Pediatric Constipation

Overview

Definition

• Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation is a relative term and depends on a number of factors including frequency, consistency Consistency Dermatologic Examination, and difficulty in passage of stool:
  • A hard stool Hard stool Appendicitis ( consistency Consistency Dermatologic Examination) passed every 3rd day (frequency) with “difficulty” requires management. 
  • A soft stool that is passed without difficulty every 2–3 days is not constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation.
• The Paris Consensus on Childhood Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation Terminology (PACCT) definition:
  • A period of 8 weeks with at least 2 of the following symptoms:
    • Defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility < 3/week 
    • Fecal incontinence 2 ⩲/week 
    • Passage of large stools that clog the toilet 
    • Palpable abdominal or rectal fecal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast 
    • Habit of withholding stool
    • Painful defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility

Epidemiology

• Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation of all etiologies:
  • Affects 30% of children
  • Makes up approximately 4% of pediatrician visits
  • Most common in 2–4-year-old children
• Functional constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation:
  • Constitutes 95% of all cases of constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
  • Most common in preschool-aged children

Etiology

• Functional constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation:
  • Meets clinical PACCT criteria for constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation with no underlying pathologic causes
• A minority (about 5%) may have constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation due to organic causes.

Pathophysiology

Functional constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation is the most common cause of constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation:  

• Causative psychologic vicious cycle 
• Dietary or environmental factors lead to hardened stool → more painful to pass.
• Bowel movements associated with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways →  withhold defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility
• Chronic stool holding → accommodation Accommodation Refractive Errors by the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy and further hardening of stool
• Reduced sensitization to defecation reflex Defecation reflex Gastrointestinal Motility and less effective peristalsis Peristalsis A movement, caused by sequential muscle contraction, that pushes the contents of the intestines or other tubular organs in one direction. Gastrointestinal Motility
• Encopresis Encopresis Encopresis is the involuntary or unintentional passage of feces in inappropriate situations in children older than 4 years of age in the absence of neuromuscular disease. Elimination Disorders (inability to hold stool):
  • Passage of proximal watery content around compacted stool 
  • May be mistaken for diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
• May rarely cause urinary stasis
• Chronic severe constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation may have an emotional impact on the patient and family.

Clinical Presentation and Diagnosis

History and exam are performed to rule out any organic causes and reassure the provider that the symptoms in question are due to functional constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation.

History

Toileting patterns:

• Frequency, consistency Consistency Dermatologic Examination, size of stools, pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, and association with bleeding are important defining and etiologic clues.
• Fecal incontinence or diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea may indicate encopresis Encopresis Encopresis is the involuntary or unintentional passage of feces in inappropriate situations in children older than 4 years of age in the absence of neuromuscular disease. Elimination Disorders.
• History of frequent urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease may indicate constipation-induced urinary stasis or vesicoureteral reflux Vesicoureteral Reflux Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the upper urinary tract. Primary VUR often results from the incomplete closure of the ureterovesical junction, whereas secondary VUR is due to an anatomic or physiologic obstruction. Vesicoureteral Reflux.

Timing of onset of symptoms:

• Dietary transition
• Recent severe illness, dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration, or diaper rash Rash Rocky Mountain Spotted Fever

Psychosocial stressors:

• Starting a new school
• Family changes (moving, birth of new sibling, or divorce)
• Toilet training

Behavioral cues:

• Squatting 
• Crossing ankles
• Stiffening the body
• Holding onto furniture

Cues pointing to organic etiologies:

• Hirschsprung’s disease:
  • Passage of meconium Meconium The thick green-to-black mucilaginous material found in the intestines of a full-term fetus. It consists of secretions of the intestinal glands; bile pigments; fatty acids; amniotic fluid; and intrauterine debris. It constitutes the first stools passed by a newborn. Prenatal and Postnatal Physiology of the Neonate (1st bowel movement) delayed for more than 24 hours
  • Constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation during early months after birth
• Lead poisoning Lead poisoning Poisoning that results from chronic or acute ingestion, injection, inhalation, or skin absorption of lead or lead compounds. Metal Poisoning (Lead, Arsenic, Iron):
  • Pica Pica Pica is an eating disorder characterized by a desire or recurrent compulsion to eat substances that are nonnutritive and not food. These compulsions and ingested substances are inappropriate for age or culture. Pica
  • Developmental delay
  • Living in older home or home with lead-based paint
• Dietary intolerances (e.g., milk protein intolerance, celiac disease Celiac disease Celiac disease (also known as celiac sprue or gluten enteropathy) is an autoimmune reaction to gliadin, which is a component of gluten. Celiac disease is closely associated with HLA-DQ2 and HLA-DQ8. The immune response is localized to the proximal small intestine and causes the characteristic histologic findings of villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis. Celiac Disease):
  • Recent transition from breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding to solid food
  • Transition from breast milk to cow milk–based formula
  • Intermittent blood noted in stool

Physical examination

General:

• Growth charts should be reviewed to ascertain appropriate growth: Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive suggests organic causes of constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation. 
• Dysmorphia and other cues to syndromes should be noted:
  • Down’s syndrome
  • Prune belly syndrome
• Prenatal history suggestive of Hirschsprung’s disease should be reviewed.

Abdominal exam:

• Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination of left lower quadrant Left Lower quadrant Anterior Abdominal Wall: Anatomy may reveal stool mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast.
• Auscultation may reveal hyperactive bowel sounds Hyperactive Bowel Sounds Abdominal Examination.

Rectal exam:

• Anal abnormalities may suggest an underlying pathology:
  • Abnormal position of the anus suggests anal atresia Atresia Hypoplastic Left Heart Syndrome (HLHS).
  • Presence of perineal or sacral dimples or hair tufts suggests spina bifida or a tethered cord.
  • Anal fissures Anal fissures A painful linear tear at the margin of the anus. It appears as a crack or slit in the mucous membrane of the anus and is very painful and difficult to heal. Constipation or fistulas
  • Hemorrhoids Hemorrhoids Hemorrhoids are normal vascular cushions in the anal canal composed of dilated vascular tissue, smooth muscle, and connective tissue. They do not cause issues unless they are enlarged, inflamed, thrombosed, or prolapsed. Patients often present with rectal bleeding of bright red blood, or they may have pain, perianal pruritus, or a palpable mass. Hemorrhoids should be noted on inspection Inspection Dermatologic Examination.
• Failure to elicit an anal wink (transient contraction) by stroking the perianal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions may indicate sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology or motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology nerve abnormalities:
  • Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy lesions
  • Tethered cord
  • Autonomic neuropathy Neuropathy Leprosy
  • Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy trauma
  • Spina bifida
  • Chagas disease Chagas disease Infection with the protozoan parasite trypanosoma cruzi, a form of trypanosomiasis endemic in central and south america. It is named after the brazilian physician carlos chagas, who discovered the parasite. Infection by the parasite (positive serologic result only) is distinguished from the clinical manifestations that develop years later, such as destruction of parasympathetic ganglia; chagas cardiomyopathy; and dysfunction of the esophagus or colon. Trypanosoma cruzi/Chagas disease
• Digital rectal examination Digital Rectal Examination A physical examination in which the qualified health care worker inserts a lubricated, gloved finger of one hand into the rectum and may use the other hand to press on the lower abdomen or pelvic area to palpate for abnormalities in the lower rectum, and nearby organs or tissues. The method is commonly used to check the lower rectum, the prostate gland in men, and the uterus and ovaries in women. Prostate Cancer Screening:
  • Large, firm stool mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast in the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy in many patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with functional constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
  • Small, empty rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal: Anatomy in Hirschsprung’s disease
  • A gush of liquid stool may occur following a digital rectal exam in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with Hirschsprung’s disease. 

Neurologic exam: 

• Absent cremasteric reflex Cremasteric Reflex Male Genitourinary Examination (pulling up of the ipsilateral testicle while stroking the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy in boys) 
• Abnormal tone of the lower extremity:  muscular dystrophy Muscular Dystrophy Becker Muscular Dystrophy 

Diagnosis

In an otherwise healthy child, functional constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation is diagnosed clinically. Laboratory examination should be directed by cues suggesting other pathologic causes:

• Laboratory testing: not indicated unless an organic cause is suspected
• Abdominal radiographs: 
  • Not performed routinely
  • In special circumstances, radiographs may show a burden of a stool mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast, especially when overflow diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea is suspected or physical examination is refused.
• Single-contrast enema (not air-contrast enema) with abdominal radiographs: 
  • May assist in the diagnosis of Hirschsprung’s disease 
  • Transitional zone Transitional zone Anal Cancer from a narrow (aganglionic) distal segment to a distended (ganglionic) proximal segment is consistent with the diagnosis.
• Anorectal manometry Manometry Measurement of the pressure or tension of liquids or gases with a manometer. Achalasia: 
  • A rectal balloon is inserted and inflated to measure rectal pressure.
  • Can be helpful in diagnosing neurologic causes of constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation 
• Rectal biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma: Absent ganglionic cells in the affected colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy confirms a diagnosis of Hirschsprung’s disease.

Management

• If an organic cause is identified, management is tailored to the specific etiology. 
• In patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with functional constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, management centers around 3 components:
  • Evacuation of colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy:
    • Oral cathartics ( lactulose Lactulose A synthetic disaccharide used in the treatment of constipation and hepatic encephalopathy. It has also been used in the diagnosis of gastrointestinal disorders. Laxatives, magnesium Magnesium A metallic element that has the atomic symbol mg, atomic number 12, and atomic weight 24. 31. It is important for the activity of many enzymes, especially those involved in oxidative phosphorylation. Electrolytes hydroxide) 
    • Enemas (saline solution ± glycerin) 
  • Elimination Elimination The initial damage and destruction of tumor cells by innate and adaptive immunity. Completion of the phase means no cancer growth. Cancer Immunotherapy of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways upon defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility:
    • Chronic sufficient laxative Laxative Agents that produce a soft formed stool, and relax and loosen the bowels, typically used over a protracted period, to relieve constipation. Hypokalemia therapy is safe and effective.
    • Dietary modifications, such as increased intake of fluids, complex carbohydrates Carbohydrates A class of organic compounds composed of carbon, hydrogen, and oxygen in a ratio of cn(H2O)n. The largest class of organic compounds, including starch; glycogen; cellulose; polysaccharides; and simple monosaccharides. Basics of Carbohydrates (fruit juice), and vegetables with removal of cow milk in very young children
  • Improving bowel habits: Regular Regular Insulin, 5–10-minute visits to the toilet, preferably after breakfast and supper, should be encouraged. 
• Surgery is rarely needed.
• Further recommendations:
  • Promote breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding in neonates.
  • Recommend a reward-focused behavior change and the avoidance of chastising the child for their toileting behavior.