Normal physiology

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The Rome II criteria are currently used to define childhood constipation based on the presenting symptom profile. Two subgroups, namely functional constipation and functional fecal retention, are distinguished. Functional constipation is defined as follows: in infants and children at least 2 weeks of scybalous, pebble-like hard stools for a majority of stools; or firm stools two or fewer times/week; and no evidence of structural or metabolic disease.2

Functional fecal retention in contrast, is defined as follows: from infancy to 16 years old, a history of at least 12 weeks of passage of large-diameter stools at intervals, fewer than two times/week; and retentive posturing, avoiding defecation by purposefully contracting the pelvic floor. As pelvic floor muscles fatigue, the child uses the gluteal muscles, squeezing the buttocks together. The main difference between functional constipation and functional fecal retention is the occurrence of retentive posturing in the latter. Retentive posturing is the behavioral withholding of stool during the sensation of urge, which, according to the authors of the Rome II criteria, mostly results from painful defecation.

However, the Rome II criteria exclude a very common and major symptom of constipation, namely fecal soiling (if substantial called encopre-sis), which is not included in the definition. Therefore, to study constipation in children and define suitable end-points in pediatric research, a different definition of constipation has been used in children over 4 years of age. Pediatric constipation is thus diagnosed if at least two out of the four following criteria are fulfilled two or fewer bowel movements/week without laxatives; two or more soiling episodes/week; periodic passage of a very large amount of stool once every 7-30 days; or palpable abdominal or rectal mass on physical examination. Using this last definition, a small group of children (between 10 and 20%) do not fulfill these criteria, but still appear constipated, having a low frequency of defecation with production of firm hard stools with retentive posturing or painful experience. This last group is difficult to study, but will usually be included by the consulting physician for treatment efforts.3

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