Constipation in children - How to ease the hard

1. CONSTIPATION IN CHILDREN-
How to ease the Hard!!
Presenter- Dr. B. PADMINI PRIYA
Assistant Professor
Dept of Pediatrics
SVRRGGH,
Tirupati.

2. No organ in the body is so
misunderstood, so slandered and
maltreated as the colon
Sir Arthur Hurs,1935
OLD SAYING..NOT TRUE ANYMORE

3. Case Scenario
A 3yr old male child brought to OPD with
C/O abdominal pain since 8 months ,Periumbilically , short course of
PPIs,probiotics, short course of laxatives ,occasional rectal suppository
Vomitings occasionally which were non-bilious, non projectile
Dewormed twice
Irregular bowel movements, passes stools once in 4 days/hard /strains
while passing, not associated with bleeding PR .
Mother noticed child passes stools involuntarily and staining of
undergarments
Adopts bizarre posturing,
No red flag signs
Toilet trained at 2 yr of age
Diet – Child is fond of dairy products and chocolates

4. O/E- Fecal lump was palpated
DRE- normal placement of anus
Nontender anal crack present
Anal wink and Cremasteric reflux was normal
Basic investigations were done – were normal
Diagnosis- Chronic abdominal Pain
Functional Constipation
Fecal impaction

5. How to avoid delay in arriving diagnosis of constipation?
Are Investigations essential in this child??
What are Red flag signs?
How early toilet training should be started?
What happens if disimpaction is not done?
How long laxatives should be continued and plan follow up?

6. One of the most common gastrointestinal problem in clinical practice.
Functional constipation
 30% of pediatric gastroenterology office practice,
4-5% of all referrals to pediatric gastroenterology tertiary care centers

7. Normal stool frequency
 stool consistency and other
features
Collateral manifestations in the form
of irritability, decreased appetite
and/or early satiety may be
observed, which improve after
defecation.
 <1 month age: 3-4 times/day;
 1 month to 1 year age: 1-2
times/day;
 1 to 2 year age: 1-2 times/day,
mostly formed;
 older than 2 year age: 1 time/day

8. “A delay or difficulty in defecation sufficient to cause
significant distress to the patient” – Constipation.
When the duration is less than 4 weeks- Acute
Constipation.
When the duration is more- Chronic Constipation
DEFINITION.

10. Fecal Incontinence- Not encopresis/Soiling..-Passage of stools
in the undergarment
(a)Constipation-associated
fecal incontinence
Retentive fecal
incontinence
(b) Non-retentive
fecal incontinence:
 No constipation
 Normal anal
sphincter tone
 Symptoms>2
months in child
with DA > 4 yrs of
child.

12. Vicious cycle of constipation..

13. Rome IV Criteria

14. CAUSES.
Functional – 90-95%
Organic causes -5-10%

15. RED FLAG SIGNS
ORGANIC
CONSTIPATION
 Onset in early infancy, H/O delayed
passage of meconium, gush of stools
on DRE,
 bilious vomiting, uniform abdominal
distension,
 failure to thrive, recurrent lower
respiratory infections,
 cold intolerance, neuro-developmental
delay or regression,
 anal malformations
 abnormal neurological examination
(paraspinal, lower limbs and anorectal
reflexes)

16. ORGANIC
CONSTIPATION
(5-10%)
INTESTINAL
NERVE/MUSCLE
FIBRE DISORDERS
ANORECTAL
ENDOCRINE/METABOLIC
DEVELOPMENTAL
DRUGS

17. ORGANIC CAUSES
• Intestinal nerve/muscle disorder : Hirschsprung disease, Intestinal
neuronal dysplasia, Pseudoobstruction, Spinal cord (Tethered cord,
myelomeningocele)
• Anorectal : Anteriorly placed anus, anal stenosis, pelvic mass
• Endocrine /Metabolic – Hypothyroid, diabetes insipidus,
hypercalcemia, cystic fibrosis, celiac disease, Diabetes mellitus
• Developmental – Mental retardation, Autism, Child Abuse
• Drugs – Opiates, Anticholinergic, Lead poisoning , Vincristine,
Phenobarbitone

18. FUNCTIONAL CONSTIPATION
Functional constipation refers to a form of chronic constipation in
children (i.e. symptoms > 2 months)
AND
there are no demonstrable anatomic, physiologic or histopathological
abnormalities to explain the same

19. IN NORMAL CHILDREN – Predisposing factors
CONSTIPATI
ON
 Exclusive and
prolonged milk intake
with minimal solids in
young infants
 Supplementary feeds
in younger babies
 Less intake of fruits
and vegetables
 More intake of bakery
foods
(a) premature initiation
of toilet training
(b) drugs and inter-
current illnesses,
(c) quick and abrupt
transition of diet and
(d) change in local
environment (start of
schooling) and
psychosocial factors

20. I SHOULD HAVE
LISTENED TO MY
MOMMY!!!

21. What’s Problem with
me??
History and examination -
Looking for precipitants of
functional constipation
eliciting issues relevant to
management
Examination

22. History and evaluation
• History and examination are relevant in making a diagnosis of
constipation,
differentiating functional and organic constipation,
looking for precipitants of functional constipation and
eliciting issues relevant to management like incontinence, impaction,
past treatment,
treatment compliance
response to treatment

23. Evaluation..
Proper Growth Assessment – to rule out organic etiology
Abdominal Examination – Palpated for fecoliths or hard indentable masses
Digital Rectal Examination - In the absence of abdominal fecoliths, anal fissure
or anal malformations, digital rectal examination helps in the following:
Presence of fecal impaction (presence of large, hard stools (fecolith) on Digital
rectal examination (DRE),
Diagnosis of Hirschprung’s disease (empty rectum, gush of stools/air on
withdrawal of finger), and
 sacral mass lesion (palpable mass).

24. EVALUATION…
Physical findings, other than those obtained from the
abdominal and rectal examinations, are usually
normal
Abdominal examination: Stool can be palpated most
notably in left lower quadrant.
Rectal examination: Anal tone
Fecal mass
 Consistency of stool
Explosive stool on withdrawal of finger
Neurologic findings:
Anal wink
Sensation, strength, and reflexes in the lower
extremities.

25. DIGITAL RECTAL EXAMINATION
DRE
 Red flag symptoms or signs,
 Onset <6 months of age,
 Non-responders despite good
compliance to therapy,
 Patients presenting with fecal
incontinence to differentiate
between constipation related
and non-retentive incontinence.

26. Investigations
Usually not needed.
Needed in those with
Red flag signs
Non Responders and Refractory Constipation.
 A plain erect Xray abdomen or barium enema is not required as a
routine investigation in all cases.

27. MANAGEMENT

29. PARENTAL COUNSELLING
Parents should be clearly explained
 the cause of functional constipation,
preferably with a diagram.
 Any precipitating factors
 Drugs causing constipation should be
stopped;
 Any psychosocial factor operating
needs to be addressed.
 Objective of treatment should be
explained

30. TOILET TRAINING
Toilet training should not be started before 24 months of age.
Follow the ‘Rule of 1
In a child with constipation:
 Make the child sit in the toilet, 2-3 times a
day for 5-10 minutes after meals (within 30
minutes of meal intake),
 Defecation should be painless
 sit in squatting position in the Indian toilet or
with foot rest in English toilet/potty seat
 reward system (positive reinforcement)

31. DIET
 Daily fiber requirement is 0.5 gm/kg/day.
 Adequate intake of fiber rich diet (cereals,
whole pulses with bran, vegetables, salad
and fruits) is recommended at the initial
counseling
 Restrict milk and encourage intake of
semisolids and solids in younger children.
 Ensure adequate intake of water.
 Normal activity is recommended.

32. MEDICATION.
Initial phase of disimpaction
Maintenance Therapy

33. Initial phase of
disimpaction
maintenance phase with
laxatives
(a)one-time hospital based (100%
success)
(b) home based in split doses (68-
97% success)
keeps the bowel moving and so that there is no
retention enabling rectum to achieve the
normal diameter and tone for proper anorectal
reflexes and pelvic floor coordination to
facilitate normal stool expulsion
Completely clear the colon so that no
residual hard fecal matter is retained.
Started only after complete evacuation
• Rectal enemas
• Oral Route
• Rarely Manual evacuation
Reviewed after 1 week
to look for reimpaction
PEG
Lactulose/lactitol

34. DISIMPACTION
RECTAL
ENEMA(ONCE PER
DAY)
DOSAGE SIDE EFFCETS
SALINE NEONATE - 5-10 ML
>1 YR- 6 ML/KG
NOT USUALLY
PRACTICED Except
in rare situations
PHOSPHATE SODA 2-18 YRS- 2.5ML/KG
MAX- 133 ML/DOSE
HYPERPHOSPHATE
MIA
HYPOCALCEMIA
Bisacodyl
Suppository
2-12 yrs – 0.5 -1
suppository /day
Diarrhea,
Abdominal cramps,
Hypokalemia

36. ORAL THERAPY FOR DISIMPACTION
Home based protocol
• PEG – 1.5 -2 g/kg/day in two
divided doses for 3-6 days
Hospital based protocol
PEG solution as lavage 25 ml/ kg/
hr orally or through N/G tube
End- point: Clear rectal effluent
Caution: Watch for bloating, fluid
overload, vomiting and electrolyte
imbalances

38. Maintenance Therapy
Osmotic laxatives:
These laxatives draw water into
the stool thereby making the
stools softer and easy to pass. The
two main osmotic laxatives
(i) PEG is the first line of therapy
and is more effective as
compared to lactulose/
lactitol.
(ii) Lactulose/lactitol
Stimulant Laxatives
• Stimulants are usually required
as rescue therapy (an acute or
sudden episode of constipation
while being on regular compliant
maintenance therapy).
• These stimulants are given for a
short duration of 2-3 days to tide
over the acute episode of
constipation, and then stopped.

39. OSMOTIC LAXATIVES
Polyethylene Glycol
0.5-1g/kg /day >12 mo age
Side effects- Bloating, Abdominal pain/cramps
term use Vomiting Loose stools
Safe for both short and long term use
Disaccharides
1.Lactulose: non absorbable 1mo-12mo: 2.5 mL BD;
Side effects - Abdominal distension Discomfort
MOA: Lactulose undergoes synthetic disaccharide
galactose and fructose
1-5y: 2.5-10 mL BD of 5-18y: 5-20 mL BD
2. Lactitol (β-galactosido- sorbitol): monohydrate is
a analogue of lactulose, consisting galactose and
sorbitol
Dose- 250-400mg/kg/day (15 mL =10 g of lactitol
monohydrate)
 Lactitol is more palatable
STIMULANT LAXATIVES –
RESCUE THERAPY
Sodium Picosulphate
 Acts through its active metabolite
that is produced by the intestinal
bacteria and increases the
peristalsis of gut
Abdominal pain, nausea, and
diarrhea- 50%
Contraindicated in setting of
proctitis and gaseous abdominal
distension
Dose- given as single dose
1 mon- 4 yrs- 2.5 – 10 mg/day
4 to 18 yrs- 2.5 – 20 mg/day

40. • PEG is a metabolically inert, large molecular weight soluble polymer with capacity to
retain intraluminal water.
• PEG is available with or without electrolytes and as PEG 3350 or 4000.
• With the available evidence, PEG 3350 or 4000 and PEG with or without electrolytes are
all equally effective in disimpaction
For one-time disimpaction there are Indian formulations where one pack (containing
polyethylene glycol of 118gm) should be reconstituted in 2 litres of water;
For maintenance or home-based disimpaction the preparation may vary from
6.5g/scoop to 17g /sachet, and needs to be confirmed before prescription.

41. FOLLOW UP
FOLLOW UP
record the stool history,
associated symptoms,
compliance with diet,
medications and toilet-training.
AFTER 14 DAYS
1 – 2 MONTHLY TILL
SUCCESSFUL OUTCOME
3 MONTHLY TILL 1 YEAR
to assess compliance
Gradually
tapering
laxatives
STOOL DAIRY-
stool frequency
and
consistency

42. SUCCESSFUL OUTCOME
 Stool normalcy while on laxatives for
a period of at least 4 weeks of
initiation of therapy, and
 Maintenance of stool normalcy for a
minimum period of 6 months before
tapering.
STOOL NORMALCY
daily, not hard, nor loose
watery stools, with absence of
pain, straining, bleeding,
posturing or incontinence.

43. WHEN TO STOP LAXATIVES
 Symptom-free while on
maintenance therapy for at
least 6 months before
attempting to taper the
laxatives.
 It is then advisable to taper
gradually over a period of 3
months.
 Laxatives should never be
stopped abruptly.
When to
stop
laxatives

44. REFRACTORY CONSTIPATION
 Constipation not responding
to optimal conventional
treatment for at least 3
months, despite good
compliance .
 These patients should be
referred to a pediatric
gastroenterologist for
evaluation.
should be investigated
hypothyroidism,
celiac disease,
Hirschprung disease,
Cow milk protein allergy
in young children,
Lead poisoning and
spinal abnormalities.
pelvic dyssynergia and
pseudo-obstruction

46. CONSTIPATION
ORGANIC CONSTIPATION
YES FUNCTIONAL CONSTIPATION
SIGNS
FECAL IMPACTION +/- RETENTIVE
INCONTINENCE
DISIMPACTION
Hospital based
Home
MAINTENANCE THERAPY
Parent
counselling
Toilet
training
Diet

47. FOLLOW UP
Response and
compliance
Laxative dose titration
Recurrence of impaction
SUCCESSFUL OUTCOME
INADEQUATE
RESPONSE
Increase the laxative
dose
Gradual weaning
NO RESPONSE GOOD RESPONSE
NO RELAPSE RELAPSE
REASSESS FOR
ORGANIC CAUSE

48. Case Scenario
A 3yr old male child brought to OPD with
C/O abdominal pain since 8 months ,Periumbilically , short cours
probiotics, short course of laxatives ,occasional rectal suppositor
Vomitings occasionally which were non-bilious,non projectile
Dewormed twice
Irregular bowel movements, passes stools once in 4 days/hard /s
while passing, not associated with bleeding PR .
Mother noticed child passes stools involuntarily and staining of
undergarments
Adopts bizarre posturing,
No red flag signs
Toilet trained at 2 yr of age
Diet – Child is fond of dairy products and chocolates

49. O/E- Fecal lump was palpated
DRE- normal placement of anus
Nontender anal crack present
Anal wink and Cremasteric reflux was normal
Basic investigations were done – were normal
Diagnosis- Chronic abdominal Pain
Functional Constipation
Fecal impaction

50. How to avoid delay in arriving diagnosis of constipation?
Are Investigations essential in this child??
What are Red flag signs?
How early toilet training should be started?
What happens if disimpaction is not done?
How long laxatives should be continued and plan follow up?

51. KEY MESSAGES
• Functional constipation is common in children
• Most need only good history and clinical examination
• Investigations are rarely required
• No wait and watch approach in functional constipation
• Educate role of diet and toilet training
• Always assess the need for disimpaction
• Continue laxatives atleast 6-9 months before deciding on withdrawal.

52. THANK YOU…