Constipation

Constipation in Children DR.GOPAKUMAR HARIHARAN

SENIOR REGISTRAR, COMMUNITY PAEDIATRICS

Introduction

Background

Definition

Pathophysiology

Causes

History and physical examination

Investigations

Management

Case scenario – discussion and summary

Background

Common – 0.7% to 30% of children: mild and short-lived to severe and chronic

Common during the introduction of solid foods to the diet, during toilet training, and at school entry.

Significant impact on quality of life

Constipation in first year of life

Healthy infants (<6mo) can strain and cry before passing soft stools (dyschezia) - inability to co-ordinate the increase in intra-abdominal pressure with pelvic floor relaxation - Unless the stools are also hard, this is not constipation and will self-resolve

Breastfed babies pass stools as infrequently as once a week

When constipation presents early in life (<6 weeks), - think organic disease

Most children defecate at least every 2-3 days – Ask consistency

Neonates presenting with constipation – discuss with senior doctor

Definition

( North American Society of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) criteria)

Delay or difficulty in defecation, present for ≥2 wk and sufficient to cause significant distress to the patient

ROME criteria

Organic constipation

Organic constipation results from a documented pathological condition

Anatomical malformations

Abnormal abdominal musculature

Intestinal

Connective tissue disorders

Metabolic or gastrointestinal diseases

Neuropathic disorders

Baker S, Liptak GS, Colletti RB, et al. Constipation in infants and children: evaluation and treatment. J Pediatr Gastroenterol Nutr. 1999;29:612–626

Functional constipation

Functional constipation accounts for the majority of diagnoses ( 95%) and is caused by situational, psychological, developmental, or dietary issues

Behavioral factors - Young children may ignore the urge to defaecate, Negative feelings toward public toilets

Food allergy - milk, egg, and wheat being the most common allergens associated with constipation.

Dietary factors - fluid and dietary fiber intake are contributors in the development of functional constipation

Anal fissures

Painful defecation

Witholding Constipation

Hard stools

Contributing factors

Changes in routine or diet

Stressful events, ie birth of a sibling, parental divorce,

Entering kindergarten and school

Intercurrent illness

Perianal irritation

Drugs: Opiates, anticholinergic, phenobarbitone, vincristine, lead, antispasmodics

Etiology of Constipation

• Hypothyroidism(defective colonic peristalsis)

• Opiates • Hirschsprungs

Defective filling

• Lesions of rectal muscles • Sacral cord afferent and efferent fibres• Abdominal and pelvic muscles• Defective anal sphincter relaxation

Defective emptying

Con

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Pathophysiology

Fecal continence is maintained by Involuntary muscles, Internal anal sphincter and Voluntary muscle contractions in perineum.

The external anal sphincter is under voluntary control

The urge to defecate - triggered when stool comes in lower rectum.

Rectal ampulla- temporary storage

facility

Distension- stimulation of

stretch receptors in the wall

Contraction of rectal muscles

Relaxation of internal anal

sphincter

Signal to brain for defecation –

voluntary signal from brain to

defecate

1) Anorectal angle decreases, almost

straightens2) Relaxation of

external anal sphincter

3) Rectum contracts in peristaltic waves

Defecation

Defecation reflex

Child who doest want to defecate

Tightens the external anal sphincter and squeezes the gluteal muscles –

Longer stay of feces in the rectum- water absorption

pushes feces higher in the rectal vault- reduces urge to defecate

Stools become harder

Withholding manoeuvre- Refusal to sit on the toilet, rise on their toes, cross their legs, scream and turn red. (Parents mistake as an attempt to defecate)

Encopresis/Faecal soiling

Prolonged stool retention and

rectal distention

Loss of rectal sensation

Decreased urge to defecate

Liquid stool proximally percolate

downstream around hard stools

Fecal soiling

Breast feeding versus formula feeding

Breast feeds

• Increased gastrocolic reflex• Increased prebiotic oligosaccharides

Oligosaccharides

• Substrate for gut bacteria • Improved osmotic balance- softer stools• Acts as dietary fibre

Formula

feeds

• Increased Gastric inhibitory polypeptides, motilin, Neurotensin – reduces transit

Complications

Abdominal distension

Recurrent abdominal cramping

Decreased food intake

Vomiting

Urinary incontinence

Urinary tract infections

Anal prolapse, fissures, or hemorrhoids

Low self-esteem, depression

History

Timing of meconium passage – most infants pass meconium in the first 24hrs of life

Straining or Painful/ precipitant

Toilet refusal and withholding behavior

Faecal or urinary incontinence, day or night

Weight loss, vomiting or PR blood loss – suggests possible organic disease

Stool description

Dietary and medication history

Examination

Height and weight – failure to thrive

Abdomen - palpable faeces

Spine – deep sacral cleft or tuft of hair

Neurology - assessment of lower limbs

Anal area – visually examine for fissures

Internal examination not required.

Indian J Pediatr (December 2013) 80(12):1021–1025

Hirschsprungs disease Transition between descending colon and sigmoidReduced caliber of sigmoid and rectum

Investigations

Functional constipation versus Hirschsprungs disease

Medications – Disimpaction and maintenance therapy (Prevent reaccumulation of

faeces)

Dietary management

Education and behavioral management

Close follow up and slow tapering of laxatives

Management

Aim - Titrate medication aiming for one soft, easy to pass bowel action per day.

A common cause of treatment failure - stopping laxatives too early.

Osmotic and lubricant laxatives can be used safely on a long term basis (months to years).

Disimpaction

Disimpaction regimen before maintenance treatment begins.

Oral Disimpaction as an outpatient is preferred

Fecal impaction is defined as ‘a large fecal mass in either the rectum or the abdomen, which is unlikely to be passed on demand

Benninga MA, Candy DCA, Catto-Smith AG, et al. The Paris Consensus on Childhood Constipation Terminology (PACCT) Group. J Pediatr Gastroenterol Nutr 2005;40:273-5

Rectal medications

Rectal treatment with suppositories or enemas should be avoided when possible ( NICE guidelines), unless all oral medications have failed.

Parents should be informed that treatment with an enema may relieve symptoms faster than PEG.

Sedation with N2O or midazolam - strongly considered.

Sodium citrate 5ml enemas (Microlax") can be used. Phosphate enemas ( Proctoclysis) is an alternative

Anal fissures can be treated with topical Petroleum Jelly to provide pain relief.

Bekkali NL, van den Berg MM, Dijkgraaf MGW, et al. Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG. Pediatrics 2009;124:e1108-15

Inpatient management

Macrogol/ electrolyte solutions (Colonlytely™, Glycoprep™) 1-3L/day, via NGT at a rate of 25mL/kg/hr (maximum rate 400mL/hr, or less depending on pump used).

Normal maintenance oral fluids should be given in addition to maintain hydration.

No net fluid input and there is a risk of dehydration

Single dose of prokinetic i.e., 5 to 10 mg of metoclopramide by mouth 15 to 30 min before the lavage can be given to prevent nausea and vomiting.

Diarrhea and abdominal pain - related to its osmotic laxative effect Mugie SM, Di Lorenzo C, Benninga MA. Constipation in childhood. Nat Rev Gastroenterol Hepatol 2011;8:502-11

Maintanance

Polyethylene glycol appears to be a reasonable first choice for maintenance therapy

Approximately 50% of all children with functional constipation recover and are taken off medication within 6 to 12 months, but about one-fourth continues to experience symptoms at adult age

Pijpers MAM, Bongers MEJ, Benninga MA, Berger MY. Functional constipation in children: a systematic review on prognosis and predictive factors. J Pediatr Gastroenterol Nutr 2010;50:256-68 Bongers MEJ, van Wijk MP, Reitsma JB, Benninga MA. Long-term prognosis for childhood constipation: clinical outcomes in adulthood. Pediatrics 2010;126:e156-62

Laxatives

Laxatives Agents

Osmotic Lactulose PEG

Stimulant Bisacodyl Senna

Stool softner Liquid paraffinColoxyl drops

Options- oral laxatives

Children: Stool softener (paraffin oil) or iso-osmotic laxative (Movicol™ or Osmolax™)

Infants 6-12mo: Coloxyl™ drops or Lactulose

Infants <6months: Coloxyl™ drops

Osmotic laxatives

Luminal accumulation of

osmotically active substances

Increased intestinal fluid

Increased peristalsis

Softening of stools

Lactulose

Osmotic gradient- increased

intraluminal fluid – colonic

peristalsis

Fermented by bacterial

enzymes to lower molecular weight

acids

Lactulose and lactitol – Synthetic

disaccharides not hydrolysed by enzymes in the small intestine

Common side effects – bloating, obdominal pain and flatulenceIntraluminal fermentation of the laxative, which results in the production of gas.

Liquid paraffin

Polyethylene Glycol

Polymer which is not metabolized and minimally absorbed in the intestine and, thus, creates an osmotic gradient in the lumen of the colon

Chaussade S, Minic M. Comparison of efficacy and safety of two doses of two different polyethylene glycol-based laxatives in the treatment of constipation. Aliment Pharmacol Ther 2003;17:165-72

PEG is superior to lactulose for the outcomes of stool frequency per week, form of stool, relief of abdominal pain and the need for additional products Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev. 2010;7:CD007570

Coloxyl

Sodium Picosulphate

Stimulant laxatives are a group of laxatives that promote colonic peristalsis and secretion, through stimulation of the enteric nervous system

Tack J. Current and future therapies for chronic constipation. Best Pract Res Clin Gastroenterol 2011;25:151-8

Fibre intake and Diet

A report from 1995 suggested using the rule “age + 5” rule to determine fiber intake

An upper limit of “age + 10” grams of fiber per day may be safe to consume, as this would be consistent with other recommendations of 10–12 g dietary fiber per 1,000 kcal.

Williams CL. Importance of dietary fiber in childhood. J Am Diet Assoc. 1995;95:1140–1146, 1149; quiz 1147–1148.

Excess fibre- reduced nutrients- reduction inweight

Avoid excessive cows milk intake

Encourage plenty of water

Behaviour modifications

Position – footstool to ensure knees are higher than hips. Lean forward and put elbows on knees.

A toilet ring should be placed over the toilet seat if needed.

Toilet sits –5 minutes three times a day, preferably after meals. A timer in the bathroom can help. Encourage child to bulge out their abdomen. Praise child for sitting on toilet, keep toileting a positive experience.

Chart or diary – to reinforce positive behaviour and record frequency of bowel actions. 

Delay toilet training attempts until child is painlessly passing soft stool. 

Follow up

GP, or with a General Paediatrician

Refer to Continence Clinic or Encopresis Clinic for faecal/urinary incontinence, suspected organic cause, complex or difficult cases.

Maintain initial “correct dose” for minimum of 3–4 mo and thereafter attempt gradual tapering.

Children with a long-standing history of constipation should be without any complaints for at least 2 months, before laxatives may be tapered gradually

Follow up at 2 wk after disimpaction and then monthly till regular bowel movement is achieved.

Check stool frequency and compliance to drug and toilet training.

Therapy is required for long duration, 6 mo to 1 y in majority 

Severe refractory constipation

Sacral neuromodulation

Surgical interventions - creation of a cecostomy for antegrade enemas.

Mugie SM, Di Lorenzo C, Benninga MA. Constipation in childhood. Nat Rev Gastroenterol Hepatol 2011;8:502-11

Summary

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