Dr Ravi Pediatric Resident MGMCRI

1. APPROACH TO A CHILD
WITH CONSTIPATION
DR RAVIKUMAR
PEDIATRIC RESIDENT
MGMCRI

2. Table Of Contents
 Prevalence
 Definition
 Risk Factors
 Etiology
 Pathogenesis Of Functional Constipation
 Clinical Manifestation
 Hirshsprung Disease
 Approach
 Management
 Refractory Constipation
Approach to Constipation 2

3. Prevalence
 Constipation is a global health problem
 Worldwide prevalence of functional constipation is 3%
 It is commonly seen among toddlers and preschool children
 In a study from India, reported 138 cases of constipation
diagnosed over a period of six years and 85% of them were
functional
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4. Definition
ROME III Criteria
Functional constipation is defined as presence of two or more of
the following in absence of any organic pathology and the
duration should be atleast one month in <4 years of age, and at
least once per week for at least 2 months in ≥4 years of age :
(i) Two or less defecations per week,
(ii) Atleast one episode of fecal incontinence per week,
(iii) History of retentive posture or stool withholding maneuver,
(iv) History of painful or hard bowel movement,
(v) Presence of large fecal mass in the rectum,
(vi) History of large-diameter stools that may obstruct the toilet.
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5. Definition
 Encopresis is the regular, voluntary or involuntary
passage of feces into a place other than the toilet
after 4 years of age
 Obstipation refers to the absence of passage of
both feces and flatus and denote often an
underlying organic obstruction or pseudo-
obstruction
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6. Category Risk factors
Patient
Related
Male sex
Poor Sleep
Obesity
Dietary Low fiber
Consumption of junk food
Cow’s milk protein allergy
Psychological Home/School-related stresses
Adverse life event including abuse
Subjected to bullying
Anxiety
Depression
Autistic spectrum disorders
Social Living in war-affected areas
Living in urban areas
Lower social class
Hostile and aggressive family environment
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7. Etiology
 Functional constipation of childhood: Poor dietary habits
including weaning formula & lack of fiber.
 Motility related: Hirschsprung disease, myopathy
 Congenital anomalies: Anal stenosis, anteriorly located anus,
spinal cord anomalies (meningomyelocele, myelomalacia,
spina bifida)
 Neurological: Cerebral palsy, mental retardation
 Endocrine/metabolic: Hypothyroidism, renal tubular acidosis,
diabetes insipidus & hypercalcemia
 Drugs: Anticonvulsants, antipsychotic, codeine containing
cough syrup & anti-diarrheal.
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8. Pathogenesis Of Functional
Constipation
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9. Vicious Cycle of Events
Fecal Retention
Rectal distension
Decreased sensory perception
Hard stools
Pain during defecation
Partial evacuation
Impaction
Fecaloma formation
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10. Clinical Manifestation
 Children adopt peculiar
postures during defecation
with many crossing their
legs or attempting to
defecate in the standing
position.
 Abdomen Examination
Palpable Fecolith in the left
lower abdomen
 Digital Rectal Examination
Rectum is usually loaded
with hard stools
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11. Approach to Constipation 11

12. Red Flags
 Fever
 Vomiting
 Bloody diarrhea
 Failure to thrive
 Anal stenosis
 Tight empty rectum
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13. Careful Clinical History to Rule
out Organic Cause:
Apart from Constipation,
 Recurrent abdominal pain
 Poor feeding
 Enuresis
 Voiding disturbances
 Urinary infections
 Most Important history to distinguish Hirschsprung
disease from functional constipation - delayed
passage of meconium beyond 48 hours & onset in
first month of life.
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14. Abnormal Physical Findings to
rule out Organic Cause:
 Failure to thrive
 Tuft of hair over spine/ spinal dimple
 Lack of lumbo-sacral curve
 Sacral agenesis
 Flat buttock
 Anteriorly displaced anus
 Tight and empty rectum
 Gush of liquid stool and air on withdrawal of finger
 Absent anal wink and cremasteric reflex.
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15. Functional vs Hirschsprung
Disease
Features Functional Hirschsprung
Delayed Passage of
Meconium
None Common
Onset After 2 years At birth
Fecal Incontinence Common Very rare
History of Fissure Common Rare
Failure to thrive Uncommon Possible
Enterocolitis None Possible
Abdominal Distension Rare Common
Rectal Examination Stool Empty
Malnutrition None Possible
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16. X-Ray of Functional Constipation
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(Delayed Film)

17. Diagnosis of Hirschsprung
 Barium enema – Not
necessarily indicated in all
cases
 Can be done only if there is
strong clinical suspicion (based
on the history of delayed
passage of meconium & empty
rectum)
 Interpretation - should be on
the basis of reversal of recto
sigmoid ratio (sigmoid becomes
more dilated than rectum) and
documentation of transition
zone and not on mere presence
of barium in rectum after 24 Approach to Constipation 17

18. Approach to Constipation
Approach to Constipation
Modified from ESPGHAN Recommendations
18

19. Management
Steps:
1. To determine presence of fecal impaction
2. To treat the impaction if present
3. Initiate Maintenance treatment with oral laxative,
dietary modification & toilet training
4. Close follow up and medication adjustment as
necessary.
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20. Disimpaction
PEG
 Oral: 1-1.5g/kg/day for 3-6 days
 NG tube: 25ml/kg/hr until clear fluid is excreted
through anus
 Successful disimpaction for Homebased regimen is
defined as either empty or a small amount of soft
stool on DRE and resolution of fecolith
 Adequate disimpaction means both lavage (input)
and stool (output) should be of same color in case
of NG tube disimpaction
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21. Disimpaction
 If PEG is not available, then enema can be used
Proctoclysis by Sodium phosphate: 2.5 mL/kg,
maximum 133ml/dose for 3-6 days
 Mineral oil is also equally effective for disimpaction with
dose of 15-30 mL/yr of age (max. 240mL)
 For infants : Glycerine suppositories are to be used for
disimpaction as enemas and lavage solution are not
indicated
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22. Maintenance Therapy
1) Dietary Modification
• Encouraged to take more fluids, absorbable and non
absorbable carbohydrate (sorbitol) as a method to
soften the stools
• Sorbitol is found in fruit juices like apple, pear and
prune
• A balanced diet that includes whole grains, fruits and
vegetables is advised
• The recommended daily fiber intake is
Age(in years) + 5 in g/day
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23. Maintenance Therapy
2) Toilet Training
 Implemented after 2 to 3 years of age
 Encouraged to sit on the toilet for 5 to 10 minutes, 3 to 4
times/day immediately after major meals initially
 Advised to maintain “Stool Diary”- daily record of bowel
movements, fecal soiling, pain/discomfort, consistency of
stool and the laxative dose
 Positive Reinforcement - should be rewarded for not soiling
and for regular sitting on the toilet
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24. Maintenance Therapy
3) Laxatives:
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Drugs Dose Adverse effects
Lactulose 1-2 g/kg, 1-2 doses Bloating, abdominal
cramps
PEG for maintenance 5-10 mL/kg/d or 0.4
to 0.8 g/kg/d
Nausea, bloating,
cramps, vomiting
Mineral oil for
maintenance
1-3 mL/kg/d Lipoid pneumonia,
interference with
absorption of fat
soluble vitamins
Milk of Magnesia 1-3 mL/kg/d, 1-2
doses
Excess use leads to
hypocalcemia,
hypermagnesemia,
hypophosphatemia
Bisacodyl 0.3 mg/kg/dose
5mg-10mg
suppository
Abdominal pain,
diarrhea,
hypokalemia

25. Follow-up Schedule
Monthly follow up till regular bowel movement is achieved:
 Check diary, physical and rectal examination.
 Laxative dose is to be adjusted
Follow-up of 3 months for next 2 years:
 Continue same dose of laxative for at least 3 months and
then slow tapering
Yearly follow-up:
 Points to be remembered while treating infants with
constipation are to exclude organic causes such as HD,
cystic fibrosis, cretinism, etc. to avoid mineral oil, stimulant
laxatives and glycerine enemas for fecal impaction.
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26. Refractory Constipation
Refractory is labelled when there is no response to
optimal conventional treatment for at least 3 months
Causes:
 Motility disorders (like slow transit constipation)
 Disorders of stool expulsion like dyssynergic defecation
 Internal anal sphincter achalasia
 Sphincter dysfunction in children with Hirschsprung
disease which persist after surgery
Motility studies like colon transit time (CTT),
anorectal manometry with balloon expulsion test,
colonic manometry
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27. CTT study
 Simplest and most informative of all the tests
 Done by use of radio-opaque markers and by
radionuclide scintigraphy
Classified:
(i) Normal transit constipation
(ii) Functional outlet obstruction or dyssynergic
defecation ()
(iii) Slow transit constipation (retained markers are
distributed all over)
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28. Slow Transit Constipation
CTT by radio-
opaque markers
showing Reduced
motility of large
intestine caused by
abnormality of
enteric nerves
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29. Functional outlet Obstruction
CTT study showing
retention of
markers in
rectosigmoid region
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30. TAKE HOME MESSAGE
 Detailed history and proper physical examination,
including digital rectal examination, can easily
differentiate functional from organic constipation
 Nearly 95% is of it is functional and often does not
need any investigation
 In most cases, prolonged (months to years)
laxative therapy is required and early withdrawal
leads to recurrence
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31. REFERENCES
1. Nelson Textbook of Pediatrics
2. Indian Pediatrics “Approach to
Constipation in Children” 2016 article
3. IAP Textbook of Pediatrics
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32. THANKYOU
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