Constipation

Constipation

Constipation is a very common pediatric complaint, reaching highest prevalence during the preschool years and accounting for nearly five percent of clinic visits. It is defined by hard stools, difficul defecation, or frequency of defecation totaling less than three times per week for over one month. The complaint is often associated with encopresis, sometimes called paradoxical diarrhea, which is defined as unintentional soiling in kids who have already been potty trained. 

Differential Diagnosis

Constipation can be caused by many different physiological, psychological, neurological disorders. It can additionally be associated with poor nutritional and dietary intake. It is important to rule out other underlying disorders with a thorough history and physical. 

  1. Functional or voluntarily withholding of stools leading to soiling (encopresis)
  2. Hirschsprung's Disease
  3. Anrectal abnormalitis - stenosis or anal strictures, or an anteriorly placed anal opening
  4. Other obstruction of the gastrointestinal tract
  5. Hypothyroidism
  6. Hypokalemia 
  7. Hypercalcemia
  8. Drugs (such as narcotics, vincristine, antacids)
  9. Excessive milk in diet, poor fluid intake, lack of bulk in diet
  10. Cow’s milk intolerance
  11. Botulism
  12. Lead poisoning

Important History to Gather

  1. How often does the child have a bowel movement? 
  2. What is the consistency of the stool?
  3. Is there pain when he goes to the bathroom?
  4. Does he have associated abdominal pain?
  5. Are the stools so large that they are unflushable and need to be chopped up?
  6. Is there blood in the stools?  Surrounding the stools?  Are the stools black?
  7. When and how have the bowel habits changed?
  8. Does he sit on the toilet? 
  9. What is his diet like?
  10. Age when potty trained

Treatment

Treatment depends on the underlying cause. 95% of constipation is functional constipation, meaning it exists in the abscence of identifyable anatomic or biochemical cause. Organic causes must be rulled out if suspected after a thorough history and physical. The prenatal screen must be checked for the possibility of Cystic Fibrosis. If Hirschsprung's disease is suspected, a rectal biopsy and/or barium enema may be necessary to confirm the diagnosis.

Diet manipulation with plenty of fiber and fluids may be helpful in the setting of a dietary cause, and the addition of stool softeners and gentle laxatives may be tried. In infants and toddlers, sorbitol-containing juice (prune or pear) may be helpful. Lots of encouragement to the child is important, and follow-up should be arranged in 1-2 weeks. If constipation is resistant to appropriate dietary modifications, early referral to a GI physician has been associated with good outcomes.

References

  1. Abi-Hanna A and Lake AM. Constipation and Encopresis in Childhood. Pediatrics in Review. 1998; 19:23-31.
  2. Bongers, Marloes EJ, et al. Long-term prognosis for childhood constipation: clinical outcomes in adulthood. Pediatrics 126.1 (2010): e156-e162.
  3. Tabbers, Merit M., et al. Nonpharmacologic treatments for childhood constipation: systematic review. Pediatrics 128.4 (2011): 753-761.
  4. Vera Loening-Baucke, Erasmo Miele, and Annamaria Staiano Fiber (Glucomannan) Is Beneficial in the Treatment of Childhood Constipation. Pediatrics, Mar 2004; 113: e259 - 264. 
  5. AI Bell, and MI Levine The psychologic aspects of pediatric practice; I. causes and treatment of chronic constipation Pediatrics 14: 259-266.
  6. H. L. Nancy Kim, Kenneth W. Gow, Janice G. Penner, Geoffrey K. Blair, James J. Murphy, and Eric M. Webber Presentation of Low Anorectal Malformations Beyond the Neonatal Period Pediatrics 105: e68.
  7. Orvar Swenson Hirschsprung’s Disease: A Review Pediatrics 109: 914-918
  8. Har, Aileen F., and Joseph M. Croffie. Encopresis. Pediatrics in Review 31.9 (2010): 368-374.
  9. Borowitz S et.al. Treatment of Childhood Constipation by Primary Care Physicians: Efficacy and Predictors of Outcome. Pediatrics April 2005
  10. Loening-Baucke V and Pashankar D. A Randomized, Prospective, Comparison Study of Polyethylene Glycol 3350 Without Electrolytes and Milk of Magnesia for Children with Constipation and Fecal Incontinence.  Pediatrics August 2006
  11. vanJijk et al. Behavioral Therapy for Childhood Constipation.  Pediatrics May 2008
  12. Chao HC, et al. Constipation and Growth: Something New to Consider. Pediatric Research. 2008;64(3):308-311
  13. Borowitz, Stephen M., et al. Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome. Pediatrics 115.4 (2005): 873-877.

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