Assessment and management of pediatric constipation for the primary care clinician.

Constipation is a common problem in pediatrics and accounts for 3-5% of all pediatric office visits and 10-25% of all pediatric gastroenterology referrals. Functional constipation accounts for about 95% of constipation cases, but "red flag" symptoms that suggest organic causes need to be considered. A diagnosis of functional constipation can be made in absence of "red flag" symptoms and a normal physical assessment. Physical assessment should focus on growth, abdominal exam, inspection of the perianal region, and examination of the lumbosacral region. Abdominal x-rays are generally not useful to differentiate between functional and organic causes of constipation. Treatment of constipation includes dietary changes, medication use, and behavioral modification. Osmotic laxatives are used as first-line treatment, and stimulant laxatives can be added if there is no improvement with osmotic laxatives. Despite improvement with laxatives, 40-50% of children with constipation experience at least 1 relapse in 5 years. Quality improvement opportunities exist for improving care of children with functional constipation by specialists partnering with primary care.