Constipation resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Samah Obaiah, MD[2]

Constipation resident survival guide (pediatrics) Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Overview

Constipation occurs when waste or stool moves too slowly through the digestive tract, causing the stool to become hard and dry. It is a common pediatric problem that needs primary care management prevalence rates up to 32.2%. Education children and their families should be included in the treatment regimen to prevent recurrences and promote health maintenance. Chronic (functional) constipation is a source of anxiety for parents who worry that a serious disease may be causing the symptom

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. [1][2]

Common Causes

the most factors can contribute to constipation in children,[3] including:

A child may ignore the urge to have a bowel movement or uncomfortable using public toilets.

  • Painful bowel movements caused by large, hard stools also may lead to avoiding a repeat of the distressing experience.

Not enough fiber-rich fruits and vegetables or fluid in a child's diet may cause constipation.

Any changes in routine — such as travel, hot weather, stress, or start school — can affect bowel function.

Certain antidepressants and various other drugs can contribute to constipation.

Complete Diagnostic Approach

The most common kind is functional constipation and not life-threatening.[4] Diagnosed with history one of these symptoms:-

  • Hard stools [5]
  • Pain or trouble passing stool
  • Less than three stools per week


Many children with an impaction have a loss of appetite and are less interested in physical activity. After passing the stool, the child feels better, and symptoms improve. Shown below is an algorithm summarizing the diagnosis of [[constipation]] according to the the [Rome III Diagnostic Criteria] guidelines[6].

 
 
 
Diagnosing Functional Constipation in Children
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
At least two of the following in a child with a developmental age younger than four years*

Symptoms suggestive of constipation:
❑2 or less bowel movements per week

❑At least one episode of incontinence per week after the acquisition of toileting skills

❑History of excessive stool retention

❑History of painful or hard bowel movements

❑Presence of a large fecal mass in the rectum

❑History of large diameter stools that may obstruct the toilet

At least two of the following in a child with a developmental age of four years or older with insufficient criteria forirritable bowel syndrome:-

❑Two or fewer bowel movements in the toilet per week

❑At least one episode of fecal incontinence per week

❑History of retentive posturing or excessive voluntary stool retention

❑History of painful or hard bowel movements

❑Presence of a large fecal mass in the rectum

❑History of large diameter stools that may obstruct the toilet

—Criteria must be fulfilled for at least one month. Accompanying symptoms may include irritability, decreased appetite, and/or early satiety, and they may disappear immediately following the passage of a large stool.

—Criteria must be fulfilled at least once a week for at least two months.
 
 

Treatment

Treatment of constipation in children ([functional constipation]) focuses on three main areas:-

-Increasing fiber in the diet and more fluids.

-Regular Exercise and bowel habit training.

Medicine is often needed to help children have regular, soft bowel movements and disimpaction.

Medicines Help Constipation in different ways. Osmotic laxatives (Polyethylene glycol without electrolytes, magnesium hydroxide, magnesium citrate, lactulose, sorbitol, phosphate sodium enema), stimulant laxatives(senna, bisacodyl ), and lubricant laxatives(mineral oil, glycerin suppository).

Oral medications regimen for disimpaction if indicated:

  • Polyethylene glycol 3350 + electrolytes, using an escalating dose regimen, as the first-line treatment. Polyethylene glycol 3350 + electrolytes may

Be mixed with a cold drink.

  • Add a stimulantlaxative if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks.
  • Substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if polyethylene glycol 3350 + electrolytes is not

Tolerated.

  • Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain.[7]

Laxatives: recommended doses are those recommended by the British National Formulary for Children (BNFC) 2009

Laxatives Recommended doses
Polyethylene glycol 3350 + electrolytes Paediatric formula: oral powder: macrogol 3350 ([[polyethylene glycol

3350]])a 6.563 g; sodium bicarbonate 89.3 mg; sodium chloride 175.4

mg; potassium chloride 25.1 mg/sachet.

Disimpaction

  • Child under 1 year: ½ to 1 sachet daily (non-BNFC recommended

dose)

  • Child 1–5 years: 2 sachets on 1st day, then 4 sachets daily for

2 days, then 6 sachets daily for 2 days, then 8 sachets daily (non- BNFC recommended dose)

  • Child 5–12 years: 4 sachets on 1st day, then increased in steps of

2 sachets daily to a maximum of 12 sachets daily (Non-BNFC recommended schedule)

Ongoing maintenance (chronic constipation, prevention of fecal impaction)

  • Child under 1 year: ½ to 1 sachet daily (non-BNFC recommended

dose)

  • Child 1–6 years: 1 sachet daily; adjust the dose to produce regular

soft stools (maximum 4 sachets daily) (for children under 2, non- BNFC dose)

  • Child 6–12 years: 2 sachets daily; adjust the dose to produce regular

soft stools (maximum 4 sachets daily) Adult formula: oral powder: macrogol 3350 ([[polyethylene glycol 3350]]) 13.125 g; sodium bicarbonate 178.5 mg; sodium chloride 350.7 mg; potassium chloride 46.6 mg/sachet (unflavoured).

Disimpaction

  • Child/young person 12–18 years: 8 sachets daily

Ongoing maintenance (chronic constipation, prevention of fecal impaction)

  • Child/young person 12–18 years: 1–3 sachets daily in divided

doses usually for up to 2 weeks; maintenance, 1–2 sachets daily

Lactulose * Child 1 month to 1 year: 2.5 ml twice daily, adjusted according to

response




  • Child 1–5 years: 2.5–10 ml twice daily, adjusted according to

response (non-BNFC recommended dose)

  • Child/young person 5–18 years: 5–20 ml twice daily, adjusted

according to response (non-BNFC recommended dose)

Sodium picosulfate Non-BNFC recommended doses

Elixir (5 mg/5 ml)

Child 1 month to 4 years: 2.5–10 mg once a day

Child/young person 4–18 years: 2.5–20 mg once a day

Bisacodyl Non-BNFC recommended doses

By mouth

Child/young person 4–18 years: 5–20 mg once daily By rectum (suppository)

Child/young person 2–18 years: 5–10 mg once daily

Senna Senna syrup (7.5mg/5ml)

Child 1 month to 4 years: 2.5–10 ml once daily

Child/young person 4–18 years: 2.5–20 ml once daily

Senna (non-proprietary) (1 tablet = 7.5 mg)

Child 2-4 years: ½ to 2 tablets once daily

Child 4-6 years: ½ to 4 tablets once daily

Child/young person 6–18 years: 1–4 tablets once daily

Docusate sodium Child 6 months–2 years: 12.5 mg three times daily (use pediatric

oral solution) Child 2–12 years: 12.5–25 mg three times daily (use pediatric oral solution) Child/young person 12–18 years: up to 500 mg daily in divided doses

Shown below are tow algorithms summarizing the treatment of [[Constipation]] according the the [ North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Constipation] guidelines.[8] FRIST ONE:-

 
 
 
Constipation in Infants Younger than Six Months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Children under 1 year:

. delayed passage of meconium (more than 48 hours after birth)

. fewer than three complete stools a week ( this does not apply to exclusively breastfed babies after six weeks of age)

. hard large stools, "rabbit droppings" or "nuts," distress on defecating, bleeding associated with hard stools

. straining, previous episode(s) of constipation, and previous or current anal fissure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical and laboratory examination should includ:-

. growth parameters

. an abdominal examination

. occult blood test

. an external examination of the perineum and perianal area

. an evaluation of the thyroid and spine

. And a neurologic evaluation for appropriate reflexes (cremasteric, anal wink, patellar).

. A digital examination of the anorectum recommended to assess for perianal sensation, anal tone, rectum size, anal wink, and amount and consistency of stool in the rectum
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If Onset before one month of age

. Delayed passage of meconium (more than 48 hours after birth) . Failure to thrive . Abdominal distension . Intermittent diarrhea and explosive stools . Empty rectum . Tight anal sphincter . Pilonidal dimple covered by a tuft of hair . Midline pigmentary abnormalities of the lower spine . Abnormal neurologic examination (absent anal wink, absent cremasteric reflex, decreased lower extremity reflexes and/or tone) . Occult blood in the stool . Extraintestinal symptoms (vomiting, fever, ill-appearance) . Gushing of stool with rectal examination . No history of withholding or soiling

. No response to conventional treatment
 
If no alarm symptoms,the treatment will be:-

incrased fluid oral rehydration with breastfed

closed followup
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suggested diagnoses will be one of these; congenital malformation of anorectum or spine, Hirschsprung disease, allergy, metabolic/endocrine condition
 
Functional constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
More evaluation according to physical examination and history finding by one of those:-

. Barium enema

. Spinal magnetic resonance imaging

. Thyroid studies

. Serum calcium and potassium levels

. Fasting glucose level

. Serum and urine osmolarity

.Anorectal manometry, rectal suction biopsy

. Colonic manometry

. History, drug level

. Lead level

. Tissue transglutaminase

. IgA, total IgA

. endoscopy

. Sweat test

. Cow's milk elimination
 
Functional constipation without impaction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement with Education, diet, fluid , medication, dairy, close follow up.
 
 
Failure of improvement with treatment and family education
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
continue treatment
 
 
re-evaluation
 
 
 
 

Second one is:-

 
 
 
Constipation in children older than one year
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
child with history of consitpation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No alarm signs as, fever, vomiting, abdominal distinction,...
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
diagnosis of functional constipation provide
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Education for cild and his or her parents :-diet, exercises,toilet training, increase fluid,and close follow up
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If there is impaction should use rectal or oral medication to disimpaction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the impaction improved, cotinus tretment with education family
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the impaction not improved should re evaluation
 
 
 

Do's

  • It is important to increase fiber slowly over two to three weeks with a current constipation.
  • Make sure the child drinks more water and juice when eating more fiber.
  • If a child becomes very upset when taken to the toilet or holding stool more or constipation is getting worse, or their history of tantrums or aggression with toileting should refer the child to a psychotherapy expert.
  • Increased the dose of medicine, if there are one of these signs, stools are small and hard, or a stool, not every day, or there complain of a hard time passing stool, or pain.
  • Decreased the dose of medicine if there, loose or watery stool, history of belly pain or cramps.
  • Length of treatment of disimpaction and functional constipation usually at least 6 months

Don'ts

References

  1. van Mill MJ, Koppen IJN, Benninga MA (2019). "Controversies in the Management of Functional Constipation in Children". Curr Gastroenterol Rep. 21 (6): 23. doi:10.1007/s11894-019-0690-9. PMID 31025225.
  2. Coughlin EC (2003). "Assessment and management of pediatric constipation in primary care". Pediatr Nurs. 29 (4): 296–301. PMID 12956550.
  3. Baker SS, Liptak GS, Colletti RB, Croffie JM, Di Lorenzo C, Ector W; et al. (1999). "Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition". J Pediatr Gastroenterol Nutr. 29 (5): 612–26. doi:10.1097/00005176-199911000-00029. PMID 10554136.
  4. Poddar U (2016). "Approach to Constipation in Children". Indian Pediatr. 53 (4): 319–27. doi:10.1007/s13312-016-0845-9. PMID 27156546.
  5. Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (2006). "Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition". J Pediatr Gastroenterol Nutr. 43 (3): e1–13. doi:10.1097/01.mpg.0000233159.97667.c3. PMID 16954945.
  6. McNamara S (2014). "Caveat regarding ESPGHAN/NASPGHAN functional constipation treatment recommendations". J Pediatr Gastroenterol Nutr. 59 (1): e14. doi:10.1097/MPG.0000000000000381. PMID 25222810.
  7. "Constipation in children and young people: diagnosis and management". National Institute for Health and Care Excellence: Clinical Guidelines. 2017. PMID 32200591 Check |pmid= value (help).
  8. Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S; et al. (2014). "Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN". J Pediatr Gastroenterol Nutr. 58 (2): 258–74. doi:10.1097/MPG.0000000000000266. PMID 24345831.