The document discusses constipation in children. It defines constipation and explains some common causes in children like low fiber diet, inactivity, and behavioral factors. It can present at any age but most commonly during periods of transition. Investigations are usually not needed for functional constipation. Treatment involves disimpaction followed by maintenance therapy using laxatives like polyethylene glycol for months to years. Education of parents and lifestyle changes also play a key role in managing 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?

16. SODIUM PICOSULPHATE 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