This document provides information on childhood constipation, including its definition, diagnosis, and treatment. Constipation is defined as delayed or difficult defecation for two or more weeks. Diagnosis involves taking a detailed history and performing a physical exam. Treatment involves disimpaction followed by maintenance therapy, focusing on dietary changes, behavioral modifications, and medications like polyethylene glycol or lactulose. Special considerations for infants less than 1 year include increased fluid intake and avoiding certain laxatives.

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Childhood ConstipationChildhood Constipation
Prof. Dr. Saad S Al- Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital
Sharjah ,UAE
saadsalani@yahoo.com

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Any definition of constipation is relative andAny definition of constipation is relative and
depends ondepends on::
• Stool consistencyStool consistency
• Stool frequencyStool frequency
• Difficulty in passing the stoolDifficulty in passing the stool

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•A normal child might have a soft stool onlyA normal child might have a soft stool only
every 2nd or 3rd day without difficultyevery 2nd or 3rd day without difficulty
•A hard stool passed with difficulty everyA hard stool passed with difficulty every
3rd day should be treated as constipation3rd day should be treated as constipation

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DefinitionDefinition
Delay or difficulty in defecation for 2 orDelay or difficulty in defecation for 2 or
more weeksmore weeks

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www.patient.co.ukwww.patient.co.uk--

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www.constipationadvice.iewww.constipationadvice.ie

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Diagnosis/evaluation
1.1.HistoryHistory
• Timing of first meconium stoolTiming of first meconium stool
• Family’s definition ofFamily’s definition of
constipationconstipation
• Duration of condition and age of onsetDuration of condition and age of onset
• Toilet training experienceToilet training experience

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Diagnosis/evaluation
1.History (cont.)
• Frequency/consistency/size of stoolsFrequency/consistency/size of stools
• Pain or bleeding with defecationPain or bleeding with defecation
• Presence of abdominal painPresence of abdominal pain
•Stool withholding behaviorStool withholding behavior

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Diagnosis/evaluation
1.History
• Change in appetiteChange in appetite
• Abdominal distensionAbdominal distension
• Anorexia, nausea, vomiting, weight loss, orAnorexia, nausea, vomiting, weight loss, or
poor weight gainpoor weight gain
• Allergies , dietary history, medicationsAllergies , dietary history, medications
1.History (cont.)

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Diagnosis/evaluation
1.History
• Developmental historyDevelopmental history
• PsychosocialPsychosocial
historyhistory• Peer interactions, possibility of abuse,Peer interactions, possibility of abuse,
toilet habits at schooltoilet habits at school
•Family history (constipation, thyroid disorders,Family history (constipation, thyroid disorders,
cystic fibrosis)cystic fibrosis)
1.History (cont.)

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Diagnosis/evaluation
2.Physical Exam
External perineum and perianal exam, digitalExternal perineum and perianal exam, digital
anorectalanorectal
exam:exam:
• Perianal sensationPerianal sensation
• Anal toneAnal tone
• Rectal sizeRectal size
• Presence of anal winkPresence of anal wink
• Amount/consistency/location of stool within theAmount/consistency/location of stool within the
rectum)rectum)

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Stool occult blood test for all infants with:Stool occult blood test for all infants with:
• ConstipationConstipation
• Any child with abdominal painAny child with abdominal pain
• Failure to thriveFailure to thrive
•Intermittent diarrheaIntermittent diarrhea
•Family history of colon cancer or colonicFamily history of colon cancer or colonic
polypspolyps
2.Physical Exam(cont.)
Diagnosis/evaluation

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Fecal impaction may be diagnosed with:Fecal impaction may be diagnosed with:
• Physical exam (hard mass within abdomen)Physical exam (hard mass within abdomen)
• Digital exam (dilated rectal vault filled withDigital exam (dilated rectal vault filled with
stool)stool)
and/orand/or
• Abdominal radiographyAbdominal radiography
2.Physical Exam(cont.)
Diagnosis/evaluation

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Treatment of functional constipation
a. Disimpaction (2–5 days)
(1) Oral/nasogastric approach:Oral/nasogastric approach:
• Polyethylene glycol electrolyte solutionsPolyethylene glycol electrolyte solutions are effectiveare effective
for initial disimpaction.for initial disimpaction.
• Magnesium hydroxideMagnesium hydroxide,, magnesium citratemagnesium citrate,, lactuloselactulose,,
sorbitolsorbitol,, sennasenna, or, or bisacodyl laxativesbisacodyl laxatives
•((Avoid magnesium-containing products in infants dueAvoid magnesium-containing products in infants due
to potential toxicity, beware of overdose in childrento potential toxicity, beware of overdose in children))

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(2) Rectal approach:(2) Rectal approach:
• Saline or mineral oil enemasSaline or mineral oil enemas..
•Avoid:Avoid:
i. Soap suds, tap water, and magnesium enemasi. Soap suds, tap water, and magnesium enemas
due to potential toxicitydue to potential toxicity
ii. Enemas in infants, may use glycerinii. Enemas in infants, may use glycerin
suppositoriessuppositories..
iii. Phosphate-containing products due to risk ofiii. Phosphate-containing products due to risk of
acute phosphate nephropathyacute phosphate nephropathy
a. Disimpaction (2–5 days)
Treatment of functional constipation(Cont.)

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b. Maintenance therapy (usually 3–12 months)
Treatment of functional constipation(Cont.)
Goal is to prevent recurrenceGoal is to prevent recurrence
(1)(1) Dietary changes:Dietary changes:
- Increase intake of fluids and absorbable and- Increase intake of fluids and absorbable and
nonabsorbable carbohydrates to softennonabsorbable carbohydrates to soften
stools.stools.
- A balanced diet that includes whole grains,- A balanced diet that includes whole grains,
fruits, and vegetables is recommended.fruits, and vegetables is recommended.

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b. Maintenance therapy (usually 3–12 months)
Treatment of functional constipation(Cont.)
(2) Behavioral modifications(2) Behavioral modifications::
- Regular toilet habits- Regular toilet habits
- Positive- Positive reinforcementreinforcement
- Proper toilet positioning :- Proper toilet positioning :
i. Stable seatingi. Stable seating
ii. Feet firmly plantedii. Feet firmly planted
iii. Knees and hips at 90-degree angleiii. Knees and hips at 90-degree angle
-Referral to mental health for help with-Referral to mental health for help with
motivational or behavioral concernsmotivational or behavioral concerns

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b. Maintenance therapy (usually 3–12 months)
Treatment of functional constipation(Cont.)
(3) Medications(3) Medications::
- Polyethylene glycol (osmotic laxatives),- Polyethylene glycol (osmotic laxatives),
lactulose, magnesium hydroxide, orlactulose, magnesium hydroxide, or
sorbitol is recommended.sorbitol is recommended.
- Avoid prolonged use of stimulant laxatives.- Avoid prolonged use of stimulant laxatives.
- Discontinue therapy gradually only after- Discontinue therapy gradually only after
return of regular bowel movements withreturn of regular bowel movements with
good evacuationgood evacuation

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4.Special considerations in infants <1 year of
age
•Increased intake of fluids, particularly of juices
containing sorbitol, such as prune, pear, and
apple
juices, is recommended within the context of a
healthy diet•Barley malt extract, corn syrup, lactulose, or
sorbitol can be used as stool softeners
•Glycerin suppositories may be useful
•Avoid: i. Mineral oil
ii. Stimulant laxatives
iii. phosphate enemas

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21. 1.http://www. mayoclinic.com/health/constipation
2. http://publications.nice.org.uk/constipation-in-children-
and-young-people-cg99
3. http://www.bmj.com
4. www.patient.co.ukwww.patient.co.uk
5.5. http://emedicine.medscape.comhttp://emedicine.medscape.com
6.6. www.constipationadvice.iewww.constipationadvice.ie
References