Infant Dyschezia: Causes, Diagnosis, and Treatment

Introduction

Infant dyschezia is one of the childhood functional gastrointestinal disorders (FGIDs) of neonates and toddlers, now also referred to as disorders of gut-brain interaction (DGBI), as classified by version IV of the Rome Criteria.⁵ 

Infant dyschezia simply means “difficulty pooping.” Infants with dyschezia have difficulty coordinating the increased intra-abdominal pressure with the relaxation of the pelvic floor muscles necessary to facilitate successful defecation.¹ It is characterised by straining, screaming, crying, and turning red or purple in the face while attempting to defecate. These symptoms usually persist for 10 to 20 minutes and are seen in infants between the ages of 0 and 9 months. Infants with dyschezia may have a successful or unsuccessful passage of soft stools several times daily.² The child’s symptoms, accompanied by persistent crying and exhaustion for 10 to 20 minutes, often creates anxiety among parents, leading them to frequently consult various healthcare providers in an attempt to seek appropriate treatment. However, in the majority of infants, the symptoms begin in the first months of life and resolve spontaneously after 3 to 4 weeks.²

According to a study conducted using the revised Rome IV Criteria to assess the prevalence of different functional gastrointestinal disorders, infant dyschezia was found in only 1 to 3% of infants.

Causes of infant dyschezia

To understand the causes of infant dyschezia, it is necessary to understand how normal defecation, or “pooping”, takes place and why infants with dyschezia struggle to do it.

Defecation is an intricate process that requires coordination between the gastrointestinal, neurological, and musculoskeletal systems.³ 

For successful defecation, the respiratory diaphragm and abdominal wall contract together, resulting in an increase in intra-abdominal and rectal pressure. Concurrently, there is relaxation of the pelvic floor muscles and anal sphincter.⁴ The coordination of these two actions facilitates the successful passage of stool from the anus. Since the gastrointestinal, neurological, and musculoskeletal systems of infants with dyschezia are still developing, they are not yet capable of coordinating these reflexes. 

Signs of infant dyschezia

• Straining, screaming, and crying with each effort to pass stool
• The face turns red or purple
• After straining and crying for 10 minutes, infants may have either successful or unsuccessful passage of soft stools
• Passage of stools is observed several times a day²

Infants (0–1 year old) are unable to verbally report symptoms such as pain. Therefore, the signs mentioned above, based on parents' observations, aid physicians in correctly diagnosing the problem. 

Diagnosis of Infant Dyschezia

The Rome criteria

In the late 1980s, Italian Professor Aldo Torsoli recruited international experts to form working teams for the 1988 International Gastroenterology Meeting. The teams implemented consensus methodology and a Delphi approach to develop classification and diagnostic criteria for functional gastrointestinal disorders, which at the time had limited scientific evidence for their aetiology, pathophysiology, and treatment. This is how the Rome process was originally started, leading to the establishment of the Rome Criteria.⁵

The Rome Criteria have been widely used for the diagnosis of functional gastrointestinal disorders for several years. However, it is necessary to update the criteria regularly to align them with new research findings, understanding of symptom patterns, and contributing pathophysiological factors. The criteria have evolved through four successive versions: Rome I, Rome II, Rome III, and the latest version, Rome IV, which was published in May 2016. 

Diagnosis of infant dyschezia according to the revised Rome IV criteria

• The infant must be between 0 and 9 months old
• There must be a minimum of 10 minutes of straining and crying before successful or unsuccessful passage of stool
• The stool consistency should be soft
• The infant should not have any other health problems²

In the Rome III Criteria, the age range for diagnosing infant dyschezia was 0 to 6 months. However, based on data gathered from a 2015 study, 0.9% of infants were found to have dyschezia even at 9 months of age. As a result, the revised Rome IV Criteria extended the age range from 0-6 months to 0-9 months. Additionally, while the Rome III Criteria linked straining and crying symptoms specifically to the successful passage of stools, the new Rome IV Criteria now include both successful and unsuccessful passage of stools.¹

Exclusion of other conditions 

To diagnose infant dyschezia, other possible anatomical abnormalities such as anal fissures, anal stenosis, anorectal malformations, rectal prolapse, Hirschsprung's disease, or intestinal obstruction must be considered. To completely rule out these conditions, a thorough physical exam should be performed, along with any necessary imaging studies or other diagnostic tests.

Treatment of infant dyschezia 

For infants with dyschezia, treatment is not indicated. The majority of infants experience symptoms in the first few months of life, which spontaneously resolve on their own within three to four weeks. However, effective parent education and reassurance are essential. Parents need to be assured that this is a typical developmental stage and that their child will eventually learn to coordinate increased intra-abdominal pressure with pelvic floor relaxation in order to defecate normally. Parents should avoid using laxatives or rectal stimulation, as these can create artificial sensory experiences that might condition the child to wait for stimulation before defecating, interfering with their natural learning process.²

FAQ’s

How do I know if my child has dyschezia or is constipated?

Infants with dyschezia and those with constipation both strain and have difficulty passing stools. However, these are distinct conditions with different characteristics and causes. Infant dyschezia is characterized by difficulty passing stools, accompanied by straining and crying, with the successful or unsuccessful passage of stool several times a day. Infant constipation, on the other hand, is defined by difficulty passing stools that are hard, dry, and large, with fewer than three bowel movements per week.⁶ Infant constipation is primarily caused by dietary changes, such as the introduction of new foods, a lack of fibre or fluid consumption, or other medical issues, and it may require dietary changes as well as medical intervention, depending on the underlying cause.⁶ In contrast, infant dyschezia is a normal developmental phase in which the infant is still learning to coordinate the reflexes necessary to pass stools. 

How do I help my baby with dyschezia?

Infant dyschezia is a short-term condition with no specific treatment. It is a learned reflex that the infant will gradually develop, allowing them to begin defecating normally within 3 to 4 weeks as they learn to coordinate the reflexes required for successful stool passage. Rectal stimulation is strongly discouraged by doctors, as it may interfere with the child's natural learning process. 

How do you diagnose infant dyschezia?

The Rome Diagnostic Criteria are commonly used to diagnose functional gastrointestinal disorders. Infant dyschezia is diagnosed when a child is between 0 and 9 months of age, has no other health problems, and strains and cries for 10 minutes before passing soft stools successfully or unsuccessfully several times a day. Furthermore, a comprehensive physical exam, diagnostic tests, and imaging are performed to rule out any other potential anatomical abnormalities.

When will infant dyschezia resolve?

It is critical to acknowledge that infant dyschezia is part of the defecation learning process. The gastrointestinal, neurological, and musculoskeletal systems that aid in effective defecation have not yet fully developed to coordinate reflexes. It will resolve on its own in three to four weeks as the child grows. It will resolve on its own in three to four weeks as the infant grows.

Summary

Infant dyschezia (difficulty pooping) is a type of functional gastrointestinal disorder (FGID) that affects infants between 0 and 9 months of age. It is caused by difficulty coordinating the increased intra-abdominal pressure with the relaxation of the pelvic floor muscles, which are necessary for successful defecation. Characteristic features of infant dyschezia include straining, screaming, crying, and turning red or purple in the face for 10 to 20 minutes, followed by either successful or unsuccessful passage of soft stools several times a day. Treatment for managing infant dyschezia is not indicated. Since the condition is temporary and subsides spontaneously, providing satisfactory reassurance is essential. Parents should avoid using laxatives or rectal stimulation, as these can create artificial sensory experiences that might condition the child to wait for stimulation before defecating, thereby interfering with the natural learning process.