CONSTIPATION IN CHILDREN 2021 Pediatrics.pdf

Constipation in children 2021 is a medical lecture designated for junior medical students.

1. CONSTIPATION IN CHILDREN
Dr. KATE KAN (MBBCh, FWACP)

2. OBJECTIVES
•Knowledge of what constipation is.
•Know the differential diagnosis of constipation
•Differentiate functional constipation and organic constipation
•Understand the pathophysiology of encopresis
•Learn treatment strategies for constipation.

3. Outline
•Introduction
•Definition
•Pathogenesis of Functional constipation
•Etiology
•Clinical manifestation
•Paraclinical investigations
•Differential Diagnosis
•Management Approach

4. INTRODUCTION 1/2
•Constipation is a common problem in children with a worldwide
prevalence of 3% of functional constipation and affects all age
groups.
•It is a common cause of anxiety among mothers and a reason for
paediatricconsultation.
•Usually, it is a term used to describe the subjective complaint of
passage of abnormally delayed and infrequent passage of dry
hardened feces.
•Any definition of constipation is relative and depends on stool
consistency, frequencyand difficulty in passing stools.

5. INTRODUCTION 2/2
Normal bowel frequency varies widely.
-neonate passes stools 1-7 times per day
-1-2 stools per day at 1 year of life
-one stool per day or every other day in preschool and older children.
•Functional constipation(non-organic) or idiopathic can usually be
differentiated from organic constipation on the basis of history and
examination.

6. Definition
Constipation is defined as a delay or difficulty in defecation present
for 2 weeks or longer (present for atleast1 month)and significant
enough to cause distress to the patient.
Rome criteria is another approach to define constipation

7. Rome IV criteria for children with functional constipation
Infants less than 4 years in toilet trained children
Must last 1 month and include atleast2 of the following:
•2 or fewer defecations weekly
•At least1 weekly episodeofincontinence/soilingafterbeing toilet
trained.
•History of excessive stool retention
•History of painful or hard bowel movements,
•History of large -diameter stoolthat may clog the toilet
•Presence of large faecalmass in the rectum

8. Romeo IV criteria 4-18 years
Must include 2 or more of the following for atleast1week for atleast1
month in a child with a developmental age of at least 4 yrwith insufficient
criteria for diagnosis of irritable bowel syndrome:
• ≤2 Defecations per week
• ≥1 Episode of fecal incontinence per week
• History of retentive posturing or excessive volitional stool retention
• History of painful or hard bowel movements
• Presence of a large fecal mass in the rectum
• History of a large-diameter stool that might obstruct the toilet
After appropriate evaluation with no known medical condition,

9. Romeo IV criteria 4-18 years
Nonretentivefecal incontinence occurs in child of developmental age
of atleast4 years lasting at least 1 month with the following
symptoms:
-Defecation into places inappropriate to the sociocultural context
-No evidence of fecal retention
-After appropriate evaluation, symptoms cannot be fully explained by
another medical condition.

10. Functional Constipation
•Also called idiopathic constipation or fecal withholding.
•Often starts after the neonatal period unlike anorectal malformations and
Hirchsprung’sdisease.
•Daytime encopresis is common in functional constipation.
•Encopresis-voluntary or involuntary passage of feces into inappropriate
places atleastonce a month for 3 conservative months once a developmental
age of 4 has been reached (excluding the effects of laxatives or medical
condition).

11. TypesofEncopresis
•Encopresis –retentive or non-retentive encopresis.
•Retentive encopresis –65-95% of cases and is associated with constipation and overflow
incontinence, associated with difficulty defecation, impaired growth, poor appetite and
large bowel movements.
•Non-retentive encopresis (without constipation and overflow incontinence) is defined as
no evidence of fecal retention (impaction) ≥1 episode per week in the previous 1 month
or defecation in places inappropriate to social context in achildpreviously toilet trained
and without evidence of anatomic, inflammatory, metabolic, endocrine or neoplastic
process that could explain the symptoms.
•Encopresis can persist from infancy onward (primary) or secondary(toilet trained) .

12. Triggers
•Usually there is intentional or subconscious withholding of stool.
•Acute episode preceedsa chronic course.
•Acute event –social stressor like initiation of toilet training, birth of a sibling, starting
school or abuse or dietary change from human to cow milk.
•The stool becomes firm, smaller, and difficult to pass, resulting in anal irritation an
often an anal fissure.
•In toddlers: coercive or inappropriate toilet training is a factor that can initiate a
pattern of stool retention
•In Older Children: retentive constipation can occur after entering a situation that
makes stooling inconvenient such as school.
Because the process of defecation is painful, voluntary withholding of faecesto avoid
painful stimulus develops

14. Withholding behaviour
➢Refers of fear, anxiety and avoidance of pain associated with defecation.
When children have the urge to defecate, typical behaviourssuch as squatting
in corners, holdingto furnitures/object while standing, stiffeningof body,
crossing of legs while lying down aimed at contracting the gluteal muscle waiting
for the call to stool to pass with the rectum accommodating the contents.
-Caregivers may misinterpret these activities as straining, but it is withholding
behavior.
-There is often a history of blood in the stool noted with the passage of a large
bowel movement.
-Normal weight gain
-Features suggestive of underlying pathology include failure to thrive, weight
loss, abdominal pain, vomiting, or persistent anal fissure or fistula.

15. Pathogenesis and Mechanism of Constipation
•Decreased in propulsive force
•Impaired rectal sensation
•Functional outlet obstruction
•Behaviouralwithholding
•Constipation cycle
Pain/irritationretentionrectumaccommodatesatonic
desensitized rectumlargevolume stoolsrectum dilatescanal
shortensstoolescapes(encopresis)

16. Secondary causes of Constipation
ANATOMIC
•Anal stenosis/atresia
•Imperforate anus
•Anal stricture
METABOLIC
•Hypothyroidism
•Hypokalaemia
•hypercalcaemia
•Diabetes mellitus/insipidus
PSYCHIATRIC DIAGNOSIS
•Anorexia nervosa
INTESTINAL NERVE/MUSCULAR
ABNORMALITIES
•Hirchsprung’sdisease
•Pseudoobstruction
•Spinal cord defects
INTESTINAL DISORDERS
•Celiac disease
•Cow milk protein intolerance
•Meconium ileus
•Cystic fibrosis
•IBD(stricture)
•Tumour
•Connective tissue disorder
•SLE

17. Secondary causes of Constipation
ABNORMAL MUSCULATURE
•Prune-belly syndrome
•Gastroschisis
•Down syndrome
•Muscular dystrophy
DRUGS
•Codeine
•Antidepressants
•Phenytoin
•Vincristine
•Vit D intoxication
•Anticholinergics
•Lead

18. Clinical Manifestations
•Difficulty in passing stools
•Irregular bowel movements
•Passage of hard or large/bulky stools.
•Crampy abdominal pain
•Soiling/daytime encopresis
•Failure to thrive

19. DIAGNOSIS
-History and physical examination
-present at birth or neonatal period
-Delay in meconium passage
-abdominal distension/vomiting
-poor weight gain/FTT
-poor feeding, voiding disturbances
EXAM
FTT, tuft of hair over spine/dimple, failure to anal wink or
cremasteric reflex-spinal pathology, displaced anus,

20. PHYSICAL EXAMINATION
•Gross distension.
•Large volume of stool palpated in the suprapubic area
•Rectal exam-dilated rectal vault filled with guaiac negative stool-
constipation.
•Gush of liquid, solid or air on withdrawal of finger-Hirhsprungdisease
•Limb deformities
•Others

21. FUNCTIONAL VS ORGANIC

22. Investigation
•Functional constipation requires minimum workup.
May be requested to exclude organic causes of constipation.
•Serum Calcium
•Thyroid function test-TSH.T4
•CBC
•Rectal biopsy
•Manometry studies.
Imaging
•Abdominal radiogragh(chronic constipation—dilated rectum)
•Barium enema
•MRI

23. Plain abdominal X-ray with barium enema in a 12
year with chronic constipation. Note dilatation of
rectum and distal colon

24. barium enema in a 3-yr-old girl with HD.Theaganglionicdistal
segment is narrow, with distended normal ganglionic bowel
above it.

25. Investigations...
•Anorectal manometry-inflation of balloon catheter inserted into the
rectum causes relaxation of the internal anal sphincter in functional
constipation but in Hirchsprung’sdisease the is failure of response
•Anal sphincter electromyography
•Rectal biopsy—absence of ganglion cells in the submucosal plexus--
HD

26. HIRCHSPRUNG’S DISEASE
•Congenital aganglionicmegacolon
•Due to absence of ganglion cells in the submucosal and myenteric plexus
in the distal colon.
•Males>female = 4:1
•Associated with various chromosomal abnormalities.
•Diagnosed in the neonatal period as the child fails to paces faeceswithin
48hours of birth and associated with abdominal distension, may have
intolerance to feeds and vomiting.
•Rare in preterm infants.
•Enterocolitis (Clostridium difficile, S.aureus, anaerobes, coliforms)

27. Hirchsprung’sdisease
•Rectal exam-empty rectum with gush of air or liquid stool.
•Contrast enema-transition zone
•Rectal suction biopsy is gold standard for diagnosis
•Anorectal manometry –internal anal sphincter while balloon is distended
in the rectum.
•In healthy individuals, rectal distension causes relaxation of the internal
anal sphincter.
•Absent in Hirchsprung’sdisease.
•Treatment is a staged surgical procedure.

29. Functional Constipation Vs Hirchsprung’s
FUNCTIONAL
CONSTIPATION
HIRCHSPRUNGS DISEASE
AGE Starts after 1year Since birth or within 1-
2months of age
SOILING common unusual
STRAINING ON
DEFECATION
Present No staining
ABILITY TO PASS BULKY
STOOLS
Common Unusual
PAIN AND BLEEDING ON
DEFECATION
Present Unusual
ANAL FISSURES Present Absent
RECTAL EXAM Full hard stool Empty
BARIUM ENEMA Dilated from anal canal up Transition zone
RECTAL BIOPSY Ganglion present Ganglion absent

30. Differential Diagnosis
•Hirchsprungsdisease
•Hypothyroidism
•Anal stenosis
•Imperforate anus
•Hypocalcaemia
•hypokalaemia
•Allergy to cow milk
•Spinal or neuromuscular abnormalities (spinal muscular atrophy and
tethered cord)
•Currarino triad ( rectal stenosis, hemi sacrum, presacral mass)
•Cerebral palsy

31. Treatment
•Aim of treatment is
•i) Education of parents about the condition
•ii) Relief of Disimpaction
•Iii) softening of stool.

32. Education
➢Understand soiling is associated with overflow from constipation and
not associated with sensation so not a willful act.
➢Toilet training by regular post prandial toilet sitting .
➢Eat a balanced diet high in fibre.
➢Avoid punitive measures
➢Encourage reward for adherence to healthy bowel regimens.

33. Disimpaction
•Rapid rectal disimpactionachieved within the first week.
•Manual disimpaction
•Enemas
•Glycerinesuppositories and phosphate enemas are recommended in
infantsnandtoodlers.
•Older children: propyletheleneglycol electrolytes enema-25ml/Kg
upto1L/hruntil clear fluid comes out of the anus.
•Milk of magnesia (2ml/Kg bid x7/7), mineral oil (3ml/Kg bid X 7/7),
lactulose or sorbitol (2ml/Kg/day x 7/7)

34. Maintenance
-Diet high in fibres-fruits and vegetables, whole grains
-Behaviouralmodification-Toilet training, Reward system
-Laxatives: lactulose, PEG(mirilax), milk of magnesia, mineral oil (>12years).
Stimulants-bisacodyl and sennsshould be used for a short time(not more
than a month).
➢Maintenance should continue until regular bowel pattern returns and
association of pain with passage with stool is abolished.

35. Follow-up
•Monthly follow-up till regular bowel movement is achieved
•Follow-up of 3 months for the next 2 years ( laxatives which are
gradually tapered)
•Yearly follow-up:

36. Take home message
•Detailed history and proper physical examination, including digital
rectal examination, can easily differentiate functional from organic
constipation.
•Nearly 95% is of functional origin and often does not require any
investigations
•In most cases prolonged months-years laxative therapy is required
and early withdrawal leads to recurrence

37. Conclusion
▪Constipation is a commonly encountered presentation in our paediatric
consultations.
▪It is important to remember that while treating infants with constipation
it is necessary to to exclude organic causes such as HirchsprungDisease,
cystic fibrosis, cretinism.
▪Avoid mineral oil and prolonged stimulant laxatives.
▪Long term follow up is important.

38. REFERENCES
•NELSON TEXTBOOK OF PAEDIATRICS 20
th
, 21
ST
EDN by KLIEGMAN
•Evaluation and Treatment of constipation in Infants and Children:
Recommendations of North American Society of Paediatric
Gastroenterology, Hepatology and Nutrition (NASPGHAN). JPGN.
2006; 43: e 1-e13.

39. •Questions????

40. ASSIGNMENT
•List 5 causes of constipation in a neonate.
•Write short notes on meconium plug.
•What is the Bristol stool form scale?

41. Thanks for
your
Attention