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Childhood ConstipationChildhood Constipation

Prof. Dr. Saad S Al- Ani

Senior Pediatric Consultant

Head of Pediatric Department

Khorfakkan Hospital

Sharjah ,UAE

saadsalani@yahoo.com

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Any definition of constipation is relative andAny definition of constipation is relative and depends ondepends on::• Stool consistencyStool consistency• Stool frequencyStool frequency

• Difficulty in passing the stoolDifficulty in passing the stool

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•A normal child might have a soft stool A normal child might have a soft stool onlyonly every 2nd or 3rd day without difficultyevery 2nd or 3rd day without difficulty

•A hard stool passed with difficulty everyA hard stool passed with difficulty every 3rd day should be treated as constipation3rd day should be treated as constipation

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Delay or difficulty in defecation for 2 or Delay or difficulty in defecation for 2 or more weeksmore weeks

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www.patient.co.uk- - 

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www.constipationadvice.ie

Company LogoDiagnosis/evaluation

1.1. HistoryHistory

• Timing of first meconium stoolTiming of first meconium stool

• Family’s definition of Family’s definition of constipationconstipation• Duration of condition and age of onsetDuration of condition and age of onset

• Toilet training experienceToilet training experience

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1.History (cont.)

• Frequency/consistency/size of stoolsFrequency/consistency/size of stools

• Pain or bleeding with defecationPain or bleeding with defecation

• Presence of abdominal painPresence of abdominal pain

•Stool withholding behaviorStool withholding behavior

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1.History

• Change in appetiteChange in appetite

• Abdominal distensionAbdominal distension

• Anorexia, nausea, vomiting, weight loss, orAnorexia, nausea, vomiting, weight loss, or poor weight gainpoor weight gain

• Allergies , dietary history, medicationsAllergies , dietary history, medications

1.History (cont.)

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1.History

• Developmental historyDevelopmental history• Psychosocial Psychosocial history history • Peer interactions, possibility of abuse,Peer interactions, possibility of abuse, toilet habits at schooltoilet habits at school

•Family history (constipation, thyroid disorders, Family history (constipation, thyroid disorders, cystic fibrosis)cystic fibrosis)

1.History (cont.)

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2.Physical ExamExternal perineum and perianal exam, digital External perineum and perianal exam, digital anorectalanorectal exam: exam: • Perianal sensationPerianal sensation• Anal toneAnal tone• Rectal sizeRectal size• Presence of anal wink Presence of anal wink • Amount/consistency/location of stool within theAmount/consistency/location of stool within the rectum)rectum)

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Stool occult blood test for all infants with:Stool occult blood test for all infants with:• ConstipationConstipation• Any child with abdominal painAny child with abdominal pain• Failure to thrive Failure to thrive •Intermittent diarrheaIntermittent diarrhea•Family history of colon cancer or colonicFamily history of colon cancer or colonic polypspolyps

2.Physical Exam(cont.)

Diagnosis/evaluation

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Fecal impaction may be diagnosed with:Fecal impaction may be diagnosed with:• Physical exam (hard mass within abdomen)Physical exam (hard mass within abdomen)• Digital exam (dilated rectal vault filled withDigital exam (dilated rectal vault filled with stool)stool) and/or and/or • Abdominal radiographyAbdominal radiography

2.Physical Exam(cont.)

Diagnosis/evaluation

Company LogoTreatment of functional constipation

a. Disimpaction (2–5 days)

(1) Oral/nasogastric approach:Oral/nasogastric approach:• Polyethylene glycol electrolyte solutions Polyethylene glycol electrolyte solutions are effectiveare effective for initial disimpaction. for initial disimpaction. • Magnesium hydroxideMagnesium hydroxide, , magnesium citratemagnesium citrate, , lactuloselactulose,, sorbitolsorbitol, , sennasenna, or , or bisacodyl laxatives bisacodyl laxatives •((Avoid magnesium-containing products in infants dueAvoid magnesium-containing products in infants due to potential toxicity, beware of overdose in childrento potential toxicity, beware of overdose in children))

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(2) Rectal approach:(2) Rectal approach:• Saline or mineral oil enemasSaline or mineral oil enemas..•Avoid:Avoid: i. Soap suds, tap water, and magnesium enemasi. Soap suds, tap water, and magnesium enemas due to potential toxicitydue to potential toxicity ii. Enemas in infants, may use glycerin ii. Enemas in infants, may use glycerin suppositoriessuppositories.. iii. Phosphate-containing products due to risk ofiii. Phosphate-containing products due to risk of acute phosphate nephropathy acute phosphate nephropathy

a. Disimpaction (2–5 days)

Treatment of functional constipation(Cont.)

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b. Maintenance therapy (usually 3–12 months)

Treatment of functional constipation(Cont.)

Goal is to prevent recurrenceGoal is to prevent recurrence

(1)(1) Dietary changes:Dietary changes: - Increase intake of fluids and absorbable and - Increase intake of fluids and absorbable and

nonabsorbable carbohydrates to soften nonabsorbable carbohydrates to soften stools. stools.

- A balanced diet that includes whole grains, - A balanced diet that includes whole grains, fruits, and vegetables is recommended.fruits, and vegetables is recommended.

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b. Maintenance therapy (usually 3–12 months)

Treatment of functional constipation(Cont.)

(2) Behavioral modifications(2) Behavioral modifications:: - Regular toilet habits- Regular toilet habits - Positive - Positive reinforcementreinforcement - Proper toilet positioning :- Proper toilet positioning : i. Stable seatingi. Stable seating ii. Feet firmly plantedii. Feet firmly planted iii. Knees and hips at 90-degree angle iii. Knees and hips at 90-degree angle -Referral to mental health for help with-Referral to mental health for help with motivational or behavioral concernsmotivational or behavioral concerns

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b. Maintenance therapy (usually 3–12 months)

Treatment of functional constipation(Cont.)

(3) Medications(3) Medications: : - Polyethylene glycol (osmotic laxatives), - Polyethylene glycol (osmotic laxatives), lactulose, magnesium hydroxide, or lactulose, magnesium hydroxide, or sorbitol is recommended.sorbitol is recommended. - Avoid prolonged use of stimulant laxatives.- Avoid prolonged use of stimulant laxatives. - Discontinue therapy gradually only after- Discontinue therapy gradually only after return of regular bowel movements withreturn of regular bowel movements with good evacuationgood evacuation

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age•Increased intake of fluids, particularly of juices

containing sorbitol, such as prune, pear, and apple

juices, is recommended within the context of a healthy diet•Barley malt extract, corn syrup, lactulose, or

sorbitol can be used as stool softeners

•Glycerin suppositories may be useful•Avoid: i. Mineral oil

ii. Stimulant laxatives iii. phosphate enemas

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1.http://www. mayoclinic.com/health/constipation2. http://publications.nice.org.uk/constipation-in-children- and-young-people-cg993. http://www.bmj.com4. www.patient.co.uk www.patient.co.uk5. 5. http://emedicine.medscape.comhttp://emedicine.medscape.com6. 6. www.constipationadvice.iewww.constipationadvice.ie

References