BASIC PEDIATRIC PROBLEM CONSTIPATION

1. CONSTIPATION
BHARAT,
POKHREL ,MD

2. Constipation
Defined as delay or difficulty in defecation
present for 2 weeks or longer and significant
to cause distress to the patient.

3. Other Terms To Know
Intractable constipation: Constipation not
responding to optimal conventional treatment
for at least 3 months.
Fecal Impaction: A hard mass in the lower
abdomen identified on PE or a dilated rectum
filled with large amount of stool on rectal
examination or excessive stool in the distal
colon on abdominal radiography.

4. FECAL IMPACTION
RESULTS IF CONSTIPATION IS NOT RELIEVED.
SYMPTOMS
LIQUID SEEPING
FROM ANUS
ABDOMINAL PAIN
NAUSEA, LOSS OF
APPETITE
ABDOMINAL
DISTENSION
RECTAL PAIN
TREATMENT
DIGITAL
REMOVAL
ENEMA

5. Other Terms to know
Soiling : the involuntary passage of fluid or
semi solid stool into clothing, usually as a
result of overflow from a faecally loaded
bowel.

6. Normal Bowel Movement
Varies from person to person
Some people have a bowel everyday, some every 2-3
days and some 2-3 times a
Some have bowel movement during the morning and
some in the evening.
Stools are normally brown in color
Feces are normally soft,formed,moist and shaped like
the rectum.

13. Constipation
Causes
A. Organic
 Structural: anal stenosis, anal fissure.
 Neuromuscular: Hirshprung disease, spina
bifida, pseudo obstruction.
 Metabolic: hypokalemia, hypercalcemia,
hypothyroidism, diabetes mellitus.
 Drugs: Narcotics, anticholenergic, lead,
 Intestinal: IBD, celiac disease,CF,tumors.

14. Constipation
Causes
B. Functional
In an otherwise healthy child constipation
may result simply from an episode of painful
defecation, difficulties during the period of
toilet training, inattention to the urge to
defecate because of involvement in other
activities or discomfort with toilet facilities.

15. Gastrointestinal disorders
Dietary: Lack of fiber and fluid intake
Motility:
Slow- transit constipation
Irritable Bowel Syndrome
Drugs
Chronic intestinal pseudo-obstruction

16. Causes
Structural
Colonic carcinoma
Diverticular disease
Hirschsprung’s disease
Defecation:
Anorectal disease (Crohn’s disease)
Obstructed defecation

17. Key components of
history-taking to
diagnose
constipation

18. Key
components
Potential
findings in a
child younger
than 1 year
Potential findings
in a child/young
person older than 1
year
Stool
patterns
•< 3 complete
stools per week
•Hard large stool
•'Rabbit
droppings)
•< 3 complete stools
per week
•Overflow soiling
•'Rabbit dropping
•Large, infrequent
stools that can block
the toilet

19. Key
components
Potential
findings in a
child younger
than 1 year
Potential findings in
a child/young
person older than 1
year
Symptoms
associated
with
defecation
•Distress on
stooling
•Bleeding
associated with
hard stool
•Straining
•Poor appetite that
improves with
passage of large stool
•Waxing & waning of
abdominal pain with
passage of stool
•Straining
•Anal pain

20. Key
compone
nts
Potential
findings in a
child younger
than 1 year
Potential findings in a
child/young person
older than 1 year
History •Previous
episode(s) of
constipation
•Previous or
current anal
fissure
•Previous episode(s) of
constipation
•Previous or current
anal fissure
•Painful bowel
movements and
bleeding associated
with hard stools

21. Constipation
Clinical features
A detailed history of pattern of defecation
may reveal stool-withholding behavior like
contracting the gluteal muscles by stiffening
the legs while lying down or holding on
furniture while standing, some children will
squat, push and cry which may be
misinterpreted as an attempt to defecate.
Accompanying symptoms include abdominal
pain, abdominal distention and flatulence.

22. Constipation
Clinical features
Sometimes rectal bleeding, poor appetite,
enuresis and history of UTI are associated.
 Soiling (an overflow incontinence of liquid
stool) can be
present in long
standing cases.

23. Constipation
Clinical features
 Physical examination of the abdomen may
reveal distention or palpable fecal masses.
Digital examination of the rectum is needed
to evaluate the sphincter and ampulla

24. Constipation
Diagnosis
 When no underlying cause is identified =>
history and physical examination
 laboratory tests => To rule out the organic
causes.
 Barium enema and anorectal manometry
are most helpful.

25. Diagnostic Criteria
The most widely accepted definitions for childhood
functional constipation => ROME III definitions,
which are divided into 2 main groups, based on the
age of the patients.
Infants up to 4 years have to fulfil >/2 criteria for at least
1 month
Children above 4 years have to fulfil >/2 of the criteria
for at least 2 months

26. Rome III diagnostic criteria
In the absence of organic pathology, >/2 of the
following must occur
For a child with developmental age <4 years

27. 1. </ 2 defecations per week
2. At least 1 episode of incontinence per week after the
acquisition of toileting skills
3. History of excessive 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

28. For a child >4 years with
insufficient criterias for IBS
<2 defecations in the toilet per week
At least 1 episode of fecal incontinence per week
History of retentive posturing or excessive volitional
stool retention
History of painful or hard bowel movements
Presence of a large fecal mass in the rectum
History of large-diameter stools that may obstruct the
toilet.

29. Constipation
Therapy
For functional constipation include:
1.Patient education, a regular bowel training
program including sitting on toilet for 5-10
minutes after each meal is often helpful in
establishing a regular bowel habits.
2. Relief of impaction can be achieved by
enema or polyethylene glycol.

30. Constipation
Therapy
 softening of stool by lactulose, high fiber diet,
or mineral oil must be continued until regular
bowel pattern has been established for
several months.
 Biofeedback training may be beneficial in
difficult cases.

31. Clinical guideline [CG99]
Published date: May 2010
Recommended laxative
doses

32. Macrogols
Laxatives Recommended doses
Polyethylene glycol 3350 +
electrolytes
Pediatric formula: Oral
powder: macrogol 3350
(polyethylene glycol 3350)a
6.563 g; sodium
bicarbonate 89.3 mg;
sodium chloride 175.4 mg;
potassium chloride 25.1
mg/sachet (unflavoured)

33. Osmotic laxatives
Laxatives Recommended doses
Lactulose •Child 1mon-1yr: 2.5 ml
twice daily, adjusted
according to response
•Child 1–5 years: 2.5–10
ml twice daily, adjusted
according to response
• 5–18 years: 5–20 ml
twice daily, adjusted
according to response

34. Stimulant laxatives
Laxatives Recommended doses
Sodium picosulfate Elixir (5 mg/5 ml)
•Child 1 month to 4 years:
2.5–10 mg once a day
•Child/young person 4–18
years: 2.5–20 mg once a
day
Perles (1 tablet = 2.5mg)
•Child/young person 4–18
years: 2.5–20mg once a
day

35. Stimulant laxatives
Laxatives Recommended doses
Bisacodyl •Child/young person 4–18
years: 5–20 mg once daily
(oral)
By rectum (suppository)
•Child/young person 2–18
years: 5–10 mg once daily

36. Stimulant laxatives
Laxatives Recommended doses
Docusate sodium •Child 6 months–2 years:
12.5 mg three times daily
(use paediatric oral
solution)
•Child 2–12 years: 12.5–
25 mg three times daily
(use paediatric oral
solution)
•Child/young person 12–
18 years: up to 500 mg
daily in divided doses

37. American dietary
recommendations

38. Total water intake per
day, including water
contained in food
Water obtained from
drinks per day
Infants 0–6 months 700 ml
assumed to be from
breast milk
7–12 months 800 ml
from milk and
complementary foods
and beverages
600 ml
1–3 years 1300 ml 900 ml
4–8 years 1700 ml 1200 ml
Boys 9–13 years 2400 ml 1800 ml
Girls 9–13 years 2100 ml 1600 ml
Boys 14–18 years 3300 ml 2600 ml
Girls 14–18 years 2300 ml 1800 ml

39. THANK YOU