Constipation
last authored: Oct 2009, Dave LaPierre
last reviewed:
Introduction
Constipation is a very common concern, the most frequent GI complaint in children. It is defined by less frequent stool, hardness, associated with symptoms.
The Case of...
Differential Diagnosis
The vast majority (over 95%) of pediatric constipation is functional, caused by psychological or dietary issues.
acronym: DUODENUM
Diet
ψsychiatry
Obstruction
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Drugs
Endocrine
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Neurologic
Unknown
Miscellaneous
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History and Physical Exam
Constipation should be considered to be clinically relevant if:
- less than 3 stools/week
- fecal incontinence is present
- stool is palpable through the abdomen
- there is retentive posturing
- defecation is painful
- history
- physical exam
History
When did it start?
- Hirschprung's: begins from birth; delayed passage of meconium
shape of stool
- functional: large stools that can clog the toilet
children behaviours
- parental coercion
- 'the busy' child
- diet
- availability of toilet
- "the poopdance" or other maneuvers as kids try to retain stool
soiling
- encopresis: with functional constipation
Physical Exam
Height and weight
HEENT
- thyroid
abdominal
- can often find fecalomas
- rectal exams not necessary if a classical history of functional. Consent is incredibly important. Anal reflex -
lowe back for occult neural tube defect
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
If treatment of functional constipation does not work, investigations should be done for
- celiac
- TSH
- electrolytes
Blood tests - CBCD, electrolytes, Ca, Mg, urea, creatinine, glucose, TSH
Diagnostic Imaging
An abdominal X-ray can show obstruction etc. On flat X-ray, divide abdomen into 4 quadrants, and rate the amount of stool in each from 0-3. Constipation is suggested if score is >6/12.
Management
For functional constipation, education of patients and families is first. Disimpaction is the next step: PEG is the first line, and should be kept up for a few weeks or months. It is not addictive and can be stopped abruptly with no concerns.
Diet is key in preventing constipation. Wheat bran, high-bran cereals, psylium 2-3tsp/d can all provide insoluble fibre. Exercise and adequate hydration are also very important. Dried prunes are also helpful (Attaturi et al, 2011).
Behaviour modification: setting reasonable expectations, routine (5 min after breakfast and supper), rewards.
Laxatives, in order of increasing potency, include:
- docusate/Colace 100-240 mg OD-QID (poor/no evidence?)
- senna 1-4 tabs daily-QID (stimulant laxative)
- milk of magnesia 15-30ml BID
- sorbitol 15-30ml daily-BID
- lactulose 15-60ml daily
- magnesium citrate 150-300ml daily
- bisacodyl/dulcolax supposititories 1 PR prn (stimulant laxative)
- tap water enema 500ml prn
- mineral oil enema 100-250 ml prn
- PEG/Golytely 4L prn
Manual disimpaction can be used in people for whom stool has hardened to such a degree it can not be expelled.
Medications that cause constipation should be reduced or held as soon as is possible.
Pathophysiology
Fecal withholding in children
Children can become quite afraid of defecation for a number of reasons, including parental pressure, painful bowel movements, or fear of toilets. Accordingly, fecal withholding is quite common as a cause of defecation.
The Case of...
Additional Resources
Attaturi A et al. 2011. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther. 33(7):822-8.
Topic Development
created: DLP, Aug 09
authors: DLP, Aug 09
editors:
reviewers:
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