Functional Constipation in Children

Juan C. Gregory, MD Pediatric Gastroenterologist, Gastroenterology Consultants

Assistant Professor of Pediatrics University of Nevada Reno

School of Medicine

No Financial Relationships with Any Commercial Entity to Disclose

OBJECTIVES

• Defining functional constipation in children

• Discuss the events leading to constipation

• Discuss the evaluation of the child with functional constipation

• Discuss the management of the child with functional constipation

• Discuss the prognosis of functional constipation

Functional Constipation in Children

• Incidence• 3% worldwide prevalence

• In 17% to 40% constipation begins in the 1st year of life

• Constitutes 25% - 30% of referrals to Pediatric Gastroenterologist

Functional Constipation in Children

• Definition: Rome III criteria• < 4 years of age• > 4 years of age

• Requires 2 or more • 2 or less stools per week• 1 episode of incontinence per week• Hard or painful stools• Large fecal mass in the rectum• Large diameter stools clogging the toilet• Retentive posturing or • Volitional retention

Mechanism of Fecal Continence

Distention of rectum by stool

Internal anal sphincter relaxes and stool enters anal canalInternal anal sphincter returns to baseline

Sensation of stool in anal canal and sensation of rectal distention

Contraction of external anal sphincter and puborectalis and rectal accommodation

Continence

Diagnosis

• History and physical exam are usually sufficient • Starts a few weeks to months of life (not at birth)• Often there are precipitating factors

• Fissure• Change of diet• Illness• Medications• Travel• Social Changes – changing homes, starting school, major family

changes• Fears and phobias

• Normal passage of meconium (> 90% 72 hours of life)

Diagnosis

• Alarming signs and symptoms that do not support the diagnosis of functional constipation

• Constipation beginning less than 1 month of age

• Family history of Hirschsprung’s Disease

• Ribbon stools

• Blood in the stool without fissures

• Failure to thrive

• Fever

• Bilious Emesis

• Abnormal Thyroid

Diagnosis cont…

• Alarming signs and symptoms that do not support the diagnosis of functional constipation

• Perianal Fistula

• Abnormal anal position (anogenital index)

• Absent anal or cremasteric reflex

• Decreased lower extremity strength/tone/reflex

• Tuft of hair or spine

• Gluteal cleft deviation

• Extreme fear during anal inspection

• Anal Scars

Differential Diagnoses of Constipation in Infants/Toddlers and Children/Adolescents

Diagnosis cont…

• Evidence does not support

– Rectal exam

– Abdominal Radiography – KUB

– Colon Transit Study

– MRI

– Colon Scintigraphy

– Transabdominal Ultrasound

– Rectal Biopsy

Diagnosis cont…

• Expert opinion does not recommend

– Anorectal Manometry

– Barium Enema

– Routine Laboratory Testing

• Hypothyroidism

• Celiac Disease

• Hypercalcemia

• Cows Milk Allergy

Treatment

• Disimpaction– PEG and Enemas are equally effective

• Maintenance Therapy– EVIDENCE shows PEG is more effective than

lactulose, MOM or mineral oil

– Lactulose is recommended if PEG is not available

– MOM or Mineral Oil can be used in addition to PEG or as second line of treatment

– Enemas are not recommended

Treatment cont…

• Expert opinion recommends

– Treatment be continued for at least 2 months

– Symptoms should be resolved for 1 month before medication be discontinued

– Treatment should be gradually decreased

– Treatment should only be stopped once toilet training is achieved

Treatment cont…

• Transcutaneous Nerve Stimulators – Evidence does not support its use

• No data for the use of

– Lubiprostone

– Linaclotide

– Prucalopride

• Surgery – Antegrade Enemas

– No randomized studies

Treatment cont…

• Evidence does not support the use of – Pre- or Probiotics– Behavioral or Biofeedback Therapy– Extra-fluid intake– Fiber supplements

• No randomized control trials found for– Multidisciplinary treatment

• Pediatrician, Pediatric Gastroenterologist, Dietitian, Psychologist, PT

– Alternative Medicine• Acupuncture, Homeopathy, Musculoskeletal Manipulation, Mind-

Body Therapy

Prognosis cont…

• Among Pediatric Gastroenterologists

– 50% recover without laxatives at 6 to 12 months

– 40% will still be symptomatic despite laxative use

– 50-80% will recover after 5 to 10 years with the vast majority not taking laxatives

– Delay in initial treatment (> 3 months) correlates with longer duration of symptoms

Treatment - Prognosis

• Recovery is correlated to how early treamentis started (< or > 3 months, 80% vs 32%)

• Looking at General Pediatrics, Primary Care, Tertiary Care settings

– 50 to 60% recover at 1 year of intensive treatment

– 50% recovery rate at 5 years

– 50% of patients relapse within the first five years after recovery

Prognostic Factor

• There is no, limited or insufficient evidence that these factors are related to prognosis – Demographics

• Sex, age of presentation, age of onset, duration of symptoms• Passage of meconium• Family history

– Clinical Symptoms• Frequency of defecation, fecal incontinence, large stools• Abdominal pain• Withholding behavior• UTI or urinary incontinence

– Physical Exam• Absence of an abdominal or rectal mass

Functional Constipation Summary

1. Diagnosis is based on the Rome III Criteria

2. History and physical examination are sufficient to make the diagnosis

3. In the presence of alarming signs or symptoms, a digital examination of anorectum is recommended

4. Routine use of abdominal radiograph has no role in the diagnosis

5. Colon transit studies, Barium enema, Rectal ultrasound and MRI are not recommended

6. Routine laboratory testing is not recommended

7. Rectal biopsy is not recommended

8. Routine use of Pre- or Probiotics are not recommended

9. Intensive behavioral protocolized and biofeedback are not recommended

Functional Constipation Summary cont…

10. PEG is recommended for use in disimpaction and as maintenance therapy;1st line

11. If PEG is not available- Enemas can be used for disimpacton- Lactulose can be used for maintenance treatment

12. Chronic use of Enemas is not recommended

13. Milk of Magnesia, Mineral oil and stimulant laxatives may be considered as additional or second line treatment

14. Maintenance treatment for at least 2 months and for at least 1 month after symptoms have resolved

15. Maintenance treatment should not be stopped until toilet training is complete

Dosages of Most Frequently Used Oral and Rectal Laxatives

Algorithm for the Evaluation and Treatment of Infants > 6 Months of Age

ACE = antegrade continence enema; MRI = magnetic resonance imaging; SNS= sacral nerve stimulation; TENS= transcutaneous electric nerve stimulation; TSH= thyroid stimulating hormone

Key Points of History and Physical Examination to Guide in the Evaluation of Constipation in Infants/Toddlers and Children/Adolescents