So most children with constipation
do not require diagnostic testing.
In most cases, if you do a good physical
exam and take an excellent history,
you can arrive at the diagnosis.
But there may be cases where
you suspect an organic cause.
For example if a patient has other
sequelae of hypothyroidism,
we will want to check to see if
that’s the cause of the constipation.
So examples of some labs we
might get are electrolytes,
thyroid functions, lead levels, lead
toxicity can cause constipation,
or sweat testing.
Again, testing for
You can, if you are concerned or confused
as to whether a child is constipated,
obtain an abdominal
X-ray, but be careful.
Abdominal X-rays have both a false
negative and a false positive rate.
The history is much
better than the X-ray.
In cases where a child is having problem
defecating that are very severe,
we may suspect a problem with the
actual enervation of the rectal tissue.
In this case, a rectal
biopsy may be in order,
in order to look for ganglion
cells within that rectal tissue
to see if this patient has
We may also do things like manometry
where we measure the pressure
when the rectal
sphincter is dilated
and we may do something
like a barium enema
to look at the contour of the
inner surface of the mucosa.
Lastly, we may get
spinal X-rays or MRIs
if we’re concerned for some sort of spinal
abnormality or neurologic impairment.
And I’ve never done this, but one could
certainly do it, which is a colon transit study
for patients who failed to
respond to aggressive treatment
in case you’re wondering whether there’s
some functional problem with the colon.
So how do we treat constipation?
Most of it’s functional.
In infants under one year of age,
we’ll generally start with something
as simple as glycerin suppositories.
Even before that, we might just suggest to
the mother to use the rectal thermometer
to stimulate the rectal area a little bit
and sometimes that’s all that’s
needed to get a kid to go.
On the other hand, we may use
osmotically active carbohydrates.
An example would be prune
juice in a very young child
and that osmotic juice will go
all the way through the colon
and cause fluid to
come into the colon,
thereby loosening up the stool
and improving the problem.
Lastly, you can use osmotic laxatives
like propylene glycol, which
is act in the same way.
In older children, we may do enemas
to relieve that distal obstruction
before we apply a medicine that will
chronically loosen up the stools.
We can also do Bisacodyl
suppositories for these children
to try and get things
going from the backend.
If they’re truly obstructed,
we’re going to do something from the front
end such as oral or NG polyethylene glycol.
NG polyethylene glycol is really what
we reserve for those very severely
constipated children where we simply
can’t clean them out well enough.
These children, we’ll apply an NG tube
and put in remarkably high
rates of polyethylene glycol,
in up to four liters
over several hours.
This acts like Roto-Reuter.
It drives right through
and everything comes out.
And you stop when they’re pooping clear
NG-administered polyethylene glycol.
You can also do a manual disimpaction
and this is sometimes
important for children
where you simply can’t get the
hard stool out the other end.
What’s most important for
constipation, however, is prevention.
One way you can prevent it from ever
starting is encourage breastfeeding.
Babies who are breastfed stool very
frequent and are almost never constipated.
However, in older children, you
would recommend a balanced diet.
Whole grain, fruits and vegetables.
The idea is to optimize the fiber
and that’s a good habit to get into
because lifelong fiber administration
prevents things like colon cancer.
For children who are still having problems,
we will advance to adding osmotic
laxatives like polyethylene glycol
or what we call Miralax powder,
which you can provide to the child.
Because this comes as a
powder and can be easily
admixed with the
beverage of your choice,
children are capable of finding
the dose that works for them.
Too much, they get diarrhea.
Too little, they’re constipated.
Generally, families figure out
what dose is right for that child.
There are stimulants that can help
in the acute setting such as senna,
but we don’t like to use stimulants
regularly because they can become addictive
and that you need your
stimulant in order to stool.
So we don’t typically start with those.
And most importantly, parental education.
Avoid reprimanding and
around the toileting behavior
that they’re having.
We do after we clean the child out with
some NG GoLYTELY or polyethylene glycol,
we will frequently encourage
behavior modification in
children who are old enough
to be using the toilet.
We’ll recommend regular toilet
sitting twice a day for half hour
even if they don’t have to go.
Remember, they may have to go
even though they don’t sense it
because of that dilated rectal vault.
We recommend parents to do stool diaries and
engage in a reward system such as candy,
which will allow the families to
reward children for a job well done.