Overview of Childhood Constipation

Overview of Childhood Constipation
GI Block
Fatima Farid
Pediatric Resident Year 2

Contents
• Practice case
• Basics of constipation
• Clinical assessment
• Investigation options
• Treatment strategies
2

“A Constipated Toddler”
Source: Case 29, 100 Cases Book
3

History
Tanya is a four-year-old girl who presents to outpatients with a two-year history of constipation.
• She opens her bowels about once every 5 days and strains.
• She soils her knickers on most days.
• She has intermittent abdominal pain, which is relieved by opening her bowels.
• Recently, there has been fresh blood on the toilet tissue.
• Lactulose has been used, with little success.
4

History
• She was delivered by emergency Caesarean section because of fetal distress and meconium
staining.
• Her mother states that she did not have a dirty nappy until 40 hours of age.
• She has recently had a urine infection diagnosed by her GP. The illness was mild and
responded well to antibiotics.
5

Exam
• Blood pressure is 101/62 mmHg.
• Weight is on the 50th centile and height is on the 25th centile.
• A faecal mass is palpable in the left iliac fossa.
• The anus appears normal.
• Rectal examination – hard stool palpated.
• The back is normal.
• There are no other signs.
6

Questions
7
What is the most likely
diagnosis?
Would you carry out any
investigations?
What is the treatment?

Brief answers!
1. Functional constipation with bleeding anal fissure
2. No investigations necessary
3. Mx:
i. Lifestyle modification with disempaction then maintenance regimens
ii. Analgesia for anal fissures
iii. Psychosocial support & counselling
8

Introduction [1]
• Constipation is one of the most common chronic disorders of childhood, affecting 1 to 30% of
children worldwide.
• It is responsible for 3% of all primary care visits for children and 10% to 25% of pediatric
gastroenterology visits.
• Children with constipation cost the health care system three times as much as children without
constipation, and the negative effect on quality of life often persists into adulthood.
9
[1] AAFP- Evaluation and Treatment of Constipation in Children and Adolescents, July 15, 2014

Terminology
• Parents often use the term constipation to refer to any number of concerns such as:
• large stool size
• excessively hard stools
• infrequent defecation
• pain during passing stool
• Healthcare providers may often hold a different understanding of the word ‘constipation’ than
parents, hence deeper inquiry is pertinent.
10

Questions
• Do all children have identical stool patterns?
• Will age influence normal frequency of defecation?
11

Normal bowel habits
• The normal frequency of defecation is highly variable & changes with age.
• An infant averages three to four stools a day in the first week of life, two stools a day later in
infancy and the toddler years, and once a day to every other day after the preschool years. [1]
• Many healthy breastfed infants go several days or longer without a bowel movement!
12
[1] AAFP- Evaluation and Treatment of Constipation in Children and Adolescents, July 15, 2014

Remember!
• Less frequent defecation patterns may be normal and must be considered in the
context of stool caliber, associated symptoms, and physical examination findings
13

Definition
The North American Society of Gastroenterology,
Hepatology, and Nutrition (NASPGHAN) defines
constipation as "a delay or difficulty in defecation,
present for 2 weeks or more, and sufficient to cause
significant distress to the patient.“ *
14
* Identical definition in Nelson Textbook of Pediatrics- 19th edition

Etiology
• Outside of the neonatal period, childhood constipation is usually functional (i.e., there is no
evidence of an organic condition).
• Functional constipation accounts for more than 95% of cases of constipation in healthy children
one year and older. [2]
• Organic causes are responsible for fewer than 5 percent of children with constipation but are
more common among young infants and those presenting with atypical features.
15
[2] UpToDate: Functional constipation in infants, children, and adolescents: Clinical features and diagnosis

Questions
• Why and how does functional constipation develop?
• Can constipation cause fecal incontinence? If yes, how?
16

Functional constipation
• Persistently difficult, infrequent, or seemingly incomplete
defecation, without evidence of a primary anatomic or
biochemical cause.
• Cycle commonly coincides with toilet training, changes in
routine or diet, stressful events, illness, lack of accessible
toilets, or in a busy child who defers defecation.
17

Functional constipation
• No gender preference.
• Three main peaks in children:
a. 6 months- 1 year: introduction of cereals & solid food
b. 2- 3 years: toilet training
c. 3- 5 years: start of school
• Children with autism spectrum disorders are also at high risk-
due to abnormal sensory processing/ medication side effect
• Triggers of adolescent constipation:
a. Busy routine/ school stressors
b. Anorexia nervosa/ bulimia: dehydration/ low fiber
c. ADHD
18

19
Please let me
take my time to
learn 

Pathophysiology
1. To avoid the passage of another painful bowel movement, the child will contract the anal sphincter
or gluteal muscles by stiffening his or her body, hiding in a corner, rocking back and forth, or
fidgeting with each urge to defecate. Parents often confuse these withholding behaviors as
straining to defecate.
2. Withholding of stool can lead to prolonged fecal stasis in the colon with reabsorption of fluid,
causing the stool to become harder, larger, and more painful to pass.
3. Over time, as the rectum stretches to accommodate the retained fecal mass, rectal sensation
decreases, and fecal incontinence may develop.
21

Rome IV criteria
23
Source: UpToDate

Fecal incontinence
• Voluntary or involuntary passage of feces in the underwear or
in socially inappropriate places in a child with a
developmental age of at least four years.
• It occurs in 1% to 4% of school-aged children and is almost
always associated with underlying constipation.
• Involuntary soiling may occur as contractions of the full
rectum inhibit the internal anal sphincter, leading to overflow.
• Condition improves once underlying constipation is treated.
24

Questions
• Can we diagnose functional constipation without ruling out serious underlying diseases?
• Do you know any organic causes of constipation?
26

Neurogenic 1. Hirschsprung disease
2. Cerebral palsy
3. Myelomeningocele, sacral teratoma, closed spinal dysraphism
4. Neurofibromatosis
5. Muscular weakness (down syndrome, prune belly syndrome, gastroschisis)
6. Infantile botulism
7. Pseudo-obstruction (myopathies, visceral neuropathies, mitochondrial
disorders)
8. Intestinal neuronal dysplasia
9. Duchenne muscular dystrophy
10. Familial/ acquired dysautonomia
28
Source: UpToDate

Endocrine & metabolic 1. Cystic fibrosis (meconium ileus, distal intestinal obstruction syndrome)
2. Hypokalemia
3. Lead poisoning
4. Vitamin D intoxication
5. Hypo or hypercalcemia
6. Hypothyroidism
7. Diabetes mellitus
8. Pheochromocytoma
9. Multiple endocrine neoplasia type 2B (MEN 2B)
10. Polyuria leading to dehydration
11. Juvenile systemic sclerosis (scleroderma) or mixed connective tissue diseases
12. Acute intermittent porphyria
29
Source: UpToDate

Anatomic & others
1. Anorectal anomalies (imperforate or anteriorly displaced anus)
2. Intestinal obstruction
3. Small left colon syndrome
4. Celiac disease
5. Medications: opiates, anticholinergics, antidepressants,
chemotherapy, aluminum containing antacids
6. Generalized joint hypermobility
30
Source: UpToDate

31
History Checklist
Source: UpToDate

33
Examination Checklist
Source: UpToDate

Investigations
• In most cases, organic causes of constipation can be
excluded based on a careful history and physical
examination.
• If warning signs of possible organic constipation are
present, focused laboratory and radiographic testing
should be performed.
36

Radiology
• Abdomen x- ray:
• Not routinely recommended- does not add to rectal exam findings, non- specific for constipation and may falsely exclude more
serious causes of presenting complaint
• Can be used if examination is limited for child’s sake (obesity, cooperation, psychologic issues)
• Barium enema:
• Good tool to detect features of Hirschsprung disease
• Should be followed by rectal biopsy for confirmation
• Lumbosacral x- rays:
• Done for children with evidence of spinal dysraphism or neurologic impairment of the perianal area/ lower extremities
• If high degree of suspicion is present, MRI is considered to investigate the possibility of tethered cord and spinal cord tumors
37
Source: UpToDate

38
Barium enema of an infant with
Hirschsprung disease, showing
the transition zone (arrow)
between the lower aganglionic
bowel and the normal colon
above.

Labs
• Celiac screening:
• For children with failure to thrive or recurrent abdominal pain, perform a CBC and serologic screening for
celiac disease (usually IgA antibodies to tissue transglutaminase).
• The symptoms of celiac disease may be subtle. Therefore, we have a low threshold for performing celiac
screening in children with constipation despite limited information about its clinical utility in this population.
• Urine routine and culture:
• For children with a history of rectosigmoid impaction, especially in association with encopresis, perform a
urine analysis and urine culture.
• This is because fecal impaction may predispose to urinary tract infections due to the mechanical effects of the
distended rectum compressing the bladder.
39
Source: UpToDate

Labs
• TSH:
• For children with impaired linear growth and depressed reflexes, or those with a history of central nervous system
disease, we suggest screening for hypothyroidism.
• If central hypothyroidism is suspected, the screen should include measurement of free thyroxine (T4) as well as TSH.
• Urea/ electrolytes & calcium (for those with metabolic abnormalities or inability to tolerate adequate fluids)
• Blood lead level:
• Screening for lead toxicity should be performed in children with risk factors. Screening recommendations vary by
community.
• Children at particular risk include those with pica, developmental disabilities, a family history of lead poisoning in a
sibling, or those living in housing built before 1950 or housing that recently has been renovated.
40
Source: UpToDate

Treatment
• Main concept is that chronic constipation causes the distended colon to be unresponsive to stool burden.
• Effective treatment requires consistent and complete emptying of the colon, so that it becomes conditioned
to work on its own, a concept known as "bowel retraining."
• The goal of therapy is the passage of soft stools, ideally once per day, and no less than every other day.
• Weeks to months, and sometimes years, of laxative and behavior therapy may be necessary before this
goal is achieved.
41

Bowel re-training
• There are four general steps in bowel retraining:
1. Disempaction
2. Prolonged laxative treatment and behavior therapy to achieve regular evacuation and
avoid recurrent constipation
3. Dietary changes (primarily increasing fiber content) to maintain soft stools
4. Gradual tapering and withdrawal of laxatives as tolerated
42

Plan
Disempaction
(6- 7 days)
Maintenance
(> 6 months)
Rescue Therapy
(as needed)
43

Disempaction
• This step is described as a ‘clean out’ to the caregivers
• Indicated for fecal impaction, which in practice includes most patients coming under medical
attention
• Characteristics of candidate children include:
a. Constipation associated with fecal incontinence
b. Significant stool mass palpable on DRE, abdomen exam or abdomen x- ray
c. History of infrequent or incomplete evacuation
44

Basics
• Oral, rectal or combined routes can be used – consider patient/ family preference
• Main oral therapy is polyethylene glycol 3350 (Movicol Pediatric Plain)
• Start with high dose for six days, then taper down as per guideline to achieve desired stool habit
• Some children will need rectal therapy first to release large disempactions to allow tolerance to
oral therapy (enemas are mostly used)
45

Disempaction modalities
Oral
• Polyethylene glycol 3350
• Polyethylene glycol- electrolyte
solution
• Mineral oil
Rectal
• Sodium phosphate enema
• Saline enema
• Mineral oil enema
• Bisacodyl suppositories
46
* Doses of all above medications are on UpToDate

Movicol (polyethylene glycol 3350)
• Macrogol 3350 acts by virtue of its osmotic action in the gut, which induces a laxative effect.
• It increases the stool volume, which triggers colon motility via neuromuscular pathways.
• The physiological consequence is an improved propulsive colonic transportation of the softened
stools and a facilitation of the defecation.
• Electrolytes combined with macrogol 3350 are exchanged across the intestinal barrier (mucosa)
with serum electrolytes and excreted in fecal water without net gain or loss of sodium,
potassium and water.
47

Dosing
• Dosage:
• One pediatric sachet is 6.9 grams
• 1 to 1.5 g/kg/day by mouth for up to 6 days
• Daily dose is dissolved in approximately 10 mL/kg body weight of water or flavored
beverage
• Example: 10 kg child  15 g/ kg every day = 2 sachets per day
48

Practical tip
49
Source: NHS UK & medicines.org.uk
Remember:
One sachet is
6.9 grams
Do not exceed
12 sachets! The daily number
of sachets should
be taken in divided
doses, all
consumed within a
12- hour period.
The above dosage
regimen should be
stopped once
disempaction has
occurred.

Making Movicol
• Each sachet should be dissolved in 62.5 ml (quarter of a glass) of water.
• The correct number of sachets may be reconstituted in advance and kept covered and
refrigerated for up to 24 hours. For example, for use in fecal impaction, 12 sachets can be made
up into 750 ml of water.
• Sachet: Do not store above 25°C.
• Reconstituted solution: Store in a refrigerator (2°C - 8°C) and covered.
• Any unused solution should be discarded within 24 hours.
50
Source: Medicines.org.uk

Side effects
51
Source: Medicines.org.uk

Sodium phosphate enema
• 33 mL enema for children 2 to <5 years; 66 mL enema for children 5 to 12 years; and 133 mL
enema for children ≥12 years.
• These enemas should not be used in children younger than two years of age.
• This dose may be repeated once within 12 to 24 hours, if necessary.
• Because these are small-volume enemas, the caregiver should be instructed to point the tip of
the enema device toward the child's back after it is inserted, to direct the contents toward the
bowel wall where it will be effective, rather than into the fecal mass.
52

Caution
• More frequent dosing should be avoided because there are several case reports of life-
threatening hyperphosphatemia and hypocalcemic tetany, particularly in young children, those
with colonic dysmotility, and/or with repeated administration of enemas.
• Phosphate-based enemas should be avoided in children with renal insufficiency.
53

Maintenance
• After disempaction, patients should be treated with a maintenance regimen of oral laxatives to
"retrain" the bowel and avoid reimpaction, which could restart the constipation cycle.
• Adequate doses of medication should be given to maintain a pattern of soft bowel movements
once or twice a day.
• It is important to start this maintenance regimen of laxatives immediately after disempaction to
avoid reaccumulation of stools.
54

Options
• Polyethylene glycol 3350
• Magnesium hydroxide (milk of magnesia)
• Lactulose
• Mineral oil
 The best studied medication is PEG without electrolytes, which appears to be efficacious and safe
 The type of laxative is not as important as using an adequate dose and ensuring compliance
55

Maintenance regimen
• Parents should be advised to adjust the laxative dose according to the response, and to increase the dose every
two days until the child has one or two soft stools each day, or to decrease it if the patient develops diarrhea.
• Parents should be warned that some leaking or soiling may continue at first, especially if the child fears or
continues to resist having a bowel movement.
• After starting the laxative treatment, parents should be advised to encourage the child to use the toilet for 5 to 10
minutes at the same time each day, preferably after breakfast or dinner.
• In children who are not fully toilet trained, delay this toileting plan until the child has had at least two to four weeks
of effective laxative treatment, to make sure that he or she is not experiencing any pain or hard stools when using
the toilet.
56

Drugs
• Movicol:
• Dose: 0.4 to 0.8 g/kg per day (up to 17 g)
• Clinical trials indicate that PEG without electrolytes has efficacy greater than or like that of lactulose and
magnesium hydroxide with fewer adverse effects and greater acceptance
• Lactulose:
• Typical doses are 1 mL/kg (up to 30 mL), once or twice daily
• Some patients report loss of effectiveness over time, presumably due to altered degradation by the colonic
bacteria
• Side effects include flatulence and abdominal cramps, which occur when the sugar is metabolized by colonic
flora
57

Movicol for maintenance
58
If the dose needs increasing this
is best done every second day.
For children below 2 years of
age, the maximum
recommended dose should not
exceed 2 sachets a day.
For children aged 2 to 11 years,
the maximum recommended
dose needed does not normally
exceed 4 sachets a day.
Treatment of children with
chronic constipation needs to be
for a prolonged period (at least 6
– 12 months)
Source: NHS UK & medicines.org.uk

Rescue therapy
• Stimulant laxatives, such as senna and bisacodyl, are sometimes used for brief periods to avoid recurrence of
impaction ("rescue" therapy), and their use for this purpose is supported by extensive clinical experience and expert
guidelines
• Most pediatric providers reserve stimulant laxatives for patients with severe constipation who do not respond to
osmotic laxatives and dietary changes, preferably under supervision from a pediatric gastroenterologist
• These laxatives are often used in conjunction with a stool softener such as docusate (Colace) or lubricant such as
mineral oil
• Stimulant laxatives also may be helpful for patients with anorectal malformations or other disorders that affect
anorectal innervation, which can affect sensory and motor function and predispose to both constipation and fecal
incontinence
59

61
Constipation with fecal incontinence
Source: UpToDate

62
Constipation without fecal incontinence
Source: UpToDate

Additional therapy
• Behaviour modification:
• Toilet sitting regularly for 5- 10 mins BD with proper positioning
• Reward system for effort
• Monitoring using stool diary
• Dietary changes:
• Balanced diet with fruits, vegetables & whole grains
• Adequate fluid intake
• Trial of cow milk elimination in select circumstances
63

Follow- up
• Planned follow-up is particularly important during the first few days of treatment,
especially if disempaction was warranted.
• The initial discussion can be by telephone, but the child may need to return to the
office if he or she is still passing hard stools.
• Patients who require disempaction also should have an office visit soon after
completing the disempaction protocol to review the details of maintenance
therapy.
• After entering the maintenance phase, the child should have regular follow-up
visits, initially on a monthly basis and then less frequently (eg, every three to four
months).
• The clinician should review the child's stool records and repeat the abdominal and
rectal examinations.
• The follow-up visits provide opportunities to evaluate progress, adjust medication
regimens, anticipate challenges, and celebrate successes.
• As laxative therapy is gradually discontinued, the importance of dietary and
behavioral interventions should be reinforced.
66

References
• AAFP: Evaluation and Treatment of Constipation in Children and Adolescents, July 15, 2014
• Medscape: Pediatric Constipation
• UpToDate: Functional constipation in infants, children, and adolescents: Clinical features and
diagnosis
• UpToDate: Chronic functional constipation and fecal incontinence in infants, children, and
adolescents: Treatment
• Illustrated textbook of pediatrics, fourth edition
• Nelson textbook of pediatrics, nineteenth edition
67

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