Persistent constipation (refractory constipation) in children
Before we begin, and in order to place this important chapter into the right context, let’s take a look at the relevant chapters we already have on this website about constipation.
a. The chapter about constipation in children – This is a super basic and super important chapter. It covers how constipation starts, what the signs and symptoms are, and outlines common management strategies.
b. The chapter about encopresis – A condition in which stool is withheld and eventually passed in inappropriate places. It is usually the result of severe constipation and requires careful evaluation and treatment.
But somewhere in the middle of all of this, we also decided to add another chapter about severe constipation in children. This is a chapter that continues on from the basic chapter.
This post was written by Dr. Lev Dorfman, an excellent gastroenterologist, a specialist in gastrointestinal motility — and from here onwards, the stage is his.
First of all, it is important to note that in most cases, constipation can be managed with changes in diet, habits, and behaviours. In most of these cases, the pediatrician will be able to resolve the problem, and pharmacological intervention is unnecessary.
Keep in mind that only in a minority of cases the initial pharmacological treatment is not helpful. These are precisely the cases where the help of a gastroenterologist is encouraged, to customize treatment and conduct further investigations as needed.
Treatment is important because chronic, refractory constipation can significantly harm a child’s quality of life — from interfering with their activities at home, to causing missed school days, and even leading to social implications due to ongoing pain or episodes of incontinence.
In addition, chronic constipation can cause irreversible damage to the intestines.
This chapter is dedicated to those severe cases.
What is refractory constipation?
There is no universally accepted definition among physicians, but refractory constipation generally refers to symptoms that persist for months to years despite initial treatment.
What investigations are required?
In refractory cases, gastroenterology specialists rely on a range of diagnostics to reach the correct diagnosis and guide treatment.
Optional tests in refractory constipation
Contrast enemas: A contrast material is administered via enema while X‑rays are taken. These images assess the structure of the rectum and large intestine—revealing areas of narrowing or dilation. Besides its diagnostic value, the enema often provides therapeutic relief by emptying stool.
Gastrointestinal transit tests
More advanced procedures to evaluate gut motility include:
Marker tests:
The child swallows a capsule containing inert plastic rings. After around five days, an abdominal X‑ray shows where the rings are located. If they’ve exited the digestive tract, refractory constipation is unlikely. If most remain in the colon—especially near the end—this suggests a pelvic outlet problem. Although not definitive, this test helps direct further evaluation.
SmartPill:
This electronic capsule was designed to measure pressures and transit times throughout the gut. Despite initial promise, limited data led to its discontinuation about a year ago.
Manometry tests:
Specialized motility centers may offer two manometry studies:
Ano-rectal manometry: Conducted while the child is awake. A small pressure-sensing tube is inserted into the rectum, and reflex responses to a balloon are measured. This test evaluates sphincter coordination and reflexes—and helps rule out Hirschsprung’s disease.
Colonic manometry: Used in severe cases. After thorough bowel cleansing, a pressure-sensing catheter is placed during colonoscopy and left in situ for several hours. This test assesses colon activity in response to meals and medications, and locates non-functioning segments to guide targeted treatment.
How is refractory constipation treated?
First, a detailed medical history is essential—examining when symptoms began, previous treatments tried, symptom patterns, and the family’s biggest concerns (e.g., pain, incontinence, social impact). Treatment plans and goals are set collaboratively, with the understanding that progress may take time. Despite this, most children achieve significant improvement.
Pharmacological treatment
Stool softeners are the first step. The standard option is polyethylene glycol (PEG), which increases water content in the stool. Many children reaching this stage have already tried PEG.
The next tier includes fiber supplements and stimulant laxatives to promote colon contractions. Newer pediatric medications—such as secretagogues that enhance fluid secretion, or prokinetic drugs like prucalopride—are now emerging, showing promising results when traditional treatments fail.
Rectal therapies
Severe constipation often involves rectal dilation and loss of normal contractions. Rectal therapies—like pediatric-safe enemas and suppositories—are highly effective for emptying the colon. Opinions vary: some professionals favor frequent use for faster therapeutic results; others reserve them for extreme cases to avoid disruption of natural bowel habits. Many children accept—and even prefer—these treatments once they experience relief.
Gastrointestinal “clean-out”
Modeled after colonoscopy prep, a clean-out involves high-dose laxatives to fully evacuate the colon, usually combined with increased fluid intake to prevent dehydration. Initial clean-outs can “reset” the system and improve the effectiveness of other treatments. They may be repeated monthly or weekly based on individual needs.
Sacral nerve stimulation
In cases where medications and enemas are insufficient, sacral nerve stimulators offer hope. This implantable device modulates neural signals to the bowel, much like a cardiac pacemaker. After a successful temporary trial, a permanent device is implanted under the skin. Studies show it effectively reduces incontinence and often improves constipation, including cases of concurrent urinary symptoms.
Pelvic floor physiotherapy
Coordinated muscle contraction and relaxation are key to healthy bowel movements. Pelvic floor physiotherapy—with or without biofeedback—helps children learn appropriate posture, timing, and control. They strengthen core muscles and develop awareness of their bodies, guided through playful exercises.
Emotional/behavioral therapy
Refractory constipation often involves emotional or behavioral components—fear, anxiety, or avoidance rooted in painful defecation. Therapy can address family dynamics, build coping skills, and break the painful cycle that worsens symptoms.
In summary: Refractory constipation represents a severe and complex chapter requiring a multidisciplinary treatment plan—medications, rectal therapies, nerve stimulation, physiotherapy, and emotional support. Even in these difficult cases, most children experience significant relief and long-term improvement.
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