Constipation in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dushka Riaz, MD

Synonyms and Keywords: Constipation in kids

Overview

Constipation in childhood is the delay or difficulty in passing stool for more than two weeks. It is one of the most common pathologies that presents to a pediatrician. The diagnosis is based on history, physical exam and a constipation log. [1]

Historical Perspective

  • [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
  • In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
  • In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

Classification

  • Constipation in children may be classified according to [classification method] into two subtypes/groups:
  • Functional - This is the most common type of constipation in children where there is no anatomic or systemic cause. The predilection is for preschool-aged children. [1] [2]
  • Organic

Pathophysiology

  • The pathogenesis of constipation in children is most often characterized by painful stools causing the child to withhold to avoid the pain developing a vicious cycle of constipation. Withholding behavior causes the rectum to absorb and retain water from the fecum further creating a harder stool. The eventual defecation of the fecum is difficult and can create anal fissures exacerbating withholding behavior. Repeated accumulation of the fecum can result in dilation of the colon with a loss of sensation leading to slow transit time. [1]
  • On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
  • On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Constipation in children may be caused by functional or organic causes.

  • Functional causes include:[1]
    • Fecal retention to avoid a painful stool
    • Developmental disorder component ie ADHD, Autism
    • Psychological, as in the case of new toilet training or sexual abuse [2]
    • Genetic predisposition
    • Poor fiber intake, low fluid intake or malnutrition
    • Introduction of formula or cow's milk [2]
  • Organic causes include:[1]
    • Neuromuscular disorders such as congenital megacolon, cerebral palsy, neurofibromatosis
    • Anatomic lesions such as gastroschisis
    • Systemic diseases such as cystic fibrosis, diabetes mellitus, hyper or hypothyroidism, Down syndrome
    • Drug exposure such as narcotics, codeine, antidepressants, and lead poisoning
    • Other causes such as cow's milk allergy or celiac disease

Differentiating Constipation in Children from other Diseases

Constipation must be differentiated from infantile dischezia, Hirschsprung’s disease,

  • Infantile dischezia is a pelvic floor dysfunction that results in diarrhea or constipation presenting in the neonatal period. It is caused by the child not being able to coordination the increased pressure in the abdomen with the relaxation of the pelvis. The disorder is self resolving as the child learns to muscle coordination and does not require any intervention. [1]
  • Hirschsprung's disease can present with difficulties in passing stool in the neonatal period because of colonic agangliosis. However Hirschsprung's disease would also present with bilious vomiting, refusal to feed, and fever caused by severe enterocolitis. [1]

Epidemiology and Demographics

  • The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
  • In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

  • Patients of all age groups may develop [disease name].
  • Constipation in children is more commonly observed among patients aged two to four years old because of the learning process of toilet training. [1]

Gender

  • Constipation in children affects boys and girls equally before the age of 5 with girls have more incidence after age 13. [3]

Race

  • There is no racial predilection for [disease name].
  • [Disease name] usually affects individuals of the [race 1] race.
  • [Race 2] individuals are less likely to develop [disease name].

Risk Factors

  • Common risk factors in the development of constipation in children are low fiber intake, stressful events such as bullying and familial changes, cow's milk protein allergy, sedentary lifestyle, low birth weight and consumption of processed foods.[1]

Natural History, Complications and Prognosis

  • The majority of patients with [disease name] remain asymptomatic for [duration/years].
  • Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
  • If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
  • Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
  • Prognosis is generally excellent for patients under five. Patients who don't do well are suspected to have noncompliance of medications. [3]
  • Prognosis for full recovery is 48%. Those with symptoms early in their life, family history of constipation and history of sexual abuse are associated with a poor prognosis. [1]

Diagnosis

Diagnostic Criteria

  • In the Paris Consensus Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met for more than 8 weeks: [1]
  • Less than 3 bowel movements per week
  • More than one fecal leakage episode per week
  • Rectal obstruction caused by large diameter stools
  • Withholding behavior
  • Painful defecation
  • In the Rome III Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met; with children over four years old requiring to have the symptoms for a minimum of two months: [1]
  • Less than 2 bowel movements per week
  • Fecal incontinence episode after achieving complete bowel control
  • Rectal obstruction caused by large diameter stools
  • Withholding behavior
  • Painful defecation
  • Large fecal mass seen in digital rectal examination

Symptoms

  • Symptoms of constipation in children may include the following:[1]
  • Straining
  • Crying
  • Bleeding per rectum
  • Anal tears
  • Withholding behavior
  • Nocturnal fecal soiling in response to loss of sensation
  • Abdominal pain
  • Nausea
  • Decreased appetite
  • Enuresis
  • Urinary tract infections because of hard fecum obstructing urinary flow
  • Hard stools [2]
  • Alarm symptoms point to an organic cause:[1]
  • Ribbon stools
  • Blood in stools without anal fissures
  • Fever
  • Bilious vomiting
  • Failure to thrive
  • More than 48 hours to pass meconium
  • Occult blood in stool
  • Fear when anus is being examined due to pain
  • Sacral dimple, agenesis
  • Perianal scars, fistula
  • Pilonidal dimple with hair tuft
  • Abnormal anus position
  • Thyroid gland abnormalities
  • Family history of Hirschsprung's disease
  • Fecal mass with empty rectum
  • Air or fluid release on digital rectal examination
  • Absence of anal wink, anal reflex, cremasteric reflex
  • Delayed lower extremity deep tendon reflexes
  • Decreased lower extremity tone, strength and sensation

Physical Examination

  • Patients with constipation usually appear pale and fatigued. [3]
  • Physical examination may be remarkable for: [3]
  • mouth ulcers
  • blood or mucus in the stools
  • perianal skin tags or fistulae
  • hypotonia
  • absent lower extremity reflexes
  • fever
  • exopthalmos and lid lad for hypothyroidism [2]
  • abdominal distension or mass
  • lumbar abnormalities or hair tufts [2]

Laboratory Findings

  • If the patient does not respond to initial treatment, testing must be done for celiac disease, lead levels, CBC, serum electrolytes and a thyroid function test, uranalysis, urine culture, sweat test, fecal occult blood test, allergy testing.
  • If lab results are negative with no response to treatment, organic causes must be further investigated through chest radiograph if there is difficulty to examine the patient, barium enema, anorectal manometry and rectal biopsy to exclude Hirschsprung's disease, and MRI of the lumbosacral spine. [1]
  • A [positive/negative] [test name] is diagnostic of [disease name].
  • An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
  • Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

MRI may be helpful in the diagnosis of constipation in children. Findings on MRI suggestive of lumbosacral spine abnormalities may be helpful to identify neuropathic causes of dysfunction [1] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

A contrast enema may be helpful in the diagnosis of Hirschsprung's disease as the cause for constipation. [2] Findings on an Hirschsprung's disease suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

  • [Disease name] may also be diagnosed using [diagnostic study name].
  • Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

  • Treatment for constipation in children depends on the age group:[1]
    • Infants 3 months to 1 year are offered sorbitol containing juices diluted with water, trial of avoiding cow's milk, breastfed children with trial of the mother avoiding cow's milk. Glycerin suppositories and laxatives can be used for children 6 months and older if needed. Infants older than 6 months should also increase consumption of fruits and vegetables.
    • In children treatment consists of three phases:
  1. Disimpaction of hard fecum through osmotic laxatives (lactulose, bisacodyl suppository, magnesium citrate, magnesium hydroxide, paraffin oil, sorbital, senna, paraffin oil) for 1-3 days.
  2. Restoring muscle tone through stool softeners for 2-6 months.
  3. Restore normal bowel movements by increasing fiber and water intake and reducing laxative use gradually for 4-6 months.
  • Treatment also includes behavior modification of re-toilet training with routine scheduled toilet visits. [1] Possible psychological issues must be addressed and a star reward system can be helpful in tracking improvement. [3]

Surgery

  • Surgery is the mainstay of therapy for [disease name].
  • [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
  • [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

  • There are no primary preventive measures available for [disease name].
  • Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].
  • Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 Xinias I, Mavroudi A (2015). "Constipation in Childhood. An update on evaluation and management". Hippokratia. 19 (1): 11–9. PMC 4574579. PMID 26435640.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 "StatPearls". 2020. PMID 30725722.
  3. 3.0 3.1 3.2 3.3 3.4 Afzal NA, Tighe MP, Thomson MA (2011). "Constipation in children". Ital J Pediatr. 37: 28. doi:10.1186/1824-7288-37-28. PMC 3143086. PMID 21668945.