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    Rome IV Diagnostic Criteria for Infant Functional Constipation

    Official Rome IV criteria for the diagnosis of infant functional constipation.


    Use in infants and toddlers (<4 years of age) with symptoms suggestive of constipation such as passing hard, painful stools and exhibiting withholding behaviors for at least 1 month.

    Patients with any of the following features must be evaluated clinically for other diagnoses even though functional constipation may be present:

    • Constipation starting extremely early in life (<1 month).

    • Passage of meconium >48. 

    • Family history of Hirschsprung disease. 

    • Ribbon stools. 

    • Blood in the stool in the absence of anal fissures. 

    • Failure to thrive or unintentional weight loss.

    • Fever. 

    • Bilious vomiting. 

    • Severe abdominal distension. 

    • Abnormal physical exam findings including:

      • Tuft of hair on spine or sacral dimple.

      • Gluteal cleft deviation.

      • Perianal fistula.

      • Abnormal position of anus.

      • Absent anal or cremasteric reflex. 

      • Anal scars.

      • Decreased lower extremity strength/tone/reflex.

    When to Use
    Why Use

    Infants and toddlers (<4 years) presenting with symptoms suggestive of constipation for at least 1 month. The diagnosis of functional constipation should be made by clinical history and physical examination.

    • Functional constipation (FC) is diagnosed based on typical history and physical examination. In the absence of alarm symptoms, no further diagnostic testing is needed in the majority of cases.

    • In early onset of constipation (infants < 6 months), the likelihood of an underlying organic disease is higher. 

    • Breastfed infants can have infrequent bowel movements. Care should be taken not to overdiagnose FC.

    • Children with constipation can present with diarrhea, resulting from overflow fecal incontinence.

    • FC frequently results from repeated voluntary withholding of stool by a child who tries to avoid defecation because of fears and/or discomfort associated with stooling. 

    • There is no role for the routine use of abdominal radiographs to diagnose pediatric functional constipation. It should be reserved for patients with suspected fecal impaction in whom a digital rectal exam is not possible.

    • Some infants with constipation respond to dairy restriction. A 2 to 4 week elimination trial can be considered (hypoallergenic formula or maternal dairy restriction for breast-fed infants).

    • Oral laxatives are equally effective for treatment as rectal therapies and should be preferred as rectal interventions such as enemas or suppositories can be traumatizing for toddlers.

    • Early initiation of appropriate treatment is important and prognostically relevant.

    • Used to diagnose functional constipation in infants and toddlers in the absence of any alarm features.

    • Making a diagnosis of functional constipation helps guide the need for further work-up and management.

    • Can be used to discuss signs and symptoms of constipation with patients and their family.

    Must have 1 month of ≥2 of the following:

    For infants <4 years of age

    Diagnostic Result:

    Please fill out required fields.

    Next Steps
    Creator Insights
    Dr. Douglas Drossman

    About the Creator

    Douglas Drossman, MD, is professor emeritus of medicine and psychiatry at the University of North Carolina School of Medicine. He is founder, President Emeritus and Chief of Operations of the Rome Foundation. He is also the founder of the Drossman Center for the Education and Practice of Biopsychosocial Care and Drossman Consulting, LLC. Dr. Drossman has written over 500 articles and book chapters, has published two books, a GI procedure manual and a textbook of functional GI disorders (Rome I-IV), and serves on six editorial and advisory boards.

    To view Dr. Douglas Drossman's publications, visit PubMed

    Dr. Lin Chang

    About the Creator

    Lin Chang, MD is responsible for the oversight and coordination of the Rome IV calculators on MDCalc. She is a Professor of Medicine at the Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA and is a member of the Rome Foundation Board of Directors.

    To view Dr. Lin Chang's publications, visit PubMed

    The Rome Foundation

    About the Creator

    The Rome Foundation is an independent not for profit 501(c) 3 organization that provides support for activities designed to create scientific data and educational information to assist in the diagnosis and treatment of Disorders of Gut-Brain Interaction (DGBI), also known as functional gastrointestinal (GI) disorders. Their mission is to improve the lives of people with DGBI. Over the last 3 decades, the Rome organization has sought to legitimize and update our knowledge of the DGBIs. This has been accomplished by bringing together scientists and clinicians from around the world to classify and critically appraise the science of GI function and dysfunction. This knowledge permits clinical scientists to make recommendations for diagnosis and treatment that can be applied in research and clinical practice. Diagnosis is based on the use of symptom-based criteria which are used in clinical trials and daily practice. The list of Rome IV categories and the Chair and Co-Chair of each chapter committee are listed below.

    Committees Chair Co-Chair
    Esophageal Disorders Ronnie Fass, MD John Pandolfino, MD
    Gastroduodenal Disorders Nicholas J. Talley, MD, PhD, FRACP Vincenzo Stanghellini, MD
    Bowel Disorders Fermin Mearin, MD Brian Lacy, MD, PhD
    Gallbladder and Sphincter of Oddi Disorders Grace Elta, MD Peter Cotton, MD
    Centrally Mediated Disorders of Gastrointestinal Pain Peter J. Whorwell, MD Laurie Keefer, PhD
    Anorectal Disorders Adil E. Bharucha, MD, MBBS Satish S. C. Rao, MD, PhD, FRCP
    Childhood Functional Gastrointestinal Disorders: Neonate/Toddler Sam Nurko, MD Marc A. Benninga, MD
    Childhood Functional Gastrointestinal Disorders: Child/Adolescent Carlo Di Lorenzo, MD Jeffrey S. Hyams, MD

    Rome IV Diagnostic Criteria Chapters, Chairs and Co-Chairs

    Rome IV Editorial Board: Douglas A. Drossman, MD, Senior Editor, Lin Chang, MD, William D. Chey, MD, John Kellow, MD, Jan Tack, MD, PhD, and William E. Whitehead, PhD.

    To view The Rome Foundation's publications, visit PubMed

    Content Contributors
    • Beate Beinvogl, MD, MPH
    Reviewed By
    • Samuel Nurko, MD, MPH
    About the Creator
    Dr. Douglas Drossman
    Dr. Lin Chang
    The Rome Foundation
    Content Contributors
    • Beate Beinvogl, MD, MPH
    Reviewed By
    • Samuel Nurko, MD, MPH