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Management Of Chronic Constipation In Infants And Toddlers - Includes Patient Information HandoutsFrom American Family Physician, 2/1/94 by Vera Loening-Baucke Constipation is usually defined in terms of alterations in the frequency, size, consistency and ease of passage of stool. Large differences in both the frequency and consistency of stools exist at varying ages. A number of studies reveal a decline in stool frequency from more than four stools per day during the first week of life to two stools per day by four months of age and one stool per day at four years of age, with a corresponding increase in stool size.[1-4] Bowel movements occur from three times per day to three times per week in 96 percent of children three to four years of age. By the age of four, an adult pattern of bowel movements is achieved.[5] Stool frequency is occasionally difficult to assess, because some children have several bowel movements each day but apparently evacuate incompletely, as evidenced by the periodic passage of large amounts of stool or the presence of a fecal mass on examination. Constipation in infants and toddlers can be defined as a stool frequency of less than three per week. However, painful bowel movements and stool retention are symptoms of constipation even when stool frequency is three or more per week. The infrequent passage of stool in a contented breast-fed baby in the early weeks or months of life is normal. Pathophysiology Defecation, like the maintenance of continence, involves the coordination of many reflex mechanisms. In a healthy person, the entry of a fecal bolus into the rectum is followed by several automatic, coordinated reflexes. The right side of the colon, including the rectum, contracts as the internal sphincter relaxes. The external sphincter initially contracts but, with a sufficient fecal bolus, the initial contraction is followed by total inhibition of the external and internal anal sphincters, leading to defecation. Fecal continence refers t