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1. Assessment and management of pediatric constipation in primary care..................................................... 1

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Document 1 of 1 Assessment and management of pediatric constipation in primary care Author: Coughlin, Elizabeth C Publication info: Pediatric Nursing 29. 4 (Jul/Aug 2003): 296-301.ProQuest document link Abstract: Assessment and management of pediatric constipation is a challenging problem frequently faced byprimary care practitioners. The purpose of this article is to offer a review of the literature including the definitionof pediatric constipation and the presentation, etiology, and management of this common childhood disorder.Education and anticipatory guidance with children and their families should be included in the treatment regimento prevent recurrences and promote health maintenance. [PUBLICATION ABSTRACT] Full text: Headnote Assessment and management of pediatric constipation is a challenging problem frequentlyfaced by primary care practitioners. The purpose of this article is to offer a review of the literature including thedefinition of pediatric constipation and the presentation, etiology, and management of this common childhooddisorder. Education and anticipatory guidance with children and their families should be included in thetreatment regimen to prevent recurrences and promote health maintenance. Constipation is a frequentcomplaint encountered by those in pediatric primary care, accounting for roughly 3% of outpatient visits and onequarter of all pediatric gastroenterology referrals (Baker et al., 1999). Assessment and management of pediatricconstipation poses many challenges for the practitioner including deciphering whether the problem is organic ornon-organic in nature; determining appropriate pharmacological, dietary, and behavioral treatment; andeducating parents as to what constitutes and may precipitate constipation. By offering education andanticipatory guidance as well as interventions tailored to the needs of the family, nurse practitioners in pediatricprimary care settings are in a position to make significant contributions to the prevention and successfulmanagement of constipation in children. Definition A review of the literature indicates there is disagreement overthe definition of constipation. Rogers (1997) outlines constipation as "the difficulty or delay in the passage ofstools, without necessarily implying that the stools are hard" (p. 40). Lewis and Muir (1996) add that thisdifficulty or delay causes distress to the child. Castiglia (2001) states that constipation refers to the lack of fullevacuation of the lower bowel, while Abel (2001) defines it as "an alteration in the frequency and consistency ofthe individual's usual pattern of defecation" (p. 211). Still others delineate the definition by time, such as "fewerthan three stools per week" (Young, 1996, p. 88), or "delay in defecation, present for two or more weeks" (Bakeret al., 1999, p. 2). Thus, it comes as no surprise that parents are often unclear as to what constipation actuallyis and when they should begin to be concerned about the lack of passage of stool in their children.Compounding the confusion is the differences in stooling patterns among breastfed versus bottle-fed infants.Breastfed infants can have bowel movements as frequently as with every feeding or as rarely as one everyseveral days. Bottle-fed infants may be more prone to hard stools because of the differences in fat digestionand absorption between breast milk and formula (Thompson, 2001). In general, infants have roughly four stoolsper day during the first 7 days, decreasing to one to two stools per day by 2 years of age and then to one stoolper day on average by 4 years of age (Baker et al., 1999). Educating parents on the breadth of normal stoolingpatterns, therefore, is an important first step in preventing complaints of constipation in the primary care setting.Assessment and Presentation History. As with all pediatric complaints, assessment of constipation begins withtaking a careful and detailed history. Parents should be asked about any medications the child is taking; theonset of symptoms; frequency, size, and consistency of the child's stool; presence of blood in the stool; andpreviously attempted treatments. Time after birth of passage of meconium, age of and techniques employed intoilet training (if applicable), and the presence of daytime or nighttime soiling or defecation in inappropriateplaces should also be ascertained. The child's dietary history, exercise patterns, behavioral history, and family

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history of bowel problems should be included as well as the parental definition of constipation and parentalresponse to the current problem (Pyles &Gray, 1997). This latter information is particularly useful in assessingthe parents' knowledge base and in formulating appropriate interventions. Signs and symptoms. The signs andsymptoms of constipation may vary depending on the age of the child. Infants may present with "grunting babysyndrome" in which straining, turning red in the face, grimacing, and even crying are manifestations (Rogers,1997). This display of effort is generally rewarded by a stool of normal volume and consistency. In toddlers,passage of stool, particularly hard stool, may be painful or result in small tears in the anal canal resulting inpain, thus causing the child to withhold the stool out of fear or avoidance of pain. This then results in a viciouscycle of pain, withholding stool, and even impaction as the longer the child resists having a bowel movement,the harder and more painful it becomes for him or her to do so (Castiglia, 2001). Parents may report the childactively resisting the urge to defecate by rocking back and forth on his or her toes, squeezing buttocks together,clenching fists, and fidgeting (Baker et al., 1999). Stool withholding can lead to retentive fecal soiling, alsoknown as encopresis. Encopresis occurs when watery stool passes by hard fecal content in the lower rectumresulting in recurrent soiling and is often confused with diarrhea. Other commonly reported symptoms include achange in normal bowel routine; passage of hard, dry, rock-like stools; blood in the stool; abdominal pain;distention or cramping, a feeling of fullness leading to decreased appetite and nausea; and a sense ofincomplete emptying of the colon (Abel, 2001). Physical examination findings. On examination, hyperactivebowel sounds may be auscultated (Creason &Sparks, 2000) and a sausage-shaped abdominal mass may bepalpated in the descending colon or even as far back as the transverse or ascending colon. The anus may showevidence of tearing or scarring. The presence or absence of the anal wink reflex should also be assessed, asthis will evaluate the ability of the anal sphincter to contract. A digital rectal exam offers the practitionerinformation regarding anal tone, length of the anal canal, dilatation of the rectum, and the presence andconsistency of fecal matter that might indicate impaction (Loening- Baucke, 1997). A test for occult blood maybe done on feces obtained at this time (Baker et al., 1999). Etiology and Differential Diagnoses Organic causesof constipation. The causes of pediatric constipation can be divided into two categories: organic or functional,also known as idiopathic. Organic causes account for only 5% of the cases of constipation in children andinclude anatomic, neuromuscular, metabolic, or endocrine causes of constipation (Castiglia, 2001). Perhaps themost well-documented and common etiology resulting in constipation in infants is Hirschsprung's disease(aganglionic megacolon). Hirschsprung's is an anatomic and neuromuscular abnormality that results in asegment of anus or rectosigmoid colon lacking ganglia in the myenteric and submucosal plexuses. This resultsin a lack of parasympathetic innervation, causing an inhibition of relaxation of that portion of the colon (Castiglia,2001). Dilatation of the proximal segment to the affected colon ensues. Constipation, vomiting, diarrhea,abdominal distention, failure to thrive, failure to pass meconium, absence of encopresis, and an empty analcanal upon examination are common manifestations of the condition (Castiglia, 2001). Other anatomic andneuromuscular organic causes of constipation that must be included in differential diagnosis are anal stenosis,anal atresia, anal fissures, presence of a pelvic mass, bowel obstruction, rectal prolapse, spinal cord disorders(including meningomyelocele), cerebral palsy, and muscular dystrophy (Abel, 2001; Kuhn, Marcus, &Pitner,1999; Loening-Baucke, 1997; Pyles &Gray, 1997). Possible metabolic and endocrine abnormalities includehypothyroidism, hypokalemia, hypercalcemia, and lead intoxication (Abel, 2001; Kuhn et al., 1999). Irritablebowel syndrome (IBS), another common cause of constipation, is generally diagnosed by exclusion. Heitkemperand Jarrett (2001) state that 65% of children diagnosed with recurrent abdominal pain qualify under the adultcriteria for IBS, yet fail to be diagnosed with this condition. Malnutrition, restricted dietary regimens, anddehydration can also result in constipation and must be planned for in the overall management plan for thesechildren. Non-organic causes of constipation. Non-organic or functional constipation, which accounts for amajority (95%) of cases of constipation in children (Loening-Baucke, 1997), has varied etiology. Commoncauses are linked to food, lack of exercise, and behavioral or psychological problems. Changes in diet habits or

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routines may precipitate constipation. For example, many parents report that a switch from breast milk toformula or a switch between formulas can precipitate bouts of constipation. Iron-fortified formula is often thoughtby caretakers to cause constipation in infants, however, this has not been shown by controlled research studiesto be a cause of constipation (Castiglia, 2001). While Castiglia cites that "insufficient data exist to supportroutine screening for cow's milk allergy as a cause of constipation" (p. 201), a double- blind, crossover study bylacono et al. (1998) comparing the use of soy milk versus cow's milk in children with chronic constipation foundthat 68% of the-children studied had improved bowel habits with soy milk. Roughly two thirds of those studiedshowed constipation to be a symptom of intolerance to cow's milk (Iacono et al., 1998). Lack of dietary fiber haslong been associated with constipation. The American Health Foundation recommends the daily fiber intake forchildren to be equal to the age of the child in grams plus five additional grams (i.e., a 5-year-old child should eat10 grams of fiber each day). A study by Hampl, Betts, and Benes (1998) found, however, that only 45% of 4- to6-year-olds and 32% of 7- to 10-year-olds consumed this amount of fiber on a regular basis. An additionalconcerning trend affecting constipation among today's young people is lack of exercise. Children's daily routinesare becoming increasingly sedentary with television viewing and "screen time" on computers or video gamestaking the place of outdoor activity. Lack of regular exercise at home is compounded by decreasing physicalactivity time in schools. Sedentary behavior, such as watching television, in addition to decreasinggastrointestinal motility and weakening abdominal muscles used in defecation decreases the time in a child'sday for physical activity and is often accompanied by consumption of high fat, low fiber foods (MacKenzie,2000). The combination of poor diet and lack of exercise then sets the stage for constipation to occur.Psychosocial and behavioral factors are often the source of constipation in children. Inappropriate toilet trainingpractices involving children too young neurologically or cognitively to understand and act on the request todefecate in a toilet, or overly demanding parents who do not have appropriate expectations of their child's abilityto be toilet trained, can lead to constipation (Kuhn et al., 1999). Caretakers can be impatient and intolerant ofaccidental soiling resulting in the child becoming fearful, anxious, and insecure (Young, 1996). Lack ofeducation on normal bowel patterns and unrealistic expectations of the child's ability to be toilet trained maylead parents to be inappropriately harsh, occasionally even abusive, with their children regarding stooling.Patterns of withholding stool, which may lead to impaction or encopresis, may emerge if children are afraid ofbeing punished for defecating. Fear of pain, as mentioned earlier, or embarassment or fear about using toiletsoutside of home, such as at school or in a store, may lead to withholding and suppressing the urge to defecate.Some children may fear plugging the toilet with a large stool, especially if this has previously happened andresulted in embarrassment or punishment. Magical thinking in toddlers can also lead to fearful reactions;children may see advertisements on television with germs and monsters climbing out of the toilet or personifytheir stool and be afraid of drowning the stool (Rogers, 1997). The disappearance of stool and the loud soundand rush of water can frighten children who may be afraid that they may be hurt by the toilet. Young children,too, may simply be too busy exploring their world to recognize the urge to defecate and go to the bathroom tohave a bowel movement.

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Management Because of the multi-dimensional etiology of constipation, a multi-faceted approach to treatmentseems most appropriate and effective. Since the vast majority of cases of constipation are functional in origin,treatment discussed will assume a non-organic etiology. The intervention plan for functional constipationincludes medication, behavioral modification, bowel retraining, and education. The North American Society forPediatric Gastroenterology and Nutrition position statement on constipation in infants and children (Baker et al.,1999) recommends an intervention algorithm that begins with treating fecal impaction if present (see Figure 1),followed by education, diet modification, medications, and follow-up. Levy (2001) suggests a similar stepwiseapproach beginning with disimpaction followed by maintenance of a clean colon, establishment of moreeffective toileting patterns, and improvement in family and social interactions. The goal of treatment is completeevacuation of the lower bowel on a daily, or near-daily, basis by the easy passage of soft stools. Treatment toregain muscle tone of the anal canal may be required for 2-6 months (Castiglia, 2001), and maintenancetherapy may be needed for up to 2 years (Thompson, 2001). Offering support to parents throughout this timeperiod is essential, as there is no easy or definitive cure, and frustrating relapses can occur (Pyles &Gray,1997).

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Medication. In the event that fecal impaction is present, initial treatment is aimed at evacuation of bowelcontents either by oral or rectal medications. High doses of mineral oil and polyethylene glycol (PEG, MiraLax)electrolyte solutions are commonly used oral means, while phosphate soda, saline, or mineral oil enemas canbe used rectally (Baker et al., 1999). The use of enemas, however, should be avoided if possible (Rogers,1997) since they are likely to cause more discomfort than oral means. In extreme cases, large volumes of bowelcleansing agents such as GoLytely(R) can be administered in the hospital, but treatment at home with mildersubstances is preferred. Once disimpaction has been accomplished, maintenance therapy can begin. A widevariety of laxatives are used, generally in incrementally decreasing dosages (see Table 1). Asking parents tokeep a diary of bowel movement frequency, consistency, and amount can assist the practitioner in adjustingdosages of medications (Lewis &Muir, 1996). Effective medications available include lubricants such as mineraloil; osmotic laxatives such as lactulose, sorbitol, or PEG; and magnesium hydroxide. Stimulant laxatives suchas senna (Senokot(R), Ex-lax(R), Fletcher's Castoria(R)) and bisacodyl (Ducolax(R)) may be neededintermittently as rescue therapy to prevent recurrence of impaction but should be avoided for long-term, dailyuse (Baker et al., 1999). Use of mineral oil carries with it some danger of aspiration and should be avoided inchildren who resist taking it or who have dysphagia or vomiting. It has not been documented to interfere withabsorption of fat-soluble vitamins (Levy, 2001). Several studies have been done comparing the effectiveness ofdifferent types of laxatives in the management of chronic constipation in children. Gremse, Hixon, andCrutchfield (2002) performed an unblinded, randomized study comparing PEG to lactulose. They found thatthere were no significant differences in stool frequency, form, and ease of passage between the twomedications but that PEG significantly decreased the total colonic transit time compared to lactulose. Parentsand caregivers cited PEG as effective in 84% of the children and lactulose as effective in only 46%. PEG overallwas the laxative of choice not only for effectiveness but also for ease of administration and tolerability. In

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another study, Pashankar and Bishop (2001) also examined the efficacy of PEG as well as the optimal dosing inchildren. They found that all 20 participants in the study had improved bowel habits with PEG on a mean doseof 0.84 g/kg/d. Beginning on high doses and adjusting accordingly to achieve desired number and consistencyof bowel movements was recommended. Side effects were limited to transient diarrhea and flatulence asdosages were adjusted, unlike lactulose, PEG was found not to cause persistent gas, abdominal pain, orperianal irritation. Cisapride (Propulsid(R)), a prokinetic agent that increases colonie propulsion, has also beentested as a treatment for constipation in children. Nurko, Garcia-Aranda, Worona, and Zlochisky (2000)performed a double-blind, placebo controlled study over a 2-year period in Mexico. Cisapride was found toimprove the number of soft bowel movements achieved by the study participants, but the response was notimmediate. This led the investigators to suggest that it not be used as first-line treatment for constipation inchildren but rather as an option when other laxatives and interventions have failed. Diet. To supplement theeffects of treatment with laxatives, changes in diet are recommended. Because a decrease in appetite issometimes associated with constipation, though, this can prove to be a challenge to parents. It has long beenthought that increasing fluids and fiber in the diet aid passage of stool, however the literature is mixed on thisissue. Thompson (2001) suggests that fiber does not play a beneficial role in the management of constipation,citing that its role in alleviating constipation has been "overemphasized" (p. 29). Baker et al. (1999) found "norandomized controlled studies that demonstrated a proven effect on stools of increasing intake of fluids, non-absorbable carbohydrates or dietary fiber in children" (p. 7). Nonetheless, many authors continue to recommenddiets that include increased fluids and soluble fiber and that are low in sugar, fat, starch, and insoluble fiber(Abel, 2001; Levy, 2001; Pyles &Gray, 1997; Young, 1996). Including carbohydrates, particularly sorbitol foundin some fruit juices, is reported to be helpful (Baker, 1999) though high osmolarity liquids such as Karo(R) syruphave not been proven effective (Young, 1996). Behavioral modification. Another controversial area is theeffectiveness of biofeedback as a treatment option for constipation. Biofeedback operates by making the childmore aware of bodily functions, such as rectal sensitivity to distention, that then "helps alter physiologicalresponses through behavioral modification techniques" (Pyles &Gray, 1997, p. 73). Loening- Bauke (1997) saysthis type of training can be attempted but the effectiveness of it "has not been well established" (p. 2234). Itappears that for severe cases of constipation and those leading to encopresis, biofeedback may be an effectivemanagement technique (Baker et al.; Pyles &Gray; Vitito, 1999). In addition to the use of medications andchanges in diet, behavioral modification and parental education are effective interventions in establishingtoileting patterns. Encouraging regular toilet use to normalize the behavior and facilitate positive associationswith toileting is effective. Colonic stimulation is greatest 10-15 minutes after eating, thus this can be anopportune time to encourage sitting on the toilet for intervals of 10 minutes or so. The child should becomfortable and relaxed; a footstool can help facilitate proper positioning for a bowel movement (Loening-Bauke, 1997; Vitito, 1999). Systems of positive reinforcement can be employed for successful use of the toiletsuch as stickers on calendars or charts, special activities, and praise (Kuhn et al., 1999; Loening-Bauke, 1997;Pyles &Gray, 1997; Vitito, 1999). Since the process of constipation management can be lengthy, the focusshould remain on continuing improvement, not on complete resolution (Vitito, 1999). Successful treatment iscontingent on patience and time-consuming interventions on the part of the family. Continual support throughclose follow- up is, therefore, essential (Baker et al., 1999). Education. Pediatric nurses and pediatric nursepractitioners can perhaps be most effective at intervening through education. Educating parents about normalstooling patterns, appropriate toilet training practices, and supportive management if problems do arise canprevent or minimize the number and extent of episodes of constipation a child may have. If anticipatoryguidance is offered, which enables parents to recognize the early signs of constipation, potentially moredeleterious conditions such as impaction and encopresis may be avoided. During well-child visits, continualreview of feeding and stooling patterns; dietary habits, including transitions between breast-milk, formulas, andsolid foods; and exercise/activity patterns can prevent problems that might lead to constipation. Kuhn, Marcus,

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and Pitner (1999) suggest using the 15- or 18- month well-child visit to discuss plans for toilet training and makesure that parents understand the importance of developmental readiness of the child. If constipation does occur,continual validation of parental concern, reinforcement of efforts being made, and a review of symptommanagement and the treatment plan can contribute to a successful outcome for the child (Abel, 2001). Ifencopresis is involved, teaching parents that soiling is outside the child's control can help alleviate some of theanger and frustration that may ensue. Scheduling follow-up visits every 3-4 weeks, as well as making periodictelephone calls provides excellent opportunities to ascertain management success and provide additionalinformation and support to families. Conclusion Constipation in the pediatric population is a commonlyencountered problem in primary care settings. Because resolution of the problem can be lengthy and taxing forfamilies, careful assessment of the situation must be made. Treatment plans must be tailored to meet thefamily's particular environmental and psychosocial situation, and continual support and follow-up are essential.Pediatric nurses can provide anticipatory guidance and education that may lead to better prevention of theproblem and overall health promotion. Sidebar The Primary Care Approaches section focuses on physical anddevelopmental assessment and other topics specific to children and their families. If you are interested in authorguidelines and/or assistance, contact Patricia L. Jackson Allen at Pat.Jackson@nursing.ucsf.edu References References Abel, E. (2001). Managing constipation in a pediatric patient: It is more than a simple problem.Clinical Excellence for Nurse Practitioners, 5(4), 211-217. Baker, S.S., Liptak, G.S., Colletti, R.B., Croffie, J.M.,DiLorenzo, C., Ector, W., et al. (1999). Constipation in infants and children: Evaluation and treatment. Medicalposition statement of the North American Society for Pediatric Gastroenterology and Nutrition. RetrievedNovember 19, 2002, from www.naspgn.org Castiglia, P. (2001). Constipation in children. Journal of PediatricHealth Care, 15(4), 200-202. Creason, N., &Sparks, D. (2000). Fecal impaction: A review. Nursing Diagnosis,11(1), 17-22. Gremse, D., Hixon, J., &Crutchfield, A. (2002). Comparison of polyethlene glycol 3350 andlactulose for treatment of chronic constipation in children. Clinical Pediatrics, 41(4), 225-229. Hampl, J., Betts,N., &Benes, B. (1998). The "Age +5" rule: Comparisons of dietary fiber intake among 4- to 10- year-old children.Journal of the American Dietetic Association, 98(12), 1418- 1422. Heitkemper, M., &Jarrett, M. (2001). It's notall in your head: Irritable bowel syndrome. American Journal of Nursing, 101(1), 26-32. Iacono, G., Cavataio, F.,Montalto, G., Florena, A., Tumminello, M., Soresi, M., et al. (1998). Intolerance of cow's milk and chronicconstipation in children. The New England Journal of Medicine, 339(16), 1100-1104. Kuhn, B., Marcus, B.,&Pitner, S. (1999). Treatment guidelines for primary nonretentive encopresis and stool toileting refusal.American Family Physician, 59(8), 2171-2177. Levy, J. (2001). Fecal soiling (Encopresis). Retrieved November19, 2002, from www.naspgn.org/sub/Encopresis.htm Lewis, C., &Muir, J. (1996). A collaborative approach inthe management of childhood constipation. Health Visitor, 69(10), 424-426. Loening-Baucke, V. (1997). Fecalincontinence in children. American Family Physician, 55(6), 2229-2235. MacKenzie, N.R. (2000). Childhoodobesity: Strategies for prevention. Pediatric Nursing, 26(5), 527-530. Nurko, S., Garcia-Aranda, J., Worona, L.,&Zlochisky, O. (2000). Cisapride for the treatment of constipation in children: A double-blind study. The Journalof Pediatrics, 136(1), 35-40. Pashankar, D.S., &Bishop, W.P. (2001). Efficacy and optimal dose of dailypolyethylene glycol 3350 for treatment of constipation and encopresis in children. The Journal of Pediatrics,139(3), 428-432. Pyles, C., &Gray, J. (1997). Encopresis: An algorithmic approach. Physician Assistant, 21(7),56, 58, 60-62, 67-68, 70-74. Rogers, J. (1997). Childhood constipation and the incidence of hospitalisation.Nursing Standard, 12(8), 40-42. Thompson, J. (2001). The management of chronic constipation in children.Community Practitioner, 74(1), 29-30. Vitito, L. (1999). Self-care interventions for the school-aged child withencopresis. Gastroenterology Nursing, 23(2), 73-76. Young, R. (1996). Pediatric constipation. GastroenterologyNursing, 19(3), 88-93. AuthorAffiliation Elizabeth C. Coughlin, RN, MSN, is a Student, Boston College, ConnellSchool of Nursing, Brighton, MA. Subject: Pediatrics; Children & youth; Digestive system; Excretory system; Primary care

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MeSH: Algorithms, Constipation -- etiology, Diagnosis, Differential, Humans, Constipation -- diagnosis (major),Constipation -- therapy (major), Pediatrics (major), Primary Health Care (major) Publication title: Pediatric Nursing Volume: 29 Issue: 4 Pages: 296-301 Publication year: 2003 Publication date: Jul/Aug 2003 Year: 2003 Section: Primary care approaches Publisher: Anthony J. Jannetti, Inc. Place of publication: Pitman Country of publication: United States Publication subject: Medical Sciences, Medical Sciences--Nurses And Nursing ISSN: 00979805 Source type: Scholarly Journals Language of publication: English Document type: Journal Article Accession number: 12956550 ProQuest document ID: 199423453 Document URL: http://search.proquest.com/docview/199423453?accountid=33171 Copyright: Copyright Anthony J. Jannetti, Inc. Jul/Aug 2003 Last updated: 2013-02-06 Database: ProQuest Medical Library

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