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Constipation in children
- 2. Dr. Taslima Akter Runa IMO Department of Paediatrics Dr. Diponkar Poddar IMO Department of Paediatrics Jalalabad Ragib Rabeya Medical College Hospital, Sylhet.
- 3. Contents Introduction Physiology of defecation Normal bowel habit Definition & causes of constipation Pathogenesis of functional constipation History & physical examination Management Take home messages
- 4. Introduction Constipation is a global health problem. Worldwide prevalence of functional constipation is 13% It is commonly seen among toddlers and preschool children. The community prevalence of self reported constipation in Asia is lower compared to other parts of the world (range 1.4-32.9% in Asia vs 0.7 -79% for the rest of the world).
- 6. Normal frequency of bowel movement Age Bowel movements per week 0-6 months Breast fed 5-40 Formula fed 5-28 6-12 months 5-28 1-3 years 4-21 >3 years 3-14
- 7. Definition Any definition of constipation is relative & depends on stool consistency, frequency & difficulty in passing stool. A hard stool passed with difficulty every 3rd day should be treated as constipation. Constipation is defined as a delay or difficulty in defecation present for 2 weeks or longer and significant enough to cause distress to the patient.
- 8. Rome III criteria (chronic constipation) Must include 1 month of at least 2 of the following in infants & children up to 4 year of age: ≤ 2 defecations per week ≥ 1 episode of incontinence after the acquisition of toilet training skills History of excessive stool retention History of painful or hard bowel movements Presence of a large fecal mass in the rectum History of a large diameter stool that might obstruct the toilet.
- 9. Accompanying symptoms may include irritability , decreased appetite, and/or early satiety. The accompanying symptoms disappear immediately following passage of a large stool.
- 10. Rome III criteria (chronic constipation) Must include 2 or more of the following in a child with a developmental age of at least 4 year with insufficient criteria for diagnosis of irritable bowel syndrome: ≤ 2 defecations per week ≥ 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 a large diameter stool that might obstruct toilet.
- 11. Constipation in newborn First meconium passes usually within the first 36-48 hours of birth, 90% of full term newborns pass stool within 24 hours. Approximately 20 % of VLBW infants do not pass meconium within first 24 hours. It must be kept in mind that infrequent bowel movements do not necessarily mean constipation. A breast fed infant usually has frequent bowel movements, whereas a formula fed infant may have 1-2 movements a day or every other day.
- 12. Aetiology Non organic causes (Functional) Idiopathic Change in diet: not enough fiber rich diets, fruits, vegetables or less fluid in child’s diet. Cow’s milk Stool withhelding Change in routine Forceful potty training Family history
- 13. Organic causes Anatomic Anal stenosis, atresia with fistula Imperforate anus Anteriorly displaced anus Intestinal stricture (postnecrotizing enterocolitis) Anal stricture Abnormal musculature Prune –belly syndrome Gastroschisis Down syndrome
- 14. Intestinal nerve or muscle abnormalities Hirschsprung disease Pseudo-obstruction Intestinal neuronal dysplasia Spinal cord defects Tethered cord Spinal cord trauma Spina bifida
- 15. Drugs Anticholinergics Narcotics Phenytoin Antidepressants Vitamin D intoxication Metabolic disorders Hypokalemia, Hypercalcemia Hypothyroidism Diabetes mellitus
- 16. Intestinal disorder Celiac disease Cows milk protein intolerance Cystic fibrosis Tumor Psychiatric disorder Anorexia nervosa
- 17. Pathogenesis of functional constipation Functional constipation, also known as idiopathic constipation or fecal withholding, can usually be differentiated from constipation secondary to organic causes on the basis of a history and physical examination. Unlike anorectal malformations and Hirschsprung disease, functional constipation typically starts after the neonatal period. Usually, there is an intentional or subconscious withholding of stool that leads to a vicious cycle.
- 18. Change in routine Change in diet Stressful event Postponing defecation Too early toilet training Painful defecation Voluntary with holding Prolonged fecal stasis: re absorption of fluids leads to increase in size and consistency More pain
- 19. Vicious cycle of events Fecal retention Rectal distension Decreased sensory perception Hard stools Pain during defecation Partial evacuation Impaction Fecaloma formation
- 20. Clinical manifestations When children have the urge to defecate, typical behaviors include contracting the gluteal muscles by stiffening the legs while lying down, holding onto furniture while standing, or squatting quietly in corners, waiting for the call to stool to pass. Caregivers may misinterpret these activities as straining, but it is withholding behavior. There is often a history of blood in the stool noted with the passage of a large bowel movement.
- 21. Findings suggestive of underlying pathology include failure to thrive, weight loss, abdominal pain, vomiting, or persistent anal fissure or fistula. In functional constipation, daytime encopresis is common.
- 22. Encopresis Encopresis is defined as voluntary or involuntary passage of feces into inappropriate places at least once a month for 3 consecutive months once a chronologic or developmental age of 4 years has been reached. Subtypes includes retentive encopresis (with constipation and overflow incontinence) representing 65-95% of cases and non retentive encopresis (without constipation and overflow incontinence)
- 23. History taking to diagnose constipation Key components Potential findings in a child younger than 1 year Potential findings in a child older than 1 year Stool patterns • Fewer than 3 complete stools per week (type 3 or 4 Bristol stool chart) • Hard large stool • ‘Rabbit dropping’ (type 1) • Fewer than 3 complete stools per week (type 3 or 4 Bristol stool chart) • Overflow soiling • ‘Rabbit dropping’ (type 1) • Large infrequent stool that can block the toilet Symptoms associated with defecation • Distress on stooling • Bleeding • Straining • Poor appetite that improves with passage of large stool • Waning of abdominal pain with passage of stool • Evidence of retentive posturing • Straining • Anal pain
- 24. Key components Potential findings in a child younger than 1 year Potential findings in a child older than 1 year History • Previous episode of constipation • Previous or current anal fissure • Previous episode of constipation • Previous or current anal fissure • painful bowel movements & bleeding associated with hard stool
- 25. History taking to diagnose idiopathic constipation Key components Findings that indicate idiopathic constipation Red flag findings that indicate constipation other than idiopathic Timing of onset of constipation & potential precipitating factors • Starts after a few weeks of life • Obvious precipitating factors: fissure, change of diet, timing of toilet training, moving house, starting school, fear etc Reported from birth or first few weeks of life Passage of meconium Within 48 hours of birth Delayed passage of meconium > 48 hours Stool patterns Ribbon stool
- 26. Key components Findings that indicate idiopathic constipation Red flag findings that indicate constipation other than idiopathic Growth & general well being Generally well, weight & height within normal limits Growth failure Locomotor development Normal Leg weakness, locomotor delay Abdomen Normal Abdominal distension with vomiting Diet & fluid intake • Changes in infant formula, weaning, insufficient fluid intake
- 27. Examination to diagnose idiopathic constipation Key components Findings that indicate idiopathic constipation Red flag findings that indicate constipation other than idiopathic Peri anal area Normal • Fistula, fissure, anorectal malformation, absent anal wink Abdomen • Abdominal distension Spine • Tuft of hair over spine /spinal dimple • Lack of lumbo-sacral curve • Sacral agenesis • Flat buttock Lower limb • Abnormal tone & reflexes
- 29. Investigations Constipation in children is mainly functional (95%). If there is any suspicion of secondary causes then go through the following : Plain x ray of abdomen Barium enema Ultrasonography of abdomen MRI Anorectal manometry Full thickness rectal biopsy Thyroid function test S. electrolytes S. calcium
- 30. Complication Fecal impaction Chronic constipation Mega colon Rectal prolapse Anal fissure Fecal soiling Urinary incontinence, urinary retention, urinary tract infection, megacystis Psychological effects
- 31. Management
- 32. Therapy for functional constipation and encopresis includes patient & parents education, relief of impaction, and softening of the stool. There needs to be a focus on adherence with regular postprandial toilet sitting and adoption of a balanced diet. If an impaction is present disimpaction followed by stool softeners are started as maintenance medications.
- 33. Medications and Dosages for Disimpaction Medication Age Dosage RAPID RECTAL DISIMPACTION Glycerin suppositories Infants and toddlers Phosphate Enema <1 yr 60 mL >1 yr 6 mL/kg bodyweight, up to 135 mL twice Milk of molasses enema Older children (1 : 1 milk : molasses) 200-600 mL
- 34. Medications and Dosages for Disimpaction Medication Dosage SLOW ORAL DISIMPACTION IN OLDER CHILDREN Polyethylene glycol with electrolytes (Over 2-3 Days) 25 mL/kg bodyweight/hr, up to 1000 mL/hr until clear fluid comes from the anus Polyethylene without electrolytes 1.5 g/kg bodyweight/day for 3 days Milk of magnesia 2 mL/kg bodyweight twice/day for 7 days Mineral oil 3 mL/kg bodyweight twice/day for 7 days Lactulose or sorbitol 2 mL/kg bodyweight twice/day for 7 days
- 35. Maintenance therapy 1. Dietary modification: Encourage to take more fluids, absorbable & non absorbable carbohydrate (sorbitol) as a method to soften the stool. Sorbitol is found in fruit juices like apple, pear, prune. A balanced diet that includes whole grains, fruits & vegetables is advised.
- 36. 2. Toilet training : The infant can be placed on the toilet seat by the age of 10 months. The child should be encouraged to go to toilet by the age of 1 year, but the attitude of parents to toilet training should be relaxed. The toddler can walk to the toilet by the age of 15-18 months & is usually ready for starting toilet training. By the age of 2 years, the child is trainable.
- 37. At 3 years, he/she can withhold & postpone his/her bowel movement. Encourage to seat on the toilet for 5-10 minutes, 3-4 times/day immediately after major meals. Caregivers should be instructed not to respond to soiling with punitive measures. Parents should be actively encouraged to reward the child for adherence to a healthy bowel regimen.
- 38. Medication Age Dose FOR SHORT-TERM TREATMENT (MONTHS) Senna (Senokot) syrup, tablets 1-5 years 5 mL (1 tablet) with breakfast, max 15 mL daily 5-15 years 2 tablets with breakfast, maximum 3 tablets daily Glycerin enemas >10 years 20-30 mL/day ( 1/2 glycerin and 1/2 normal saline) Bisacodyl suppositories >10 years 10 mg daily 3. Medications:
- 39. Medication Age Dose FOR LONG-TERM TREATMENT (YEARS) Milk of magnesia > 1 month 1-3 mL/kg bodyweight/day, divided into 1-2 doses Mineral oil >12 months 1-3 mL/kg bodyweight/day, divided into 1-2 doses Lactulose or sorbitol >1 month 1-3 mL/kg bodyweight/day, divided into 1-2 doses Polyethylene glycol 3350 (MiraLAX) >1 month 0.7 g/kg bodyweight/day, divided into 1-2 doses
- 40. Maintenance drug therapy is generally continued until a regular bowel pattern has been established and the association of pain with the passage of stool is abolished. If any secondary causes are present then it should be managed accordingly. In cases where behavioral or psychiatric problems are evident, involvement of a psychologist or behavioral management is required.
- 42. History & physical examination Functional constipation Fecal impactionDisimpaction followed by maintenance therapy Maintenance therapy (diet, laxative, toilet training) Reassess Reeducate Different medication Wean & observe Investigations Yes No Effective Not effective Not effective REDFLAG
- 43. Take home message Detailed history, physical examination can easily differentiate functional from organic constipation. Nearly 95% cases are functional & often doesn’t need any investigations & managed well by proper education of child & parents as well as modification of diet. Caregivers should be instructed not to respond to soiling with punitive measures. Parents should be actively encouraged to reward the child for adherence to a healthy bowel regimen.
- 44. References Nelson textbook of Pediatrics, 20th edition Textbook of pediatric gastroenterology & nutrition by Stefano Guandalini Constipation in children & young people: diagnosis & management by NICE NASPGHAN clinical practice guidelines
- 45. THANK YOU