Pediatric Annals

Healthy Baby/Healthy Child 

Constipation Management in Pediatric Primary Care

Leah Khan, MD

Abstract

Constipation is a common and often difficult to manage problem encountered in outpatient primary care. Although we give our patients many different modalities to treat constipation (eg, diet changes, behavior modification, probiotics, medication), there is little evidence to support any of these modalities. We also tend to order unnecessary tests during the diagnostic process. This article tries to clarify the diagnostic process and provide a clear treatment path to be used for functional constipation. [Pediatr Ann. 2018;47(5):e180–e184.]

Abstract

Constipation is a common and often difficult to manage problem encountered in outpatient primary care. Although we give our patients many different modalities to treat constipation (eg, diet changes, behavior modification, probiotics, medication), there is little evidence to support any of these modalities. We also tend to order unnecessary tests during the diagnostic process. This article tries to clarify the diagnostic process and provide a clear treatment path to be used for functional constipation. [Pediatr Ann. 2018;47(5):e180–e184.]

Constipation is a common problem in primary care, accounting for approximately 3% to 5% of all office visits and 10% to 25% of all pediatric gastroenterology referrals.1–3 Constipation is defined as a disorder in which a child passes infrequent bowel movements (generally two or fewer per week), has painful defecation, or passes large-caliber hard stools that require excessive straining.4 There are also more stringent medical definitions based on the Rome criteria, but a more general definition is most helpful in the clinical setting.5 About 95% of the time, constipation can be further classified as “functional,” which is constipation with no structural or biochemical explanation.3,6 Constipation is considered acute if it has been going on for less than 4 weeks and chronic if it has been present longer.4 Symptoms occur most commonly around the time of toilet training but also have peaks at the introduction of solid foods and at school entry.4,6

Although constipation itself is uncomfortable for the patient and disruptive to their daily functioning, it can also lead to significant complications that have their own medical and social impact. Undiagnosed and/or untreated constipation can lead to anal fissures, which cause pain and lead to stool withholding, which promotes fecal impaction and then fecal incontinence.4,6 If this is a chronic problem, it can result in loss of rectal sensation and the normal urge to defecate, which just perpetuates the problem.6

Although most constipation can be classified as functional constipation, about 5% of cases do have an underlying medical cause.6 Among these causes are Hirschsprung's disease, cystic fibrosis, Down syndrome, anorectal malformations (anal stenosis, imperforate anus), neuromuscular disorders, and metabolic and endocrine (diabetes, celiac disease, hypercalcemia) disorders.6,7 Medications such as antacids, anticholinergics, antidepressants, and opiates can also lead to constipation.7 It is important to obtain a thorough history and a detailed physical examination to catch “red flags” and ensure that the diagnosis is truly functional constipation. For the purpose of this article, we focus on the evaluation and management of functional constipation only.

Diagnosis

The initial evaluation for constipation is a detailed history and physical examination. There are several key points in the history that are important in determining the cause and severity of the constipation, helping to guide the diagnosis and treatment course. When obtaining a history, the provider should ask first about the family's definition of constipation as this varies widely and can range from 1 missed day of bowel movements to weeks of infrequent and difficult-to-pass stools.7 It is also important to know (particularly in infants) the timing of the passage of first meconium.7 Beyond these two key questions, the provider will want to know the age of onset, frequency and consistency of stool, associated pain, vomiting, anorexia, weight loss, and blood in the stool.5–7 The provider should also inquire about fecal incontinence and withholding behavior to assess the severity of the constipation and degree of impact on daily life.5,6 The provider should be prepared to ask detailed questions and give examples, as many children and families find talking about their stools embarrassing and difficult. The Bristol Stool Scale is a standardized way for patients to describe their stools in a way that is helpful diagnostically.5 Finally, the provider should assess for any stressful life events, medications the child is taking, dietary history, and developmental history including questions related to toilet training.6,7

The physical examination should include evaluation of growth parameters, a thorough abdominal examination (specifically palpating for stool and assessing for masses and pain), inspection of the perianal region (for fissures, polyps, or any obvious anomalies), and an examination of the lumbosacral region (to evaluate for pits, dimples, and creases).5,6 A digital rectal examination is not recommended as part of a routine evaluation.5 In the absence of warning signs, there is no indication for further evaluation with laboratory tests or imaging.5,6,8 An abdominal X-ray may be helpful in those in whom fecal impaction is suspected and the physical examination is not reliable (ie, obese child) but is otherwise not recommended.5

Treatment

Once functional constipation has been diagnosed, we must then help families treat and manage this condition. Treatment approaches are generally divided into two age categories: infants and toddlers/children. We will discuss general treatment strategies for both categories then detail more specifically the different treatment modalities.

General Treatment Strategies

In infants, if constipation has an onset prior to age 1 month, it is important to have a high index of suspicion for an organic cause such as Hirschsprung's disease or cystic fibrosis.3–5 It is also important to differentiate between constipation and something called infant dischezia, which is a condition in which infants have constipation-like symptoms (straining, difficulty passing stool) but then pass soft frequent stools.4 This is caused by a discoordination of the sphincter muscles and will resolve on its own without intervention.4,5 For infants who truly do present with constipation, there are several modalities to offer families before referral to gastroenterology would be necessary. First, there are dietary measures that can be taken. Infants often respond well to sorbitol-containing juices like apple, prune, or pear juice.3,4 Families should also be educated that when they are introducing solids, the addition of prunes, peas, and whole wheat or multigrain cereal to the regimen can help lessen constipation.4 If dietary measures are not sufficient, families can also promote peristalsis with rectal stimulation using a lubricated rectal thermometer.4 If these initial measures fail, some infants will require further treatment with osmotic laxatives or glycerin suppositories.3

In children and toddlers, there is often a stepwise approach to treatment. The first step is disimpaction, often called a “cleanout.”3 This is essential for children who have associated fecal incontinence, significant stool palpated on examination or seen on X-ray (although this modality is not a recommended part of the testing), or for children with incomplete evacuation.3 Disimpaction can be accomplished in many ways. Often, a high dose of oral laxatives in the outpatient setting is adequate, although for some children hospitalization and the use of nasogastrically delivered osmotic laxatives is necessary.3 Sometimes, physical disimpaction is also needed and is accomplished with a digital disimpaction or an enema.3 In younger children, a lubricated rectal thermometer can also be used.4 Once disimpaction has been accomplished, the next step is prolonged laxative treatment and behavior therapy.3 This is called maintenance therapy and should continue for at least 2 months. Maintenance therapy should stop no sooner than 1 month after resolution of symptoms.5 Parents should also be educated not to stop therapy during toilet training or other stressful life events.5 The third step is focused on dietary changes and step four involves the gradual tapering and withdrawal of laxatives.3 It is important to note that many children require months or even years of treatment to reach the goal of normal bowel movements.3 It is important to set realistic expectations for families, as many anticipate a cure within days or weeks.

Specific Treatments

Now that we have laid out a general approach to constipation, we will focus more on specific interventions. The first and most important intervention is education about constipation, its causes, and its consequences. It is crucial to inform families that constipation can take a long time to resolve.3 It is also important to emphasize that associated withholding and soiling due to overflow incontinence is not a purposeful or defiant behavior but is psychological and a result of a significant physical problem.3 Families should also be counseled to postpone any toilet training until constipation is managed appropriately.3

There are some dietary measures that can be helpful in managing constipation. Increasing fiber in the diet (up to 5–10 g/day, as more has not been proven to be more effective) can be helpful.3 Increasing fluid intake can also have a positive impact when done in conjunction with fiber.4 It is important to note, however, that studies do not show improvement in symptoms of constipation with doses of fiber and fluids beyond the daily-recommended doses.5 One study did show that parents and physicians perceived an improvement in symptoms with increased fiber; however, there was no statistically significant change in any symptoms other than stool frequency.9 Excessive fiber intake should also be avoided in patients with stool withholding and fecal impaction as it can make symptoms worse.3,4 Limiting the intake of cow's milk may also improve constipation symptoms as cow's milk can slow intestinal motility and also satiates children, promoting less intake of stool-promoting foods.3,4,6

There are also some behavior-modification strategies that may promote regulation of stooling. There is minimal evidence available regarding the efficacy of behavior modification, but in addition to other treatments, it could enhance the treatment experience and help families feel like they are taking an active role in the management of constipation. To avoid stool withholding, it may be helpful to allow students unlimited access to a private bathroom.3 Encouraging patients to sit on the toilet regularly, especially after a meal, can also promote regular stooling behavior.3 Using a step stool to rest the feet on can encourage a posture that is helpful for passing stools as well.3 A reward system for sitting on the toilet (not for having a bowel movement) can be good motivation for some children who are resistant to the process.3 Finally, keeping a log of stools, medications, pain, diet, fluid intake, and associated symptoms can help identify patterns or perhaps inciting events.3,5

There are several medications that are used to treat constipation (Table 1). They are the mainstay of constipation management and have the best evidence with regard to their efficacy.5 The most commonly used and most effective medication is the osmotic laxative, polyethylene glycol (PEG).3 Although other osmotic laxatives such as sorbitol and lactulose are valuable, none work quite as well as PEG.3,5 PEG is available both with and without electrolytes, but the formulation without electrolytes is much better tolerated.3 When used correctly, it is successful at improving constipation in about 95% of patients.3 Side effects may include diarrhea, bloating, and abdominal pain.3 If using PEG with electrolytes, it is suggested to administer it via nasogastric tube, as it is not well tolerated orally.3

Pharmacotherapy for Constipation

Table 1:

Pharmacotherapy for Constipation

Lactulose, another osmotic laxative, is recommended only if PEG is not available.5 It is well tolerated but does lose its effect over time.3 Its side effects include flatulence, abdominal cramps, and fecal incontinence.3,6 Other oral medications include stimulant laxatives such as bisocodyl and senna. These should be used only for short periods of time (ie, disimpaction) in children who have severe constipation that does not respond to other treatment.3 In the past, mineral oil was a mainstay of treatment for constipation. This is still used today but is not recommended in young patients or those at high risk of aspiration.3

Enemas are another form of medication used primarily for disimpaction. They are not recommended for use in infants.3 The most common types of enemas used for constipation are sodium phosphate enemas, saline enemas, and mineral oil enemas.3 These cause higher rates of abdominal cramping than the osmotic laxatives but work quickly.6 Glycerin suppositories are also effective and are often used in the infant population.4

One other therapy that is currently being studied is the use of prebiotics and probiotics in the management of constipation. Some individual studies have shown improvement in stool frequency; however, little other success has been demonstrated.2 The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition reviewed the literature and notes that there is insufficient evidence to support the use of prebiotics or probiotics in the treatment of constipation.5 Interestingly, in one study, about 35% of children with functional constipation were already using some form of alternative treatment to help manage their symptoms.9 These included things such as acupuncture, homeopathy, mind-body therapy, chiropractic manipulation, and yoga.9 There is currently no clear evidence to support the recommendation of these interventions.

Follow-Up

Once a treatment plan has been determined and implemented, it is important to have close follow-up to ensure clinical improvement. Adherence to the regimen is key, and if families are not seeing satisfactory results they may stop treatment prematurely. We are often not aggressive enough in our approach to constipation, so revisiting frequently and modifying the treatment plan may be necessary. One study showed that after 2 months of treatment in the primary care setting, about 40% of patients were still symptomatic.6 Studies also show that after 6 to 12 months of treatment, only 50% to 60% of patients were able to achieve successful outcomes and discontinue laxative use.5,6,9 Even in children who present to a tertiary care center and receive intensive treatment, only 80% report good clinical outcomes by age 16 years.5,6 Delay in treatment longer than 3 months from the onset of symptoms was also a risk factor for longer duration of symptoms.5 This indicates that early recognition and treatment of symptoms will result in a faster and shorter treatment course.

Conclusion

Although constipation is a frequent topic of discussion in the pediatrician's office, we may not be managing it in the most effective or evidence-based way. It can be frustrating for parents to hear, but it is important to discuss that most constipation does not have a specific cause. It is also vital to educate families that this is a chronic problem that may require months or even years of treatment. Although we often recommend dietary changes, exercise, and probiotics, there is no good evidence to support these measures, so osmotic laxatives should be the mainstay of treatment in toddlers and children. We should also avoid extensive testing in children with functional constipation. If we apply these principles, primary care physicians should be able to efficiently and effectively treat our young patients with constipation.

References

  1. Mallon D, Vernacchio L, Trudell E, et al. Shared care: a quality improvement initiative to optimize primary care management of constipation. Pediatrics. 2015;135(5):e1300–e1307. doi:. doi:10.1542/peds.2014-1962 [CrossRef]
  2. Huang R, Hu Jianan. Positive effect of probiotics on constipation in children: a systematic review and meta-analysis of six randomized controlled trials. Front Cell Infect Microbiol. 2017;7:153. doi:. doi:10.3389/fcimb.2017.00153 [CrossRef]
  3. Sood M. Chronic functional constipation and fecal incontinence in infants and children: treatment. UpToDate. September 29, 2017. https://www.uptodate.com/contents/chronic-functional-constipation-and-fecal-incontinence-in-infants-and-children-treatment?search=chronic%20functional%20constipation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed April 25, 2018.
  4. Sood M. Prevention and treatment of acute constipation in infants and children. UpToDate. June 21, 2017. https://www.uptodate.com/contents/prevention-and-treatment-of-acute-constipation-in-infants-and-children?search=Prevention%20and%20treatment%20of%20acute%20constipation%20in%20infants%20and%20children&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed April 25, 2018.
  5. Tabbers M, DiLorenza C, Berger M, et al. European Society for Pediatric Gastroenterology, Hepatology, and NutritionNorth American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;8:258–274. doi:10.1097/MPG.0000000000000266 [CrossRef].
  6. Levy E, Lemmens R, Vandenplas Y, Devreker T. Functional constipation in children: challenges and solutions. Pediatr Health Med Ther. 2017;8:19–27. doi:. doi:10.2147/PHMT.S110940 [CrossRef]
  7. Navidi T. Gastroenterology. In: Engorn B, Flerlage J, eds. The Harriet Lane Handbook. 20th ed. Philadelphia, PA: Elsevier Saunders; 2015:272–273.
  8. Ferguson C, Gray M, Diaz M, Boyd K. Reducing unnecessary imaging for patients with constipation in the pediatric emergency department. Pediatrics. 2017;140(1):e20162290. doi:. doi:10.1542/peds.2016-2290 [CrossRef]
  9. Tabbers M, Boluyt N, Berger M, Benninga M. Nonpharmacologic treatments for childhood constipation: systematic review. Pediatrics. 2011;128:753–761. doi:. doi:10.1542/peds.2011-0179 [CrossRef]

Pharmacotherapy for Constipation

Medication Class Use Dose
Polyethylene glycol without electrolytes Osmotic laxative Maintenance Disimpaction 0.2–0.8 g/kg/day 1–1.5 g/kg/day with 10 mL/kg fluid for up to 6 days
Polyethylene glycol with electrolytes Osmotic laxative Disimpaction 25 mL/kg/hr up to 1,000 mL or 20 mL/hr for 4 hours/day
Lactulose Osmotic laxative Maintenance 1–2 g/kg/day
Magnesium hydroxide Osmotic laxative Maintenance Age 2–5 y: 0.4–1.2 g/day Age 6–11 y: 1.2–2.4 g/day Age 12–18 y: 2.4–4.8 g/day
Mineral oil Fecal softener Maintenance (not for those at risk for aspiration) 1–3 mL/kg/day Maximum dose: 90 mL/day
Bisocodyl Stimulant laxative Disimpaction Age 2–10 y: 5 mg/day Age >10 y: 5–10 mg/day
Senna Stimulant laxative Disimpaction Age 2–6 y: 2.5–5 mg/day Age 6–12 y: 7.5–10 mg/day Age >12 y: 15–20 mg/day
Sodium phosphate Enema Disimpaction Age 2–5 y: 1.13 oz Age 5–12 y: 2.25 oz Age >12 y: 4.5 oz Or 2.5 mL/kg up to 133 mL
Saline Enema Disimpaction Age 1–2 y: 6 mL/kg Age 2–11 y: 30–60 mL Age >11 y: 60–150 mL
Mineral oil Enema Disimpaction Age 2–11 y: 30–60 mL Age >11 y: 60–150 mL
Glycerin Suppository Disimpaction 0.25–1 suppository
Authors

Leah Khan, MD
 

Leah Khan, MD, is a Pediatrician, Park Nicollet Clinics.

Address correspondence to Leah Khan, MD, 300 Lake Drive East, Chanhassen, MN 55317; email: leahdkhan@gmail.com.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20180426-02

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