Emergency Department and Inpatient Clinical Pathway for Evaluation/Treatment of Children with Constipation

Diagnostic Criteria for Constipation
Symptoms present for at least 2 wks with 2 criteria present:
  1. ≤ 2 defecations per week
  2. At least 1 episode of incontinence per week after toilet trained
  3. History of excessive stool retention
  4. History of painful or hard bowel movements
  5. Presence of a large fecal mass in the rectum
  6. History of large-diameter stools that may obstruct the toilet
Fecal Impaction
  • History of no stool passage for more than several days
  • History of encopresis
  • Stool in rectum on digital rectal exam or in the descending colon/rectum
    on imaging
  • Palpable LLQ abdominal stool mass
ED Team Assessment
Functional Constipation Likely
Low risk for alternative diagnoses
< 12 mos
≥ 12 mos
Consider glycerin suppository
  • No fecal impaction
  • Mild/moderate pain
  • Adequate intake
  • Fecal impaction or
  • Significant pain
  • Vomiting, inadequate intake
  • Some stool passed
  • Pain improved
  • Tolerating PO
  • Not effective at 1 hr
  • Pain not improved
  • Not tolerating PO
  • Some stool passed
  • Pain improved
  • Tolerating PO
Not effective at 1 hr
Reassess for Alternative Cause
  • Review History and Physical
  • Consider:
    • 2-view XR
    • Rectal exam if not already completed
    • GI vs. Surgery Consult
    • Manual disimpaction or further evaluation
  • Clear output
  • Pain improved
  • Tolerating PO
Continued symptoms
Further Evaluation as indicated
Posted: April 2024
Editors: Clinical Pathways Team