Infantile Dyschezia

Infantile dyschezia is the finding, in an infant under 9 months of age, of at least 10 minutes of straining and crying before the successful passage of soft stool, with no other health problems.

• Cause: lack of coordination between increased intra abdominal pressure and relaxation of the pelvic floor and anal sphincter during defecation, a normal developmental phenomenon in the first weeks of life.
• Typical onset in the first month; resolves by 3 to 4 months of age (often within 1 to 4 weeks) as coordination matures, without treatment.
• Stools are soft or normal, and the infant gains weight and feeds well; it is not constipation.
• Affects about 2 to 9 percent of infants.

• Grunting, straining, drawing up of the legs, red faced crying, and screaming for 10 to 20 minutes or more before passing a soft or mushy stool or flatus, with relief afterwards; stool frequency may be several times a day or less often; abdomen soft.
• Otherwise healthy: normal feeding, no vomiting, no distension, normal growth.
• Red flags (consider organic disease): delayed meconium over 48 hours after birth; hard stools; blood in stool or fissure; abdominal distension; bilious vomiting; failure to thrive; abnormal anal position, patulous anus, anal stenosis; tuft of hair or sacral dimple; hypotonia; explosive stool on rectal examination (Hirschsprung); ribbon stools; fever; poor feeding; symptoms starting after 9 months.

• Clinical diagnosis from history and examination (growth, abdomen, perianal inspection, anal position and sphincter tone, spine).
• No investigations if typical. If red flags: thyroid function, electrolytes, calcium, rectal suction biopsy and anorectal manometry (Hirschsprung disease), abdominal and spinal ultrasound, stool for blood, assessment for cow's milk protein allergy.
• Differentials: functional constipation, Hirschsprung disease, anorectal malformation, cow's milk protein allergy, hypothyroidism, spinal dysraphism, anal stenosis, infant colic.

• Reassure parents that straining and crying is normal and temporary and that the infant is not constipated.
• Avoid interventions that can cause harm or dependence: rectal stimulation with thermometers, cotton buds or suppositories (glycerin), laxatives, enemas, formula changes, or herbal remedies; they prolong the problem by interfering with normal learning of defecation.
• Practical measures: comforting, holding, a warm bath, bicycle leg movements, and abdominal massage; place in a flexed knee-to-chest position if it helps; ensure adequate feeding volume and correct formula preparation.
• For breastfed infants: continue breastfeeding.
• Review in 2 to 4 weeks or earlier if stools become hard, blood is seen, or feeding fails.
• Refer for red flags or persistence beyond 4 months.