarm features are present, routine laboratory or imaging tests are not required.^[6]

A few tests have a defined place:

• Abdominal radiograph is not a routine test, but is reasonable when impaction is suspected and the child cannot be examined satisfactorily.
• Colonic transit studies are not for routine diagnosis. They are useful when the picture is uncertain, or to separate functional constipation from non-retentive faecal incontinence, because transit is typically prolonged in constipation and normal in non-retentive incontinence.
• Anorectal manometry is used by specialists to look for the anorectal inhibitory reflex; an absent reflex points to Hirschsprung disease.
• Routine laboratory screening (thyroid, coeliac serology, calcium) is not recommended without alarm features. A trial of cow's milk protein avoidance for 2 to 4 weeks is suggested by expert opinion (NICE CG99 surveillance; ESPGHAN-derived guidance) for intractable constipation; the newer AGA-NASPGHAN (2026) pathway suggests a 2-week trial in infants and toddlers with atopy or anal fissures.^[1][3]
• Allergy, thyroid and coeliac testing are only indicated when the picture or the family history suggests them.

Rome IV criteria for functional constipation, quoted from the 2024 guideline protocol (Box 1), require at least two of the following, present at least once per week for a minimum of 1 month, with insufficient criteria for irritable bowel syndrome, and after appropriate evaluation the symptoms cannot be fully explained by another medical condition^[3]:

• In an infant or toddler up to 4 years of age: two or fewer defecations per week; a history of excessive stool retention; painful or hard bowel movements; large-diameter stools; or a large faecal mass in the rectum. In a toilet-trained child, add at least one episode per week of incontinence, or large-diameter stools that may obstruct the toilet.
• In a child or adolescent with a developmental age of at least 4 years: two or fewer defecations in the toilet per week; at least one episode of faecal incontinence per week; retentive posturing or excessive volitional retention; painful or hard bowel movements; a large faecal mass in the rectum; or large-diameter stools that can obstruct the toilet.

Non-retentive faecal incontinence is the separate category: at least one month of defecation into places inappropriate to the child's social context, with no evidence of faecal retention and no medical condition that explains the symptoms; Rome IV requires a 1-month history, while DSM-5 requires at least one such event each month for at least 3 months. Children in this category usually have normal stool frequency and normal transit.^{[4] [3]}

Severity scores have a place in research and in tracking outcome, not in diagnosis. Common scores (Holschneider, Pena, Krickenbeck, Rintala) each mix questions about soiling frequency, continence, constipation severity and social impact. Choose a score by the question being asked.

Management proceeds in a fixed order: assessment first, disimpaction if needed, then daily maintenance.

1. Look for red flags. If any are present, refer rather than treat.^[1]
2. Establish whether the child is faecally impacted, using history (overflow soiling, very infrequent stools, abdominal discomfort that improves after a massive stool) plus physical examination.
3. Teach the family, in simple terms, what constipation is and that soiling is involuntary. Shame and punishment make everything worse.^[4]
4. Do not start with diet alone. Diet supports laxative treatment; it does not treat established constipation.^[1]

If the child is impacted, clear the load first. An escalating oral regimen of macrogol (polyethylene glycol with electrolytes) is first-line.^[1]

Traditional and widely quoted doses for functional constipation are PEG 1 to 1.5 g per kg per day for 3 to 6 days for home disimpaction, and 0.2 to 0.8 g per kg per day for maintenance.^[2] If the child does not respond to the macrogol within 2 weeks, add a stimulant laxative. If the macrogol is not tolerated, substitute a stimulant, singly or with an osmotic such as lactulose.^[1]

Practical pointers:

• Give disimpaction over 3 to 6 days, not as one massive day.^[2]
• PEG can be mixed with a cold drink; infants and small children may accept it better cooled and in smaller volumes through the day.
• Warn families in advance that soiling and abdominal pain may initially increase during disimpaction, so they do not panic and stop.^[1]
• Sodium citrate enemas are offered only if all oral medication has failed.^[1]
• Phosphate enemas are reserved for specialist use in hospital or clinic, after oral medications and sodium citrate have failed.^[1]
• Manual evacuation under anaesthesia is the last resort, after optimum oral and (if needed) rectal treatment has failed.^[1]
• Review any child undergoing disimpaction within 1 week.^[1]
• Do not use rectal medications for disimpaction unless oral medication has failed and the child and family consent.^[1]

Start maintenance as soon as disimpaction is complete, without waiting for a 'clean' child first.^[1]

• First line: macrogol (PEG) at a dose adjusted to the child's symptoms, guided by stool frequency and consistency. A useful guide after disimpaction is to start at about half of the disimpaction dose and titrate.^[1]
• If PEG fails or is not tolerated: add a stimulant laxative (senna or sodium picosulfate), or substitute a stimulant, with or without an osmotic such as lactulose, and add lactulose or docusate if stools are hard.^[1]
• Other laxatives (magnesium hydroxide, lactulose, mineral oil as a lubricant, stimulants) are second-line agents, used when PEG is unavailable or not tolerated, or as adjuncts. Lubiprostone and prucalopride have not shown efficacy over placebo in paediatric trials and are not routine in children; linaclotide 72 mcg once daily is licensed in the United States for functional constipation in children aged 6 to 17 years and is suggested conditionally in the 2026 ESPGHAN/NASPGHAN guideline after other pharmacological therapies have failed, although licensing, access, cost, and the ability to swallow capsules vary by region.^[3][5]
• Duration. Continue at a maintenance dose for several weeks after a regular bowel habit is established; this often takes several months. Children who are toilet training should stay on laxatives until training is well established. Reduce the dose gradually over months in response to stool consistency and frequency, not abruptly. Some children need laxatives for several years, and a minority need them indefinitely.^[1]

Behavioural component, run alongside the drug and never instead of it:

• A toilet routine: sitting after meals, two to three times a day, for 5 to 10 minutes, feet supported, relaxed posture, encouraged and rewarded.^[4]
• A bowel diary, demystification (showing the child how the bowel works), non-punitive scheduled toileting, and positive reinforcement. Older children benefit from a visual card or a simple agreement.^[1]
• Information for the family: what to expect from laxatives, how to recognise a relapse (illness, stress, change of routine), and the importance of continuing treatment until told to stop.^[1]
• Cognitive behavioural therapy is useful when behaviour, fear, or family stress is a large driver.^[4]

Diet and fluids, supporting:

• A balanced diet with adequate fibre from fruit, vegetables, high-fibre bread and whole grains. Unprocessed bran can bloat and reduce absorption of micronutrients and is not recommended.^[1]
• Adequate fluid intake, roughly following childhood fluid targets: about 500 to 1000 ml for children of 5 to 10 kg, rising to 2250 to 2500 ml for those over 50 kg, with clinical judgment more important than the chart.^[4]
• Physical activity at a normal level. Routine biofeedback is not recommended for uncomplicated childhood constipation.^[1] Prebiotics are not established as effective. Probiotics are not recommended as standalone treatment for uncomplicated childhood constipation; selected strains may add value when combined with laxatives, but polyethylene glycol remains preferred and the evidence remains low-quality.^[3]

These children soil but are not constipated. Disimpaction is not needed. Management is behavioural and psychological, because the driver is usually emotional rather than physical, although a co-existing neurological or sphincter problem must first be excluded.

The behavioural programme reused here is the same set of skills, but with greater emphasis on the emotional content: assess for school, family, bullying and abuse; confirm absence of constipation with careful history and, if needed, a transit study or manometry. Toilet training is scheduled, after meals, three times a day for 5 to 10 minutes, with rewards and no punishment or shaming. Families are helped to manage their own anxiety. Cognitive behavioural therapy, when available, helps. Assess for oppositional defiant patterns, attention difficulties, significant life events such as a new sibling or a change of home, incontinence that starts early in the afternoon after school, and a history of coercive toileting. Victims of sexual abuse must be recognised and referred for specialist support.

Follow-up: non-retentive incontinence has a poorer long-term outcome than the retentive kind. Two years of intensive medical and behavioural treatment cleared it completely in only 29% in one long-term study, and 15% of those adolescents still had the condition at age 18.^[4]

Refractory constipation is constipation that persists despite optimal conventional treatment for at least 3 months.^[3] A working consensus definition used in newer literature is constipation that persists despite two laxatives of different classes, with good adherence, over at least 3 months in secondary or tertiary care.^[3]

Handle refractory disease in this order:

1. Check the basics first: is the child actually taking the dose, is fear still present, has disimpaction been repeated after any relapse. Many 'refractory' cases are adherence or fear problems, or an under-dose.
2. Look again for an organic cause: repeat the examination, and investigate new neurological signs, atypical features or a change in growth.
3. Treat contributors: a slow-transit colon, an anal fissure that never healed, a constipating drug, and anxiety each suggest a different intervention.
4. Add or swap laxatives, including stimulants, lubricants and osmotics in combination.
5. Specialist options, all by tertiary teams: antegrade enemas, botulinum toxin to the anal sphincter, transcutaneous electrical stimulation, sacral nerve stimulation, and anal dilatation where indicated. Linaclotide 72 mcg once daily is licensed in the United States for functional constipation in children aged 6 to 17 years; its place in therapy is conditional (after other pharmacological therapies have not been effective) and newer than the older guidelines, so check local licensing and current guidance.^[5]
6. Surgical management (antegrade continence enema, stoma, resection) is rare, reserved for the most severe intractable cases after full medical and rehabilitative failure.

Severity scores have a place in research and in tracking outcome, not in diagnosis. Common tools include the Pena, Krickenbeck, Rintala and Holschneider scores, which capture soiling frequency, frequency of defecation, continence and social impact. The Rintala score is the most comprehensive and includes social and quality-of-life items. Consistency matters more than the particular tool.^[4]

• Faecal impaction and overflow (often mislabelled 'diarrhoea') leading to school absence and family stress.
• Chronic dilatation of the rectum and sigmoid, which can make recovery slow.
• Anal fissure and bleeding.
• Urinary symptoms and urinary tract infections in some children.
• Social, educational and emotional harm: bullying, avoidance of school, low self-esteem, anxiety. These are the most important complications in practice.
• Misdiagnosis: treating an organic disease as functional.
• Over-investigation of a healthy constipated child.

The majority of children respond well once the cycle is broken and treatment is given time. Recurrence is common when laxatives are stopped too soon. Some children need treatment for several years. Setting realistic expectations from the start prevents families abandoning a treatment that needs months to work.

Prevent constipation by preventing pain. Keep stools soft, encourage regular toilet habits, a healthy diet with fibre, adequate fluid, and physical activity, and avoid withholding during toilet training. Treat any anal fissure early. Parents should be warned never to use laxatives only at weekends, and to keep treatment going long enough to reverse rectal adaptation.

Infants. First-pass meconium is normally within 48 hours. In the first weeks the causes to be wary of are Hirschsprung disease, anorectal malformation, cystic fibrosis and hypothyroidism. Rome IV infant criteria require 2 of 5 features for at least 1 month. In infants, an acceptable first osmotic option, where PEG is unavailable, is lactulose; education, gentle massage and positioning also help. Rectal stimulation should not be routine: it risks conditioning the infant to wait for stimulation to defecate.

Toilet-training age. The peak period. Starting a potty before readiness, or applying pressure during stress, is a common precipitant. Children should stay on laxatives until training is stable.

Adolescents. Embarrassment, fear of school toilets, puberty and diet changes predominate. Address psychosocial issues and school access, not only the bowel. Provide a discreet management plan.

Neurological and spinal conditions. These children often have neurogenic bowel dysfunction, with slow or fast transit. Combined oral, rectal and, in many cases, antegrade enema programmes are needed; specialist multidisciplinary care is essential. Obedience to the bowel plan matters more than any single drug.

Autistic or learning-disabled children. Picky eating, sensory issues and poor recognition of urge are common. Adapt the plan: picture cards, scheduled toilet times, sensory-friendly seating, short clear steps.

Constipation is diagnosed clinically; this is an advantage where tests are scarce.

• Recognise red flags early and refer children with suspected Hirschsprung disease, spinal lesions or severe malformation.
• Start with an affordable osmotic such as lactulose or magnesium milk when macrogol is unavailable or unaffordable; macrogol is the best-evidenced first line but not the only option.^[1][3]
• A simple sodium citrate enema may be used where safe and authorised, but avoid phosphate enemas outside specialist settings.^[1]
• Focus on education: explaining overflow soiling as a medical condition gains family cooperation and protects the child.
• Fibre can be supplied cheaply from local fruit, vegetables and pulses; adequate fluids are the rule.
• The cheapest, most effective intervention is often the behavioural toilet programme: scheduled sitting, feet supported, relaxed posture, rewards.

• Functional constipation is common, with a pooled world prevalence of about 9.5% of children; faecal incontinence after age 4 is reported at 1.6 to 4.4%.^[3][4]
• Constipation is a clinical diagnosis; idiopathic constipation is diagnosed by excluding red flags on history and examination.^[1]
• Rome IV defines functional constipation by at least two features for at least 1 month, and separates retentive from non-retentive faecal incontinence.^[3][4]
• Red flags (constipation from birth, delayed meconium, ribbon stools, poor growth, distension with vomiting, neurological abnormality) point to an underlying disease; treat that disease, not the bowels, and refer. Hirschsprung disease is the critical differential.
• Diagnose faecal impaction clinically; do not order routine X-rays, labs, transit or manometry in uncomplicated cases.
• Disimpaction comes first when impaction is present: macrogol over 3 to 6 days, with stimulant added if no response after 2 weeks.^[1][2]
• Maintenance is macrogol first line, with a starting post-disimpaction dose often around half the disimpaction dose, titrated to symptoms, and 0.2 to 0.8 g per kg per day is the acceptable usual range.^[1][2]
• Continue maintenance for weeks to months after the bowel habit normalises, reducing slowly; some children need years of therapy.
• Behavioural support (toilet routine, rewards, diary, demystification) and diet support treatment but do not replace it.
• Reassess refractory cases for adherence, fear, under-dosing and undiagnosed organic disease before escalating.
• Non-retentive incontinence is a different problem: it needs assessment and behavioural or psychological treatment rather than laxatives, and has a guarded long-term prognosis.
• In low-resource settings the clinical diagnosis, an affordable osmotic, simple enemas when authorised, fibre, fluids and a structured toilet programme are the priorities.

Idiopathic constipation with red flags. Hirschsprung disease. Anal fissure. Encopresis and non-retentive faecal incontinence. Urinary tract infection. Coeliac disease. Hypothyroidism. Behavioural and emotional disorders of childhood.