constipation in children , pediatric constipation , management of constipation in children , understanding constipation , causes of constipation in children , functional constipation in children , treatment of constipation ,approach to constipation in children ,constipation in infants

1. CONSTIPATION IN CHILDREN
Dr. sayed ismail
Professor of pediatrics
Seha emirate hospital and Ibn-Nafees MC
sayedahmed1900@gmail.com
+971-0551256783

2. Objectives
1. What is constipation ?
2. What are causes of the pediatric constipation ?
3. How to the mange pediatric constipation ?

3. Incidence
• Constipation is a very common pediatric problem
• Affecting 1% to 30% of children worldwide
• Constipation accounts for 5% of general pediatric office
visits

4. Normal stool patterns

5. Definition

6. Definitions:
For practical clinical purposes,
constipation is generally defined as
infrequent , hard and /or painful
defecation

7. Fecal impaction
This term is used to describe markedly
increased amounts of stool in the rectum
and colon.
It is a subjective judgement based on
clinical findings, such as a large stool
mass noted on physical examination
and/or radiograph
Fecal impaction Functional fecal incontinence

8. Functional fecal incontinence
Is the repeated involuntary passage of stool in the
underwear after the acquisition of toileting skills
(typically after four years of age).
This term is preferred rather than encopresis or soiling.

9. Functional
constipation
95% of cases
Organic ---- 5 %
• Hirschsprung disease
• Congenital anomalies: Anal stenosis, anteriorly
located anus,
• Spinal cord anomalies (meningomyelocele, , spina
bifida)
• Endocrine/metabolic: Hypothyroidism, renal tubular
acidosis, diabetes insipidus, hypercalcemia
• Drugs: Anticonvulsants
CAUSES OF CONSTIPATION IN CHILDREN
Functional gastrointestinal disorder (FGID) are defined as
disorders that cannot be explained by structural or
biochemical findings

10. Pathogenesis of functional constipation

11. Clinical Diagnosis
• A history and physical examination are usually
sufficient to differentiate functional constipation
from constipation caused by an organic condition
• Functional Constipation is common at three
times in child's life:
• After starting cereal and puréed foods,
• During toilet training
• after starting school

12. History
• C/O
• Abdominal pain
• Poor feeding
• Difficult defecation
• Fecal incontinence
• Important questions in the history
• Age of onset: Onset in young Infants suggests organic etiology
• Consistency, frequency of stools
• Pain or bleeding with passing stools
• Systemic symptoms (e.g., fever, vomiting, weight loss,..)
• Timing of first bowel movement after birth
• Social history, including toilet training, stressors

13. Examination
• Typical examination is normal; in functional constipation
,however, you should rule out any organic cause
• Check Growth parameters : FTT in organic constipation
• Abdomen : palpable mass in left iliac fossa
• Anorectal :Take note of the anal position and skin tags or
fissures
• Lumbosacral region :Note any dimple, tuft of hair, to
evaluate for signs of neural tube defects.
• Rectal examination : Evaluate for presence of anal
stenosis or fecal impaction

14. RED FLAGS SUGGESTED DIAGNOSES
Delayed passage of meconium (more than 48 hours after
birth)
Hirschsprung disease, cystic fibrosis, congenital malformation
of anorectum or spine
Onset before one month of age Congenital malformation of anorectum or spine,
Hirschsprung disease, allergy, metabolic/endocrine condition
Failure to thrive Hirschsprung disease, cystic fibrosis, metabolic condition
Severe abdominal distension Hirschsprung disease, impaction,
Tight anal sphincter , Abnormal position of anus Hirschsprung disease, anorectal malformations
Pilonidal dimple covered by tuft of hair Spinal cord abnormality
Abnormal neurologic examination (absent anal wink, absent
cremasteric reflex, decreased lower LIMB reflexes and/or
tone)
Spinal cord abnormality
No response to conventional treatment Hirschsprung disease, neurenteric problem, spinal cord abnormality
Red Flags Suggesting an Organic Cause of Constipation in Children

15. Differential Diagnosis of functional Constipation in Children
Diagnosis
• Anorectal manometry
• Rectal suction biopsy
Hirschsprung disease

16. Anorectal malformation
Note abnormal and anterior displacement of anus.
Diagnosis
• Physical examination
• barium enema

17. Diagnosis : Spinal magnetic resonance imaging, anorectal manometry,
Spinal cord abnormality

18. investigations
• Generally investigation are unnecessary unless the child has red
flags, Or metabolic condition is suspected
• Thyroid FT , serum calcium, electrolytes to exclude
hypothyroidism, hypercalcaemia or hypokalaemia.
• Plain abdominal X-ray that may show areas of fecal matter
(stool is white surrounded by black bowel gas).
• MRI for spinal cord disorders such as tethered spinal cord.
• Rectal biopsy if suspicion of HD
• Anorectal , colonic manometry

19. Treatment
There are 3 general steps :
1- Fecal disimpaction
2- Maintenance therapy
3- Follow-up schedule

20. 1- Fecal disimpaction (Colon Evacuation)
Oral route: is noninvasive ,For most children, we suggest an oral
regimen for disimpaction
• Polyethylene glycol (PEG)
• For outpatient treatment, PEG 3350 The dose is 1 to 1.5
g/kg/day . dissolved in 10 mL/kg body weight of water or flavored beverage
• Continue twice-daily dosing of PEG for up to 6 days total, until the child has
passed a large amount of stool
• Adherence with the necessary volume may be difficult
• Inpatients –
• PEG-electrolyte solution may be given by nasogastric tube at 25
mL/kg/hour until the stool appears clear
Rectal (enema) is faster but invasive,
• Sodium phosphate enema :
• 2.5 mL/kg, maximum 133ml/dose
• This dose may be repeated once within 12 to 24 hours
• Not used in children < 2yr.
This can be achieved by oral or by rectal route or a combination
Combination treatment with oral and rectal medications is often the most effective approach for moderate or severe fecal impaction

21. THERAPY DOSAGE
Oral
Osmotics
Polyethylene glycol 3350 1.5 g per kg per day by mouth for up to six days.
Polyethylene glycol solution 25 mL per kg per hour via nasogastric lavage
Magnesium citrate < 6 years: 2 to 4 mL per kg per day
6 to 12 years of age: 100 to 150 mL per day
> 12 years: 150 to 300 mL per day
Stimulants
Senna 2 to 6 years of age: 2.5 to 7.5 mL (8.8 mg per 5 mL); ½ to
1 ½ tablets (8.6 mg per tablet) per day
6 to 12 years of age: 5 to 15 mL; 1 to 2 tablets per day
Bisacodyl (Dulcolax) ≥ 2 years: 5 to 15 mg (1 to 3 tablets) per day in a single
dose
Lubricants
Mineral oil 15 to 30 mL per year of age per day
Rectal agents
Enemas (one per day)
Saline 5 to 10 mL per kg
Mineral oil 15 to 30 mL per year of age up to 240 mL
Phosphate soda 2 to 12 years of age: 66-mL enema (should not to be
used in children < 2 years because of the risk of
electrolyte abnormality)
> 12 years: 133 mL
Suppository (one per day)
Bisacodyl ≥ 2 years: 5 to 10 mg (½ to 1 suppository)
Glycerin* ½ to 1 infant suppository; adult suppository for those
older than 6 years
Medications that have
been used successfully for
for Disimpaction in
Children

22. 2- Maintenance therapy
• Should follow successful fecal disimpassion
1. Prolonged laxative treatment
2. Education and behavior modification
3. Dietary modification

23. Laxatives treatment
• Polyethylene glycol
• Because many studies show that PEG is most effective , safe and has fewer side
effects than lactulose or milk of magnesia, it is recommended for first-line
maintenance treatment
• Dose : 0.4 - 0.8g/kg/day
• Titrate the dose up and down by ½ or 1 teaspoon every other day to achieve 1 to 2 soft bowel
movement per day . Maximum dose is (17 g) twice daily.
• The effective dose should be continued for at least 3 months to help the distended bowel to
regain its function.
• Point to be remembered here is that laxative needs to be continued for several
months and sometimes years

25. • There is no evidence that tolerance develops to osmotic laxatives
like (PEG and lactulose )and very little evidence that this is a problem
for stimulant laxatives such as senna or bisacodyl
• Children treated with senna seem to have more difficulty weaning off
of medication as compared other medications.

26. Behavior Modification
• Behavior modification consists of a regular toileting
regimen with reward system to encourage cooperation.
• Toilet sitting : about 5 to 10 minutes after meals,
especially breakfast and dinner;
• Use of a foot rest or toddler potty chair may be
beneficial.
• Reward system, such as stickers, or small sweets or
coins if child has a bowel movement.

27. Family education
• Explain the cycle of pain/fear, stool
withholding, , and fecal incontinence and how
to reverse this
• Provide education about how to adjust the
dose up or down to achieve 1 to 2 soft bowel
movements per day.
• Recovery will be gradual : may be some initial
leakage due to dilation of the rectum and anal
sphincter. This should improve within few days.

28. 3- Dietary modification:
• Encourage to take more fluids
• Non-absorbable carbohydrate (sorbitol) is found in some fruit
juices like apple, pear and prune juices.
• A balanced diet that includes whole grains, fruits and
vegetables is advised.
• Eliminating cow's milk from the diet improves constipation in
some children with atopic symptoms, probably because of an
occult cow's milk intolerance

29. Treatment in infant
• Rule out organic constipation : congenital megacolon , anal stenosis ,
hypothyroidism…
• Increase fluid intake ,many respond to sorbitol containing juices ( apple,
pear , prune), multigrain cereals instead of rice cereal
• If these measures are unsuccessful, Lactulose and PEG are safe
• Glycerin suppositories are useful
• Avoid :
• Enema
• Stimulant laxatives
• Mineral oil

30. 3- Follow-up schedule
• 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).
• On each visit, by reviewing stool records and repeating abdominal and (if
required) rectal examination.
• If necessary, dosage adjustment is to be made.

31. Discontinuation
• May begin weaning laxatives once child has regular soft daily stools and no
episodes of acute constipation or fecal incontinence for 3-6 months
• The laxative dose is gradually decreased to a dose that will maintain one to two
bowel movements per day
• If reoccurrence occurs once weaning has started, it is important to have a rescue
plan in place for the family

32. Management of relapses
• Relapses are common and may be managed in several ways
• If PEG has been prescribed, ensure that the parents are mixing it as advised in the
correct type and amount of fluid (water, juice, or soda; milk ) Briefly increase the dose
of oral laxative (eg, double the dose for one to three days, until the child is having large
soft stools).
• Use an enema to empty the rectum.
• Give one or two doses of a stimulant laxative, such as senna and bisacodyl.
• If this intervention is successful, treatment is continued with the maintenance osmotic
laxative but at a higher dose.

33. • 60 % of children with functional constipation had successful outcome with laxative
therapy for 12 months
• 30% require long-term therapy and they may continue to have constipation as an
adult.
Outcome

34. • Refractory constipation
• constipation is considered refractory when there is no response to optimal
treatment for at least 3 months
• The true refractory constipation is extremely uncommon

35. Causes of refractory constipation
1. Organic : Hirschsprung disease, anorectal and spinal cord abnormalities
2. Motility disorders (like slow transit constipation), disorders of stool expulsion
internal anal sphincter achalasia and sphincter dysfunction in children with
Hirschsprung disease which persist after surgery
3. Hypothyroidism, celiac disease, hypercalcemia, should be ruled out

36. Referral
• Referral to a pediatric gastroenterologist may be needed when:
1. A child with constipation has red flags for organic disease
2. Refractory constipation

38. Key points
• Majority of childhood constipation is functional
• Detailed history and examination are sufficient to diffentiate functional and
organic constipation
• Presence of red flags suggests organic constipation
• Polyethylene glycol (PEG), is the principle laxative for maintenance therapy and for
treatment of fecal impaction.
• Both education and behavioral interventions are important parts of treatment
• Treatment may be required for months to years, depending on the severity.

39. References
1. Steutel NF, Zeevenhooven J, Scarpato E, et al. Prevalence of Functional Gastrointestinal Disorders in European Infants and Toddlers. J Pediatr 2020; 221:107.
2. Benninga MA, Faure C, Hyman PE, et al. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016.
3. Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014;
58:258.
4. Bekkali NLH, Hoekman DR, Liem O, et al. Polyethylene Glycol 3350 With Electrolytes Versus Polyethylene Glycol 4000 for Constipation: A Randomized, Controlled Trial. J Pediatr Gastroenterol Nutr 2018; 66:10.
5. Van den Berg MM, Benninga MA, Di Lorenzo C. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol. 2006 Oct. 101(10):2401-9. [Medline].
6. [Guideline] North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for
Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006 Sep. 43(3):405-7. [Medline].
7. Benninga M, Candy DC, Catto-Smith AG, et al. The Paris Consensus on Childhood Constipation Terminology (PACCT) Group. J Pediatr Gastroenterol Nutr. 2005 Mar. 40(3):273-5. [Medline].
8. Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J
Pediatr Gastroenterol Nutr. 2014 Feb. 58 (2):258-74. [Medline].
9. De Lorijn F, Reitsma JB, Voskuijl WP, et al. Diagnosis of Hirschsprung's disease: a prospective, comparative accuracy study of common tests. J Pediatr. 2005 Jun. 146(6):787-92. [Medline].
10. Loening-Baucke V. Polyethylene glycol without electrolytes for children with constipation and encopresis. J Pediatr Gastroenterol Nutr. 2002 Apr. 34(4):372-7. [Medline].
11. Bekkali NL, van den Berg MM, Dijkgraaf MG, et al. Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG. Pediatrics. 2009 Dec. 124(6):e1108-15. [Medline].
12. Pijpers MA, Tabbers MM, Benninga MA, Berger MY. Currently recommended treatments of childhood constipation are not evidence based: a systematic literature review on the effect of laxative treatment and dietary
measures. Arch Dis Child. 2009 Feb. 94(2):117-31. [Medline]
13. Khan S, Campo J, Bridge JA, et al. Long-term outcome of functional childhood constipation. Dig Dis Sci. 2007 Jan. 52(1):64-9. [Medline].
14. Bardisa-Ezcurra L, Ullman R, Gordon J; Guideline Development Group. Diagnosis and management of idiopathic childhood constipation: summary of NICE guidance. BMJ. 2010;340:c25
15. Maffei HV, Vicentini AP. Prospective evaluation of dietary treatment in childhood constipation: high dietary fiber and wheat bran intake are associated with constipation amelioration. J Pediatr Gastroenterol Nutr.
2011;52(1):55–59.
16. Nurko S, Youssef NN, Sabri M, et al. PEG3350 in the treatment of childhood constipation: a multicenter, double-blinded, placebo-controlled trial. J Pediatr. 2008;153(2):254–26
17. Candy D, Belsey J. Macrogol (polyethylene glycol) laxatives in children with functional constipation and faecal impaction: a systematic review. Arch Dis Child. 2009;94(2):156–160
18. Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev. 2010;(7):CD007570.
19. Siddiqui AA, Fishman SJ, Bauer SB, Nurko S. Long-term follow-up of patients after antegrade continence enema procedure. J Pediatr Gastroenterol Nutr. 2011;52(5):574–580.
20. Corazziari E, Staiano A, Miele E, Greco L; Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition. Bowel frequency and defecatory patterns in children: a prospective nationwide survey. Clin Gastroenterol
Hepatol. 2005;3(11):1101–1106.
21. Brazzelli M, Griffiths PV, Cody JD, Tappin D. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. 2011;(12):CD002240