Pediatric Annals

Feature Article 

Constipation in Children: A Practical Review

Shailender Madani, MD; Lisa Tsang, BS; Deepak Kamat, MD, PhD, FAAP

Abstract

Pediatricians and other child care providers manage a large number of children with constipation, a recurrent medical problem that is frustrating to patients, their care givers, and the health care providers themselves. Most often the constipation in children is functional in nature, and only a very small percentage of patients have an organic cause for it. In this review, we discuss the epidemiology, causes, evaluation, and management of children with functional constipation. [Pediatr Ann. 2016;45(5):e189–e196.]

Abstract

Pediatricians and other child care providers manage a large number of children with constipation, a recurrent medical problem that is frustrating to patients, their care givers, and the health care providers themselves. Most often the constipation in children is functional in nature, and only a very small percentage of patients have an organic cause for it. In this review, we discuss the epidemiology, causes, evaluation, and management of children with functional constipation. [Pediatr Ann. 2016;45(5):e189–e196.]

Constipation is one of the most common conditions for which children are brought to health care facilities. It accounts for 3% of all visits to primary care physicians and up to 25% of referrals to pediatric gastroenterologists.1,2 Not only is it a common symptom that distresses parents and children alike, childhood constipation also costs the US health care system an estimated $3.9 billion per year.3 Moreover, 25% of children who present with functional constipation will continue to have bowel problems as adults.4 In addition to the health implications, the social ramifications of constipation include self-esteem issues, social isolation, and family disruption.3,5,6 Thus, the long-term health, social, and economic implications of childhood constipation should provide enough impetus for the primary care physician to learn a practical, goal-oriented approach for its evaluation and management.

What Is Considered Constipation?

Constipation occurs when there is an abnormally delayed or infrequent passage of hard feces accompanied by excessive straining and or pain.7 Functional constipation is an abnormally delayed or infrequent passage of hard feces accompanied by excessive straining and/or pain without an organic etiology. Although there are a number of definitions, the Rome III definition is the most accepted definition of functional constipation.7 For a child younger than age 4 years, at least two of the following criteria must be present for 1 month: two or fewer defecations per week, at least one episode of incontinence per week, history of excessive stool retention, history of painful or hard bowel movements, presence of large fecal mass in the rectum, or history of large-diameter stools that may obstruct the toilet.7 For a child at age 4 years or older without evidence of irritable bowel syndrome, at least two of the previously mentioned criteria must be present for at least 2 months.7 Aside from the small minority of children who have an organic cause of constipation, which is usually discovered during the neonatal period, the majority of children have functional constipation.2,8

What Is Considered a Normal Bowel Pattern?

Normal bowel pattern varies depending on the age of the child. An infant in the first week of life on an average passes four stools per day.1,2 At age 2 years, the average frequency is closer to two stools per day. Around age 4 years, the frequency of bowel movements is similar to adult patterns (from 3 times per day to 3 times per week).1,2 In healthy breast-fed babies, bowel movements may not occur for several days, which can be alarming to parents who are unaware that this pattern is considered normal as long as the baby does not show signs of distress with defecation.8,9

What Is the Mechanism of Functional Constipation?

Functional constipation can occur when a child experiences dietary changes or stressful events; during toilet training, illness, or dehydration; or if the child has a busy schedule.10 Other factors include neurodevelopmental disorders of any kind, autism spectrum disorders, and prescription medications.11 In these situations, the child fights the urge to defecate and contracts the anal sphincter and gluteal muscles, fidgeting in a dance-like behavior with each urge to defecate.10 Parents may misinterpret this “stool dance” as the child straining to defecate.1,2 Withholding of stool can lead to stagnant stool in the colon, which can become harder, larger, and more difficult to pass as more fluid reabsorption occurs. Over time, these children experience fecal incontinence due to overflow caused by stretching and desensitization of rectum by fecal impaction.1,10Table 1 shows common risk factors for constipation.


            Common Associations with Constipation

Table 1.

Common Associations with Constipation

A Quick and Easy Method for Evaluating Constipation

A simple goal-directed history and physical examination is all that is necessary to efficiently diagnose constipation. Answers to two questions hold the key to diagnosis: (1) What was the age when constipation first started? and (2) What were the circumstances/events around the initial constipation event? Refer to Table 2 and Table 3 for a quick diagnosis and management based on answers to these two questions.


            Answers to the Two Cardinal Questionsa that Are Key to Diagnosis and Management
            Answers to the Two Cardinal Questionsa that Are Key to Diagnosis and Management

Table 2.

Answers to the Two Cardinal Questions that Are Key to Diagnosis and Management


            Organic Causes of Constipation

Table 3.

Organic Causes of Constipation

Other information that is useful includes whether or not there was delayed passage of meconium, how the patient and caregivers define constipation, what is the frequency of bowel movements, what are the consistency and size of stools, whether there is pain or blood upon defecation, and if there is a history of stool-withholding behavior in the child.2 Additional important information includes medication use; dietary, family, and social history; incidence of stressful life events such as a death in the family; parental divorce; school problems; sexual abuse; and if there is a history of treatment for constipation.12

In evaluating a patient with constipation, a thorough physical examination is a simple but important tool that the physician can use to further elucidate the cause of constipation. Important aspects of this include the abdominal examination, perianal inspection, anorectal digital examination, thyroid examination, and spinal evaluation.1,12 The abdominal examination can provide any indication of gas or fecal accumulation, whereas inspection of the perianal region can provide clues to sexual abuse and show skin tags, fissures, or dermatitis.12 A routine digital anorectal examination for the diagnosis of functional constipation is not recommended by the National Institute for Health and Care Excellence, the European Society for Paediatric Gastroenterology Hepatology and Nutrition, or the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.7,11 However, the digital anorectal examination is indicated when there are worrisome symptoms and signs such as deep anal fissure(s), unexplained anemia, poor growth/weight loss or encopresis/enuresis. Digital anorectal examination can assess for the presence of anal wink, perianal sensation, anal tone, and size of the rectal vault.1 However, this should be avoided when children present with clear withholding behavior or when trauma is suspected.1,2 A test for fecal occult blood in the stool is recommended in all infants with constipation, significant abdominal pain, failure to thrive, family history of colon cancer, or colonic polyps.1,2

Warning Signs of Organic Constipation

Although most cases of constipation presenting for evaluation are functional constipation, there is a small minority of organic cases in which the practitioner must quickly act in to prevent complications and decreased quality of life for the patient and even for family members. If clinical manifestations include delayed meconium passage (>48 hours after birth), failure to thrive, abdominal distention, empty rectum, and tight anal sphincter, a diagnosis of Hirschsprung disease must be considered.1,2 The health care provider must consider the possibility of congenital malformation of the anorectum or spine, milk protein allergy, cystic fibrosis, and metabolic or endocrine conditions causing hypercalcemia.1

Physical examination results that signal an organic cause of constipation include pilonidal dimple covered by a hair tuft, abnormal neurologic examination, and abnormal pigmentation near the lower spine.1 With these findings, one must consider evaluation for spinal cord abnormalities such as tethered cord. Also, one has to be alert when the following clinical manifestations are present: occult blood in stool, perianal skin tags, fistulas, anterior displacement of the anus (ie, the anogenital index, which is the distance in centimeters from the vagina or scrotum to the anus, divided by the distance from the vagina or scrotum to the coccyx [the normal anogenital index in females is 0.39 cm + 0.9 cm and in males is 0.56 cm + 0.2 cm]). One also has to be alert if there is vomiting, fever, bladder dysfunction, or decreased lower extremity strength.12,13 Being aware of these signs and symptoms allows one to identify organic causes of constipation.

Treatment Options

The treatment of functional constipation is a four-pronged approach: education, disimpaction, maintenance therapy, and long-term follow up. All of these are vital for success in the long run in the backdrop of a strong partnership between the physician, parent, and child. Table 4 lists common medications used to treat constipation.


            Medications Used to Treat Pediatric Constipation

Table 4.

Medications Used to Treat Pediatric Constipation

Education

The first and most important step in educating the parent and child (in an age-appropriate manner) is to explain the pathophysiology of constipation and fecal incontinence. In this discussion, it is crucial to emphasize that fecal soiling happens because of involuntary overflow of the stool and not because of deliberate defiance.2,10 Remember, parents and patient can feel ashamed, guilty, and helpless in their own way. During this conversation, the physician should encourage parents to be supportive and to maintain a positive attitude throughout the treatment process as it can be frustrating for the child as well. Remember to set clear and realistic expectations that relapses do occur and that the proper management of constipation is a long-term process.8,12,14 At this time, recommend the use of a footstool so that the child can use their legs to increase intra-abdominal pressure and effectively use their pelvic muscles to defecate.8 A major setback to success in treatment is the parents' commonly held belief about “dependence on” or “addiction” to laxatives. This results in parental under-dosing in which parents administer doses intermittently or only as needed. Often times parents may even prematurely discontinue treatment before a pain-free bowel movement pattern is established. A major task to ensure success is for the physician to dispel this misconception and offer unambiguous reassurance regarding the use and safety of laxatives.8

Disimpaction

When there is a palpable fecal mass on abdominal examination or hard stool is felt in a dilated rectum on a digital rectal examination, disimpaction is warranted. Disimpaction can be done via oral therapy, rectal therapy, or a combination of both. Children tolerate the oral route better because it is not invasive and it gives children a sense of control.2 On the other hand, rectal disimpaction has been shown to be faster, but it is invasive.2 The method of choice should be determined with a discussion among the physician, parent, and child. The first-line therapy for oral fecal disimpaction is polyethylene glycol (PEG) 3350 solution in adequate doses.7 Alternatively, magnesium citrate given orally and repeated again after 4 to 6 hours if response is inadequate, is effective therapy. PEG 3350 administered via nasogastric tube can be considered as a third option.

When rectal disimpaction is deemed necessary, a phosphate enema is a good choice, but phosphate enemas are contraindicated in children younger than age 2 years.3,10,14 Glycerine suppositories are also an effective and safe choice, especially in infants.14

Maintenance Therapy

When fecal disimpaction has been accomplished, the goal thereafter should focus on preventing recurrences with use of maintenance therapy. Maintenance therapy consists of laxatives in adequate doses for requisite duration, dietary supplementation with fiber, and behavioral modifications.2 PEG 3350 is the recommended laxative to be used for maintenance therapy, with lactulose as the preferable alternative.7,11 Experts agree that laxative treatment should last for at least 2 months and that regular bowel movements should occur for at least 1 month before discontinuing laxative treatments.7 In some cases, laxatives may need to be used for months or years. When providing instructions to parents, advise them that laxatives can be titrated to treatment response.1,8 Along with laxative use, behavioral modification should be implemented. Such an approach has been shown to be more effective when used in combination with laxatives.15 Behavioral modification includes scheduled toilet time for 5 to 10 minutes after meals combined with a reward system when the constipated child uses toilet time.1,2,12 Additionally, caretakers should also keep diaries of stool frequency, which can be taken to the health care provider and serve as positive reinforcement for the child.2,8 In some cases, referral for counseling may be helpful when there are motivational or behavioral issues. Besides laxatives and behavioral modification, dietary changes can play a role in decreasing symptoms of constipation. Although probiotics, prebiotics, and fiber supplementation are not recommended for treatment of functional constipation in children,7 increased intake of fluids and carbohydrates, especially sorbitol (which is found in juices) can increase the frequency and water content of stools.8,16 Moreover, a balanced diet that includes fruits, whole grains, and vegetables is recommended for treatment.2,8

Rescue Therapy

Rescue therapy should be considered when there is recurrence of impaction for any reason (missed dose, ran out of medication) or when osmotic laxatives are ineffective.1,2 Stimulant laxatives, such as senna (an herb), should be used intermittently or for short periods in these situations.1,2 Be aware that further evaluation is necessary when a child requires long-term stimulant laxatives.1

What Are Some of the Challenges to Successful Treatment?

The following are phrases or messages that have been found to be effective for the parent to hear to ensure adherence.

If there is parental prejudice about the term “laxative” and concern for becoming “laxative dependent,” then these sentences can be helpful: “A laxative is a medication that encourages a bowel movement but it has a negative connotation in society. However it is what your child needs to get better.” Other messages are that “Laxatives are safe when used under medical guidance” and “What looks like dependence when medication is withdrawn is not a dependence but a sign that the gut is not ready to function on its own without assistance.”

If the parents complain that the medication is not working and they stopped giving it, you can tell them that “PEG 3350 is best given in 6 to 8 ounces of water/juice/milk in the morning when the child is relatively thirsty and most likely to finish it at one sitting. You will see the difference. If added to a 16-ounce ‘sippy cup’, and consumed over the course of the day it does not function optimally.”

If the parents observe that a full dose of laxative helps but still the stool is somewhat hard, then you should tell them that “In our experience, using white grape juice to make PEG 3350 solution, gives better results. This has an additive effect without increasing the dose of PEG powder.”

If the parents say something like “I gave this medicine as you suggested, but my child got the runs. So, I stopped. Now there has been no bowel movement for the last 3 days!” then you should tell them that “Some children respond with diarrhea to a standard dose. This is not an illness that will result in dehydration. A given dose may give no response, partial response, or an exaggerated response. We always start at a standard dose. The ‘runs’ your child had can be seen as resolving the disimpaction. We need to adjust the dose with a goal of having bowel movements 1 to 3 times per day to 1 to 3 times per week as long as the stool is soft and evacuation occurs without pain.”

If the parents ask if the constipation is a “psychological problem” you should tell them “No, it is not. What you are seeing is merely a reflex protective response of your child. It is as ‘psychological’ as tightening up your gut upon seeing a hostile fist coming at your belly.'

If the parents ask about the safety of PEG 3350 use, you can tell them that “Some families have reported concerns to the US Food and Drug Administration (FDA) that some neurologic or behavioral symptoms in children may be related to taking PEG 3350. It is unclear whether these side effects are due to PEG 3350. The FDA is presently investigating this. Until the FDA releases the results of is findings, this is the position statement of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Neurogastroenterology and Motility Committee.”

Generally speaking, you should let the parents know that if their child has been prescribed PEG 3350 as part of the treatment plan, and the medicine provides benefit, then they should feel safe continuing PEG 3350. You can let them know that at this time that PEG 3350 appears to be safe based on current medical literature. Tell the parents that you are willing to discuss their concerns about the safety of PEG 3350, and if they prefer to discontinue it, other options can be discussed before stopping PEG 3350 therapy. Although abruptly stopping PEG 3350 is not considered dangerous, it could lead to a relapse/worsening of constipation.

What to Expect in the Long-Term

Successful treatment of chronic childhood constipation was shown to be 60% by age 1 year and 80% by age 8 years in a study of children older than age 5 years.17 Additionally, successful treatment was seen more in children with an age of onset at 4 years or older and in children presenting with constipation without encopresis.17 In the same study, 50% of those treated successfully had at least one relapse.17 Moreover, another study of children age 4 years or younger showed that one-third of patients still had chronic constipation 3 to 12 years after initial evaluation and treatment.18 In a Dutch study that evaluated outcomes in adulthood, one-fourth of children with functional constipation were shown to still have symptoms as adults.4 As the evidence shows, management of constipation may be a life-long process that may require prolonged treatment, lifestyle changes, and patience from the parent, child (eventually adult), and physician.

When to Refer to a Pediatric Gastroenterologist

Consultation with a pediatric gastroenterologist is necessary when treatment fails or a concern for an organic cause exists.1 “Treatment failure” is defined as recurrence of constipation after adequate dosing and regularity of use, and after requisite duration of therapy. The concern for an organic cause arises when there are red flags on history, examination, and/or on basic investigation. The pediatric gastroenterologist re-evaluates the child for underlying organic processes and reviews previous management strategies before performing additional studies.2,10

Conclusion

Constipation is a challenging medical conundrum for not only pediatric patients and their parents, but also medical providers. Besides the small minority of children who have an organic cause of constipation, most other children will have functional constipation.2,8 Functional constipation requires a multipronged approach that includes education, disimpaction, maintenance therapy, and long-term follow-up along with a strong relationship among the health care provider, parent, and patient. With this approach and encouragement from the physician, the patient and the parent have a better chance of resolving the distress caused by constipation. Table 5 provides a list of the salient points discussed in this article.


            Take-Home Messages

Table 5.

Take-Home Messages

References

  1. Nurko S, Zimmerman LA. Evaluation and treatment of constipation in children and adolescents. Am Fam Physician. 2014;90(2):82–90.
  2. Baker SS, Liptak GS, Colleti RB, et al. Constipation in infants and children: evaluation and treatment. J Pediatr Gastroenterol Nutr. 1999;29:612–626. doi:10.1097/00005176-199911000-00029 [CrossRef]
  3. Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C. Health utilization and cost impact of childhood constipation in the United States. J Pediatr. 2009;154:258–262. doi:10.1016/j.jpeds.2008.07.060 [CrossRef]
  4. Bongers ME, van Wijk MP, Reitsma JB, Benninga MA. Long-term prognosis for childhood constipation: clinical outcomes in adulthood. Pediatrics. 2010;126(1):e156–162. doi:10.1542/peds.2009-1009 [CrossRef]
  5. Philichi L. When the going gets tough: pediatric constipation and encopresis. Gastroenterol Nursing. 2008;31(2):121–130. doi:10.1097/01.SGA.0000316531.31366.27 [CrossRef]
  6. Youssef NN, Langseder AL, Verga BJ, Mones RL, Rosh JR. Chronic childhood constipation is associated with impaired quality of life: a case controlled study. J Pediatr Gastroenterol Nutr. 2005;41:56–60. doi:10.1097/01.mpg.0000167500.34236.6a [CrossRef]
  7. Tabbers MM, Di Lorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol. 2014;58(2):258–274. doi:10.1097/MPG.0000000000000266 [CrossRef]
  8. Rowan-Legg A. Managing functional constipation in children. Paediatr Child Health. 2011;16(10):661–665.
  9. Weaver LT, Ewing G, Taylor LC. The bowel habit of milk-fed infants. J Pediatr Gastroenterol Nutr. 1988;7:568–571. doi:10.1097/00005176-198807000-00015 [CrossRef]
  10. Auth MKH, Vora R, Farrelly P, Baillie C. Childhood constipation. BMJ. 2012;345:1–11. doi:10.1136/bmj.e7309 [CrossRef]
  11. Greenwald BJ. Clinical practice guidelines for pediatric constipation. J Am Acad Nurse Pract. 2010;22:332–338. doi:10.1111/j.1745-7599.2010.00517.x [CrossRef]
  12. Mugie SM, Di Loranzo C, Benninga MA. Constipation in childhood. Nat Rev Gastroenterol Hepatol. 2011;8:502–511. doi:10.1038/nrgastro.2011.130 [CrossRef]
  13. Agarwal J. Chronic constipation. Indian J Pediatr. 2013;80(12):1021–1025. doi:10.1007/s12098-013-1133-5 [CrossRef]
  14. Pashankar DS. Childhood constipation: evaluation and management. Clin Colon Rectal Surg. 2005;18(2):120–127. doi:10.1055/s-2005-870894 [CrossRef]
  15. Brazzelli M, Griffiths P. Behavioral and cognitive interventions with or without other treatments for the management of faecel incontinence in children. Cochrane Database Syst Rev. 2006;2:CD002240.
  16. Kneepkens CMF. What happens to fructose in the gut?Scand J Gastroenterol. 1989;24(171):1–8. doi:10.3109/00365528909091365 [CrossRef]
  17. Van Ginkel R, Reitsma JB, Buller HA, van Wijk MP, Taminiau JAJM, Benninga MA. Childhood constipation: longitudinal follow-up beyond puberty. Gastroenterology. 2003;125(2):357–363. doi:10.1016/S0016-5085(03)00888-6 [CrossRef]
  18. Loening-Baucke V. Constipation in early childhood: patient characteristics, treatment, and longterm follow up. Gut. 1993;34:1400–1404. doi:10.1136/gut.34.10.1400 [CrossRef]

Common Associations with Constipation

Type of Risk Factor Example
Dietary Transition from breast-milk to formula or to cow's milk Starting rice cereal Lack of fiber
Psychosocial Toilet training Birth of sibling Starting school Parental strife/divorce Toilet phobia Sexual abuse Depression/anxiety
Medications Antidepressants ADD/ADHD medications Opiates
Anatomic or medical conditions Anal stenosis Anterior displacement of the anus Spinal cord abnormalities Hirschsprung disease Cow's milk protein intolerance Celiac disease Cystic fibrosis Irritable bowel syndrome Perianal lesions due to Crohn's disease Lead ingestion Hypercalcemia

Answers to the Two Cardinal Questionsa that Are Key to Diagnosis and Management

Age Clinical Scenario Diagnosis Next Step
Newborn Otherwise healthy newborn who has distressed defecation since birth with no delay of meconium passage, no clinical evidence of obstruction, with or without a family history of constipation Idiopathic constipation Use corn syrup or lactulose
10 days Breast-fed baby with no bowel movements since discharge 5 days prior. Baby is comfortable but mother is distressed Breast-milk constipation Offer effective parental reassurance
2 weeks Breast-fed baby presents with no bowel movements for 3 days since starting formula supplementation. Baby cries, turns red in the face, and passes hard small stools every 1–2 days for past few days Formula constipation Treat with lactulose Can consider adding 1 tsp/oz of infant oatmeal to formula
4 months Formula-fed baby, previously healthy, presents with 2 weeks of constipation. Baby was recently started with rice cereal supplementation Rice cereal constipation (rice blocks chloride channel) Advise parent to add infant oatmeal cereal 1–2 tsp/oz 2–3 times per day Lactulose use is another effective option
1–6 months Otherwise well breast-fed/bottled-fed infant with bowel movement 1–2 times per day, who screams and strains for 10 minutes before evacuating soft stool Infantile dyschezia Provide education and reassurance (eg, thisis a self-limited condition that improves with maturation of muscle coordination) Oatmeal supplementation can help
1 year Healthy child who is growing normally with previously normal bowel movements presents with a 2-week history of constipation. Stools are described as “rock hard” (with or without bright red blood on the surface). Child has history of whole milk consumption Whole milk constipation (due to higher protein to carbohydrate ratio) Treat with lactulose, or PEG 3350 solution and supplemental fiber in diet Routine advice to introduce whole milk gradually at age 1 year
4 years Otherwise healthy child with previously normal bowel movements who presents with recent onset of constipation for 3–4 days. There is associated excessive straining and crying. Patient recently started toilet training and showed withholding behavior Psychosocial constipation Educate family on the role of psychosocial factors (autonomy vs shame and doubt) Provide reassurance to patient and parent Treat with PEG 3350 solution for as long as required (months to years)
5 years Otherwise healthy child with previously normal bowel movements, except for occasional irregular stools, now presents with constipation Functional constipation Educate regarding constipation and regular toileting habits with foot support Treat with PEG 3350 solution for as long as required (months to years) Promote high-fiber diet
7 years Otherwise healthy child presents with no bowel movements for 10 days and a history of constipation since birth and multiple past emergency department visits. History of passing wide-caliber hard stool that plugs the toilet Functional constipation (remember that after establishing regularity, an inability to wean off a laxative is a “red flag” for an organic cause like Hirschsprung disease) Establish rapport with patient and patient'sfamily Treat with an adequate dose of PEG 3350 solution daily for as long as required (reassure safety of long-term use) Promote high-fiber diet Educate regarding constipation and regular toileting habits with foot support
12 years Healthy child with a history of constipation during infancy who presents with leakage of feces into underwear. Child may or may not have bowel movements in the toilet and fecal lumps are felt per abdomen Functional fecal retention with overflow Rule out neurologic problems on neurologic examination. If abnormal, X-ray and or MRI of lumbosacral spine should be considered Rule out potential psychosocial issues Educate family Reassure child Implement regular toilet schedule Treat with PEG 3350 and stimulant laxative (senna herb)
13 years Previously well teenager who presents with constipation and encopresis starting 6 weeks priorDuring examination, patient appears detached and often replies, “I don't know” to inquiriesMay be afraid of physical examination or anal inspection Sexual abuse constipation Obtain history from child with sensitivity Give perspective to child and parent Make appropriate referrals (social work andpsychiatry)

Organic Causes of Constipation

Age Clinical Scenario Diagnosis Next Step
Newborn Newborn presents with abdominal distention with or without vomiting, and no meconium passage after 48 hours of life Hirschsprung disease Refer to surgery or gastroenterologist Needs rectal biopsy and or rectal manometry
7 months Infant who previously defecated normally presents with constipation for 1 month after introduction of weaning foods. History of negative occult blood test Celiac disease Order TTG IgA antibody and quantitative IgA level to screen Refer to gastroenterologist if positive
5 years Child with a history of cerebral palsy/shunted hydrocephalus who presents with 7-day history of no bowel movements. Bowel movements usually occur every 3–4 days with laxative only. Fecal lumps per abdominal examination Functional outlet obstruction with decreased propulsive forces and impaired rectal sensation Consider enema with or without digital impaction Change to a different laxative Consider PEG 3350 solution administeredvia NGT or gastrostomy tube
Any age child Child, with history of slow growth and anorexia who presents with constipation and abdominal distension with or without pain. Occult blood test is negative Celiac disease Order TTG IgA antibody and quantitative IgA level to screen Refer to gastroenterologist if positive
Any child >5 years Child with history of slow weight gain, anemia, and positive occult blood test who presents with constipation and abdominal pain. Look for perianal lesions Crohn's disease Order CBC, ESR, CRP, albumin Refer to gastroenterologist for upper endoscopy and colonoscopy
10–12 years Child with history of chronic constipation, poor weight gain, intermittent diarrhea, fecal lumps, and inability to wean off PEG 3350 solution who presents with discharge of foul-smelling liquid stools/gas after withdrawal of finger from rectal examination Hirschsprung disease Refer to surgery or gastroenterologist Needs rectal biopsy and or rectal manometry

Medications Used to Treat Pediatric Constipation

Type of Therapy Medication Dosage Side Effects
Disimpaction Magnesium citrate Age <6 years: 1–3 mL/kg/day Age 6–12 years: 100–150 mL/day (single or divided dose) Magnesium poisoning (infants) Hypermagnesemia, hypophosphatemia, and secondary hypocalcemia
Polyethylene glycol 3350 1–1.5 g/kg/day for 3 days Limited, occasional abdominal pain, bloating, loose stools
Maintenance Polyethylene glycol 3350 Starting dose 0.4–1.0 g/kg/day Limited, occasional abdominal pain, bloating, loose stools
Lactulose 1 mL/kg/day (single or two divided doses) Flatulence, abdominal cramps, anaphylaxis
Rescue Senna Age 2–6 years: 2.5–7.5 mL/day Age 6–12 years: 5–15 mL/day Idiosyncratic hepatitis, melanosis coli, hypertrophic osteoarthropathy, analgesic nephropathy

Take-Home Messages

Always ask the two cardinal questions:

When did constipation first start (and at what age)?

What were the circumstances/events around the initial onset of constipation?

A goal-directed history and physical examination specifically related to constipation is all that is required to help differentiate between functional and organic causes in almost all cases

Laboratory and imaging studies are rarely required with this approach

Constipation is very common in children with neurodevelopmental disorders such as autism spectrum disorders, attention-deficit/hyperactivity disorder, and use of psychopharmaceutic agents

Education is important at each visit to help the parent and child to improve compliance and outcome

Encourage parents to remain positive and patient throughout the treatment process

Deliver hope and positive messages to the child and parent at every visit

Regular follow-up visits are important to ensure success of treatment

Combination therapy with behavioral modification and medication therapy is recommended

Use 1 to 2 medications routinely for the disimpaction, maintenance, and rescue phases to develop familiarity and confidence

Know that most children require long-term treatment

Disimpaction can usually be achieved with oral and/or rectal medications

Polyethylene glycol 3350 can be used for disimpaction and maintenance therapy (it is easy to administer, noninvasive, and well tolerated)

Even though anecdotally useful, probiotics, prebiotics, and fiber supplementation are not recommended for treatment of functional constipation in children

Consider referral to a pediatric gastroenterologist when you suspect an organic cause for constipation or when constipation is unresponsive to adequate treatment

Authors

Shailender Madani, MD, is an Assistant Professor of Pediatrics, Wayne State University School of Medicine, Division of Pediatric Gastroenterology, Children's Hospital of Michigan. Lisa Tsang, BS, is a fourth-year Medical Student, Wayne State University School of Medicine. Deepak Kamat, MD, PhD, is a Professor of Pediatrics, Wayne State University School of Medicine, Department of Pediatrics, Children's Hospital of Michigan.

Address correspondence to Shailender Madani, MD, Wayne State University School of Medicine, Division of Pediatric Gastroenterology, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201; email: smadani@dmc.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00904481-20160323-01

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