MANAGEMENT OF THE
CONSTIPATED PATIENT IN THE
PEDIATRIC SETTING
John T. Stutts, MD, MPH
University of Louisville Department of Pediatrics
Division of Pediatric Gastroenterology
DISCLOSURE
• The speaker has been a part of the
speaker bureau for Abbott Nutrition in the
past.
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DEFINITION
• Constipation: “A delay or difficulty in
defecation, present for ≥ 2 weeks and
sufficient to cause significant distress to the
patient.”1
• Encopresis: “The involuntary loss of formed,
semi-formed, or liquid stool in the child’s
underwear, in the presence of functional
constipation after the child has reached a
developmental age of 4 years.”1
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CONSTIPATION: PREVALENCE
• As many as 3% of visits to the primary
care physician.1
• As many as 25% of visits to the pediatric
gastreoenterologist.1
• 16 – 37% of otherwise healthy 4 to 11
year old children have constipation.2-6
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IN YOUR CLINIC …..
• Constipation is the #1 cause of
abdominal pain.
• If the chief complaint is abdominal pain
…. think constipation until proven
otherwise.
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IN YOUR CLINIC …..
• A question not to ask:
- Is your child constipated?
• A better question that will give you
a clearer picture:
- How many days does your child
skip between bowel movements?
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FUNCTIONAL VS. ORGANIC
• Functional Constipation
- An umbrella term describing persistent,
difficult, infrequent or seemingly incomplete
defecation without evidence of a primary
anatomic or biochemical cause.7
- Accounts for greater than 95% of
constipation-related symptoms in children
and infants, except those during the
neonatal period when organic causes are
more likely.7
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FUNCTIONAL: ETIOLOGY
• 3 critical time periods
- Introduction of cereals/solids
- Toilet training
- Start of school
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FUNCTIONAL
• Infant Dyschezia
- At least 10 minutes of straining
and/or crying before successful
passage of soft stool in an otherwise
healthy infant < 6 mos of age.
- The symptom is due to failure to
relax the pelvic floor during the
defecation effort and resolves
spontaneously.8
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FUNCTIONAL
• Fecal Incontinence
- In children with constipation, there
is no clear difference in the
pathophysiology or psychology
between children with and without
fecal incontinence.9
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FUNCTIONAL: TREATMENT
• 2 phases to treatment
- Phase 1: The Cleanout
- Phase 2: Maintenance
Phase 1 is arguably the most important!
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FUNCTIONAL: CLEANOUT
OPTIONS
• Enemas
- Phosphate Enemas
Adult (≥ 3 yoa)
Pediatric (< 3 yoa)
- SMOG (Saline, Mineral Oil, Glycerin)
- Milk and Molasses
• Magnesium Citrate
- 1 oz per year of age to a max of 10oz
- once daily x 3-6 days
- not for infants/toddlers
• Polyethylene glycol
- “multiple doses” vs “the gallon”
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FUNCTIONAL:
MAINTENANCE OPTIONS
• Osmotic
- Polyethylene glycol (1 capful = 17 grams)
3 yoA
½ capful Q day
6 yoA
½ capful BID
*10 yoA
1 capful BID
13 yoA
1 – 1 ½ capfuls BID
18 yoA
1 – 2 capfuls BID
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FUNCTIONAL:
MAINTENANCE OPTIONS
• Osmotic
- Milk of Magnesia
≤ 1 year
2 – 6 years
7-8 years
≥ 9 years
1-2 tsp BID
2 tsp BID
1 T BID
2 T BID
- Lactulose
1 – 3 mL/kg/day
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FUNCTIONAL:
MAINTENANCE OPTIONS
• Lubricant
- Mineral Oil
• Not recommended
• Lipoid pneumonia if aspirated
• Stimulant
- Senna
≤ 2 yrs
2 – 4 yrs
5 – 6 yrs
7 – 9 yrs
≥ 10 yrs
¼ - 1 tsp BID
½ - 1 tsp BID
1 tsp BID
1 tablet BID
2 tablets BID
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HOW DO WE COME OFF
THE LAXATIVE?
• Fiber is the KEY!
AGE
DOSE
1 – 3 years
15 grams/day
4 – 8 years
20 grams/day
9 – 12 years
25 grams/day
≥ 13 years
30 grams/day
• Wean the laxative slowly!!
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SO WHEN IS IT MORE
THAN JUST CFC?
• The question of Organic etiology…
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ORGANIC CONSTIPATION
• Organic causes are responsible for
fewer than 5% of cases of
constipation in children.
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ORGANIC CONSTIPATION
• Anatomic
-
Anal stenosis
Imperforate anus
Anteriorly displaced anus
Pelvic mass (sacral
teratoma)
• Metabolic
-
Hypothyroidism
Hypercalcemia
Hypokalemia
Cystic Fibrosis
Diabetes Mellitus
Celiac disease
MEN type 2B
• Neuropathic
- Tethered cord
• Intestinal nerve/muscle
disorder
- Hirschsprung's disease
- Visceral myopathies
• Abnormal abdominal
musculature
- Prune-belly
- Down syndrome
- Gastroschisis
• Connective tissue
disorders
- Scleroderma
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ORGANIC CONSTIPATION
• Medications
- Opiates
- Antacids
- Phenobarbital
• Miscellaneous
- Cow’s milk protein intolerance
- Lead ingestion
- Botulism10,11
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COW’S MILK PROTEIN
ALLERGY/INTOLERANCE
• 0.3 – 7.5% of normal infants
• Think about this in the infant who has
constipation in association with rhinitis,
dermatitis or bronchospasm
• Options:
- Dairy elimination for the breast feeding
mother
- Casein Hydrolysate formulas
- Elemental amino acid-based formulas12,13
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HIRSCHSPRUNG'S DISEASE
• More than 90% of normal infants,
but only 10% of infants with
Hirschsprung's disease, pass
meconium within the first 24 hours
of life.14
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HIRSCHSPRUNG'S DISEASE
• A motor disorder of the colon caused
by failure of neural crest cells to
migrate completely during colonic
development.
• The result … the affected segment of
the colon fails to relax causing a
functional obstruction.14
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HIRSCHSPRUNG'S DISEASE
• Consider in the following
circumstances:
The
“classic
triad”
present
in 82%
of
cases.
- Delayed passage of meconium (after 48
hours of life)
- Abdominal distention
- Vomiting
- Onset of symptoms in the first week of
life
- A transition zone on contrast enema14
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HIRSCHSPRUNG'S
DISEASE: DIAGNOSIS
• Rectal exam – The “Wine Goblet”
Explosion…
VS
H.D.
CFC
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HIRSCHSPRUNG'S
DISEASE: DIAGNOSIS
• Unprepped contrast enema
- If H.D. present, a transition zone will be
seen ~ 70% of the time.
• Anorectal manometry
- When the rectal balloon is inflated,
reflex relaxation of the internal anal
sphincter fails to occur.
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HIRSCHSPRUNG'S
DISEASE: DIAGNOSIS
• Rectal suction or full-thickness biopsy
═ The definitive test
-
absence of ganglion cells
-
high acetylcholinesterase
accumulation on staining
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CYSTIC FIBROSIS
• Constipation is common
• DIOS = Distal Ilial Obstruction
Syndrome
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TETHERED CORD
SYNDROME
• What is it exactly?
Stretch-induced dysfunction of the
caudal spinal cord and conus caused
by attachment of the filum terminale to
inelastic structures caudally.
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TETHERED CORD
SYNDROME
• Associated signs/symptoms
- constipation
- bladder dysfunction
- weak lower extremity reflexes
• Diagnosis
- MRI of the lumbosacral spine
• Treatment
- Neurosurgical release
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ORGANIC PEARLS
• If since the neonatal period, there
has been constipation (especially
with delayed passage of
meconium)…. do an unprepped
contrast enema.
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ORGANIC PEARLS
• If a patient has recurrent UTIs,
consider constipation as an etiology
due to mechanical effects of the
distended rectum pressing on the
bladder.
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ORGANIC PEARLS
• If the patient has FTT, RAP and
constipation (+/- anemia), consider
celiac disease.
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ORGANIC PEARLS
• If there is spinal dysraphism or
neurological impairment of the lower
extremities and/or daytime wetting in
association with constipation, obtain an
MRI of the lumbosacral spine.
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ORGANIC PEARLS
• If there is impaired linear growth
and depressed reflexes…. consider
hypothyroidism.
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ORGANIC PEARLS
• If at risk of electrolyte disturbances
(metabolic abnormalities or unable
to tolerate adequate fluids)…..
check a serum Calcium.
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ORGANIC PEARLS
• If at risk for lead toxicity…. test for it.
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ORGANIC PEARLS
• If the H & P remains equivocal for
etiology, don’t be afraid to get a
KUB …. but remember the readings
can be inconsistently interpreted.
So, don’t be afraid to look at the film
yourself.
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Thank you!
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