Constipation in children
- 1. CONSTIPATION IN CHILDREN DR SHAILESH MEHTA M.D. PEDIATRICS PRACTICING CONSULTANT
- 2. What do the following children have in common? • 1 yr old girl with hard pellet-like stools. • 4-year-old girl with frequent complaints of dysuria and hard stools. • 7-year-old boy with a weekly stool that is large enough to clog a toilet. • 11-year-old boy with daily fecal staining underpants
- 3. WORKING DEFINITION OF CONSTIPATION Constipation can be roughly defined as- Infrequent passage of hard/uncomfortable stools that are distressing to the child.
- 4. Symptoms are often masked. You have to elicit proper history Children with constipation often present with vague complaints like - Abdominal pain - Decreased appetite More Distressing to both the child and the parents than infrequent passage of stools or fecal soiling or hard stools
- 5. WHY DOES IT HAPPEN? EXPLAIN THE MECHANICS OF CONSTIPATION • Inadequate hydration • Low-fiber diet • Slow intestinal transit • Minimal activity level or inactivity • Behavioral factors • Can manifest at any age and most commonly presents during a period of transition in the child’s life.
- 6. At what age children have a pattern and frequency of bowel movements similar to those of adults? A. Three years. B. Four years. C. Five years. D. Six years. E. Seven years.
- 7. At what age children have a pattern and frequency of bowel movements similar to those of adults? A. Three years. B. Four years. C. Five years. D. Six years. E. Seven years.
- 8. 5 yrs old Amit is brought to you by his anxious parents.They reveal that he is passing hard stools, with pain during defecation since 3 months According to them he strains a lot to pass the poop and even stands up or stretches his legs while sitting on the commode but with little on no success Have tried almost all laxatives but with little or no effect What next?
- 9. What more to ask on history? • He has episodes of loose stools leaking in his pants around 2-3 times a week • The poop is not XXL so as to clog the toilet. • He passes very small amounts of stools on alternate days.
- 10. No Red flags on history and examination • M No h/o delayed meconium passage after birth • B No h/o bloody stools • B No h/o severe abdominal bloating/distention • S No sacral dimple • F No h/o failure to thrive/poor weight gain • A Anal wink elicited, anal tone normal • I On inspection-No anal fissure, skin tags, fistula • L Lower limb reflexes, tone ,power , sensation are normal Amit refuses DRE. Is DRE essential for every child?
- 11. Rome III defines functional constipation • 2 or more of the following (fulfilled at least weekly for 2 months) in a child older than 4 years who does not have irritable bowel syndrome: • 1. Two or fewer defecations in the toilet per week. • 2. At least one episode of fecal incontinence per week. • 3. History of retentive posturing or excessive volitional stool retention. • 4. History of painful or hard bowel movements. • 5. Presence of a large fecal mass in the rectum. • 6. History of large-diameter stools that may obstruct the toilet.
- 12. Choice of Investigations In Functional Constipation • XRAY ABDOMEN? • Free T4/TSH ? • Barium enema? • TTG IgA? • Rectal manometry? • Rectal biopsy?
- 13. NO INVESTIGATIONS RECOMMENDED IN FUNCTIONAL CONSTIPATION ESPGHAN & NASPGHAN JPGN Volume 58, Number 2, February 2014 • XRAY ABDOMEN- Helps to educate parents • Free T4/TSH – Constipation is never a sole presenting complaint in hypothyroid kids • Barium enema- Only when Red flags seen • TTG IgA- Should be done in difficult to treat constipation with FTT
- 14. Treatment Options • SODIUM PICOSULPHATE • BISSACODYL • SENNA GLYCOSIDES • LACTULOSE • POLYETHYLENE GLYCOL
- 15. PEG 3350 DOSE?
- 17. LACTULOSE DOSE?
- 18. Dr starts a laxative (sodium picolinate) Amit reports worsening of loose stools leaking in his pants with no relief in painful defecation even after a week of regular laxative use • Piclin dose for Amit (wt-20kg ) 5ml bd x 1 week • He changes to Lactulose 20ml O.D. at bedtime x 2 weeks • Amit passes stools but pain and fecal soiling persists. • The dose of lactulose is hiked to 30ml O.D.
- 19. Amit passes normal stools for some days with no discomfort. After 2 weeks he again has similar symptoms. This time he goes to a famous doctor • What did the last doctor miss?
- 20. The right approach matters Treatment given in the following order 1-EDUCATION 2-DISIMPACTION- 3-6 days 3-MAINTAINANCE THERAPY FOR 8 weeks AMIT IS ADVISED FIBRE RICH DIET AND TAPERING DOSES OF LAXATIVES. THE GOAL IS TO GET SOFT STOOLS AT LEAST ONCE PER DAY FOR 2 MONTHS HE LIVES HAPPILY THEREAFTER
- 21. EDUCATION OF PARENTS AND KIDS ENCOURAGE CHILD TO SIT ON THE COMMODE FOR 3-10 MINUTES, AFTER 1 HOUR OF ANY MEAL
- 22. EDUCATION OF PARENTS AND KIDS Tell parents not to scold the child for fecal soiling
- 23. EDUCATION OF PARENTS AND KIDS
- 24. DISIMPACTION- MOST IMPORTANT • DECOMPRESS RECTUM • ORAL- POLYETHYLENE GLYCOL 3350 recommended 1-1.5mg/kg/dose for 3 -6 days • SUPPOSITORIES PLUS ORAL LAXATIVES IN DIFFICULT CASES • ENEMAS- NOT MORE EFFECTIVE THAN ORAL LAXATIVES FOR DISIMPACTIONS- AVOID AS FAR AS POSSIBLE TO DIVERT ATTENTION FROM ANAL REGION PAIN /TRAUMA • MANUAL DISIMPACTION - ONLY UNDER ANAESTHESIA
- 25. MAINTAINANCE THERAPY • Months to years • PEG 3350 most commonly used and recommended. 0.4/mg/kg/day to 0.7mg/kg/day When full evacuation of the rectum consistently occurs with stooling for 1 to 2 months without hard stools or withholding behaviors, The laxative medication may gradually be reduced along with addition of fibre rich diet THE HIGH FIBRE DIET APPROACH ALONE is not effective and can prolong the misery of the child
- 26. Sunny , 7 yrs old, does not pass stools in the toilet. He passes stools in his pants daily. The stools are normal in consistency and quantity is similar to a regular bowel movement. • Careful history and examination reveals the diagnosis.
- 27. Points on history taking which clinch the diagnosis • No h/o of delayed passage of meconium at birth • No h/o tape like stools or XXL Poop • Stools passed daily, normal consistency • No pain while passing stools • No abnormal posturing /retentive posturing • No pain abdomen • No urinary incontinence • No leakage of loose stools in underpants • No blood in stools
- 28. Anthropometry and physical examination are normal No abdominal distension No masses palpable per abdomen Anal position and appearance is normal No skin tags, fissures DRE not allowed by the child Lower limb Tone, Power ,Reflexes and sensations normal. Anal wink elicitable No sacral dimple Diagnosis? What has been missed in history?
- 29. DELAYED BOWEL TRAINING • He feels the urge to defecate but is unwilling to use the toilet at that moment • Has regular bowel movements in his underpants (WELL FORMED STOOLS) • BECAUSE OF- fear, anxiety, oppositional behavior, skill deficits, or lack of interest or motivation Is it same as encopresis?
- 30. Which of the following are the reasons of - Stool withholding 1) INTENTIONAL-To avoid unpleasant sensations 2) INTENTIONAL-May not want to use the toilet at school 3) INTENTIONAL-May not want to interrupt an enjoyable activity 4) INVOLUNTARY- Learned Behaviour MORE THAN 1 ANSWER MAY BE CORRECT
- 31. Which of the following are the reasons of - Stool withholding 1) INTENTIONAL-To avoid unpleasant sensations 2) INTENTIONAL-May not want to use the toilet at school 3) INTENTIONAL-May not want to interrupt an enjoyable activity 4) INVOLUNTARY- Learned Behaviour ALL OF THE ABOVE
- 32. ENCOPRESIS • Defined as defecation at inappropriate places, Usually underpants. • Fecal incontinence/ encopresis is often the result of liquid/soft stool leaking around a large mass of stool in the rectum, which clinicians should describe as Constipation with overflow. • Encopresis is not a developmental variation after the age of 4 to 5 years
- 33. Newborn Term baby has had delayed passage of meconium. At 56 hrs , he is feeding well and passes a small, thick stool. Which of the following is the most likely diagnosis? • A. Anterior displacement of the anus. • B. Celiac disease. • C. Cystic fibrosis. • D. Hirschsprung disease. • E. Hyperthyroidism.
- 34. Delayed passage of meconium- Beyond 24 hrs • Most common cause 1:500 –Meconium plug syndrome • Less common 1: 2500 – Cystic fibrosis • Even less common 1:5000 – Hirschsprung’s • Rare – anorectal malformation • EXTREMELY RARE- Small left colon, hypoganglionosis, Neuronal intestinal dysplasias
- 35. 3yrs old Rahul WT 10 KG HEIGHT 87CM Passes stools once in 3 days since birth. His tummy remains bloated. He has lack of appetite and colicky pain Parents have to insert suppositories on regular basis to evacuate the stools. They have tried various medicines with little or no response. There is no h/o intermittant diarrhoea with blood in stools.
- 36. History and exam • No history of bilious vomits • No h/o pain while defecation • No h/o retentive posturing • No h/o staining of underpants with leaking stools or overflow incontinence • No h/o recurrent respiratory infections • Poop is not XXL but is hard • Has FTT, Anemia • Lower limb Tone/power /reflexes –normal Something more to be asked or done?
- 37. History and examination • History of delayed passage of meconium at birth- after 48 hrs On DRE External anal opening normal and contracted Tone normal Rectum not loaded with faeces A large amount of stool is passed as the examiner removes the finger after DRE
- 38. Short Segment Hirschsprung’s disease • Without ganglion cells and nerve fibers to innervate the intestinal musculature, the affected colonic segment remains in a chronic contracted state. • Thin or tape like stools may be passed • Difficult to treat chronic constipation * with FTT* and anemia* and sometimes enterocolitis • Encopresis rare • Bloated abdomen * • DRE- empty rectum /explosive stools on removal of finger * Celiac disease or Gluten sensitivity –close DD!
- 39. Hi Fi Investigations • Ano-Rectal manometry-Purely a research tool. Presence of Recto-anal inhibitory reflex i.e. relaxation of internal anal sphincter on distention of rectum by air , virtually rules out Hirschsprung’s Disease • Rectal biopsy-Full thickness vs Rectal suction Bx- Red flags on history and examination
- 40. MRI SPINE RARELY NEEDED Spinal Imaging- Not necessary in the absence of red flags however there are reports of picking up spinal defects when examination was normal and constipation was Intractible ( more than 3 months treatment fails)
- 41. 4-month-old Sonia presents with substantial straining with bowel movements. She cries and turns red in the face just before she passes a soft stool, after which she relaxes. No history of delayed passage of meconium No h/o abdominal distention/bilious vomits No h/o blood in stools Passes stools once or twice daily –semisolid Gaining weight. Exclusively breast fed. Physical examination shows NO RED FLAGS
- 42. Which of the following is the most likely diagnosis for this infant’s signs and symptoms? • A. Anal achalasia. • B. Functional constipation. • C. Hirschsprung disease. • D. Infant dyschezia. • E. Neuronal dysplasia. What is the treatment/advice ?
- 43. Which of the following is the most likely diagnosis for this infant’s signs and symptoms? • A. Anal achalasia. • B. Functional constipation. • C. Hirschsprung disease. D. Infant dyschezia. • E. Neuronal dysplasia. • Coordination between increasing intraabdominal pressure with relaxation of pelvic floor muscles is absent. • Spontaneously resolves at 6 months
- 44. KEY RECOMMENDATIONS • A history and physical examination are usually sufficient to distinguish functional constipation from constipation caused by organic conditions. • Abdominal radiography is of limited value in diagnosing chronic constipation because it lacks interobserver reliability and accuracy. • Polyethylene glycol–based solutions (Miralax) are effective, easy to administer, noninvasive, and well tolerated in children with constipation.
- 45. KEY RECOMMENDATIONS • The addition of laxatives is more effective than behavior modification alone in children with constipation. • The addition of enemas to oral laxative regimens does not improve outcomes in children with severe constipation. • Most children with functional constipation require prolonged treatment. • Exclusively breast fed infants < 6months who have infrequent /painful stooling need watchful waiting for 2 weeks before starting laxatives
- 46. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. Evidence does not support the use of fiber supplements in the treatment of functional constipation. Evidence does not support the use of extra fluid intake in the treatment of functional constipation JPGN Volume 58, Number 2, February 2014 World J Gastroenterol 2012 December 28; 18(48)
- 47. EAST OR WEST PEG IS THE BEST • PEG SCORES OVER ANY OTHER LAXATIVE IN TERMS OF SAFETY AND EFFICACY FOR DISIMPACTION AND MAINTAINANCE PHASE OF CONSTIPATION • FOR DISIMPACTION 1-1.5MG/KG/DAY • FOR MAINTAINANCE 0.4 – 0.7 MG/KG /DAY • LACTULOSE IS THE NEXT PREFERRED LAXATIVE • STIMULANT LAXATIVES- SENNA, BISACODYL, SODIUM PICOSULPHATE- SHORT TERM RESCUE THERAPY Twenty-five RCTs (2310 participants) were included in the review ( AGE- BIRTH TO 18YRS) Gordon et. al Cochrane Database of Systematic Reviews 2016, Issue 8
- 48. Which of the following can be seen in untreated/missed constipation ? 1) ENURESIS 2) UTI 3) RECTAL PROPLAPSE 4) PELVIC DYSSYNERGIA
- 49. Which of the following can be seen in untreated/missed constipation ? 1) ENURESIS 2) UTI 3) RECTAL PROPLAPSE 4) PELVIC DYSSYNERGIA ALL OF THE ABOVE
- 50. What to expect after treatment • 60% of children with functional constipation are symptom-free between 6 and 12 months after beginning treatment, with the remaining 40% of children still experiencing symptoms. • 25% of children with functional constipation continue to experience symptoms into adulthood Children with red flags and intractible constipation need to be referred to a Gastroenterologist
- 51. Thank you