Chronic Constipation in children

Chronic constipation in children Anshu Srivastava Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India

2 yr 2 yr 3 yr SGPGI Constipation 3 yr boy Stool freq 1/day Once in 7-8 days Stool: hard, large size Painful defecation Withholding manoeuvre No blood with stool Milk intake: 1 liter/ day No h/o enterocolitis: abdominal distension, fever, loose stools No h/o drug intake Passed stool on day 1 of life Normal growth Developmentally normal Lactulose Enemas Modified diet Soiling

Anthropometry Height : 87.5cm Weight : 12 kg OFC : 47cm Age Appropriate No pallor, edema

Examination Per abdomen: Not distended Fecoliths palpable in left iliac fossa Inspection of anal area: Normal position No perianal tags Anal wink present. No anal fissure Soiling of undergarments present Per rectal: Normal anal sphincter tone Hard stool present in the rectum No gush of air after removing the finger No blood

Examination CVS and RS: NAD CNS: Normal muscle tone Power: 4/5 DTRs Normal Planters reflexes- Flexor response Gait: Normal Sensations: Touch and pain present Good urinary stream Back and spine: Normal

Functional Constipation with soiling Onset After 1 yr of age Fecoliths, Withholding maneuver Normal Growth No Enterocolitis Possibility

Clarity of terminology Fecal incontinence Organic Functional Constipation associated Fecal impaction Large fecal mass Rectum Abdomen

Red flags on history Age of onset 48hr) Failure to thrive Absence of withholding Absence of soiling Bladder dysfunction Extra-intestinal symptoms No response to conventional therapy ? PCNA 2002;49:27-51

Red flags on examination FTT Abdominal distension Pilonidal sinus Midline pigmentary abnormalities Patulous anus, anteriorly placed anus Empty rectum Gush of liquid stool & air from rectum after finger withdrawal Absent anal wink, cremastric reflex Lower limb weakness

Investigations Bil Conj Protein Albumin AST ALT SAP Jan 2010 1.3 0.2 7.8 4.2 54 42 134 Hb TLC DLC Platelets PF Jan 2010 11.1 11400 60/36/4 323000 NCNC Thyroid function tests (from elsewhere) Normal Barium enema (done elsewhere)- Megacolon Not s/o Hirschsprungs disease

Algorithm for evaluation Constipation Red flags on evaluation Functional constipation Assess fecal impaction Disimpact Investigate and manage No No Yes yes Dietary advise Toilet training Maintenance Laxative therapy Follow up - response and compliance - dose titration - recurrence of impaction

Clear Fecal Retention Prevent Future Retention Promote Regular Bowel Habit Management-treatment plan

Management contd. Clearance of fecal retention: Dis-impaction of stools Admitted Polyethylene glycol (PEG) with electrolytes: 20ml/kg/hr till disimpaction achieved End point of disimpaction: Passage of clear fluid of nearly same color and consistency as being used for disimpaction

Management contd. Counseling of parents: Acquired disorder and curable Toilet training: Diet chart: high fiber diet Maintenance: Laxative Polyethylene glycol (Dose: 1g/kg/day) sachet (12 g)/ day

Dietary advise Preferred food Whole grains Whole pulses/beans Green leafy vegetables, beans Fruits-guava, pomengranate, dates, amla, apple with peel Avoid X Refined wheat flour Arhar, dhuli moong Predominant milk diet Banana, papaya, mango Ideal fiber intake- age in years + 5 g Healthy nutritious diet with adequate fluid intake Some benefit that fibre is better than placebo Ped 2011;128:753

Diet chart: High Fiber Diet - , , , , I ( ) / ( ) I , , , , , I

Drug Dosage Side effects Bisacodyl 6y-1-2 oral tablets (5 mg) Abdo pain, diarrhea. Senna 2-4y:3.75-15mg/d 4-6y: 3.75-30mg/d 6-18y: 7.5-30mg/day Abdo pain Skin rash and fixed drug eruption rare Sodium picosulfate

Chronic Constipation in children

Health & Medicine

response

rectum

air