Recent_Onset_Constipation_Algorithm_Case.pptx

Update of constipation

1. Recent-Onset Constipation in Infants & Children Clinical Algorithm – Based on UpToDate 2025

2. Step 1: Assessment - Duration <8 weeks? → Yes = recent-onset - Alarm signs (since birth, delayed meconium, bilious vomiting, severe distension, abnormal neuro exam)? • Yes → Evaluate for organic cause • No → Proceed

3. Step 2: Infants (<1 year) If not yet on solids: • Sorbitol juices (<4 mo: 1–2 oz prune; ≥4 mo: 2–4 oz apple/pear/prune) • Lactulose 1 mL/kg/day If on solids: • Fiber-rich foods (peas, prunes, barley/multigrain cereals) • Occasional glycerin suppository/rectal stimulation If persistent (>6 mo): • Osmotic laxatives (PEG 3350, lactulose, sorbitol) • Avoid mineral oil, enemas, bisacodyl

4. Step 3: Toddlers & Children (≥1 yr) Mild symptoms: • Hard stools, straining, minimal pain, no fissure/withholding → Increase dietary fiber (age+5–10 g/day), fluids (32–64 oz/day) Moderate/Severe: • Withholding, pain, fissure, bleeding → PEG 3350: 0.4 g/kg/day • Impaction: PEG 1–1.5 g/kg/day ≤6 days • Alternatives: milk of magnesia, lactulose • Fissure: petroleum jelly

5. Step 4: Nonresponse / Relapse Check triggers: • Painful stooling, fissures • Fear of school toilet • Early laxative withdrawal Management: • Optimize diet (fiber + fluids) • Fiber supplements (psyllium, methylcellulose) + fluids • Clean-out laxatives or sodium phosphate enema • Maintenance laxatives if needed

6. Step 5: Follow-Up • Goal: soft, pain-free stools (not necessarily daily) • Schedule follow-up visits if recurrent • Educate parents on prevention: - Solid food introduction - Toilet training - School entry

7. Flowchart: Recent-Onset Constipation in Infants & Children Step 1: Assess - Duration <8 weeks? - Alarm signs? Infants (<1 yr) - Juices / Lactulose - Fiber foods - PEG if persistent Toddlers & Children (≥1 yr) - Mild: Fiber + Fluids - Severe: PEG / Laxatives Nonresponse / Relapse - Check triggers - Fiber supplements - Clean-out / Enema Follow-Up - Soft, pain-free stools - Prevent recurrence - Parent education

8. Flowchart: Recent-Onset Constipation in Infants & Children (Enhanced Visuals) Step 1: Assess - Duration <8 weeks? - Alarm signs? Infants (<1 yr) - Juices / Lactulose - Fiber foods - PEG if persistent Toddlers & Children (≥1 yr) - Mild: Fiber + Fluids - Severe: PEG / Laxatives Nonresponse / Relapse - Check triggers - Fiber supplements - Clean-out / Enema Follow-Up - Soft, pain-free stools - Prevent recurrence - Parent education

9. Interactive Case Question 👶 Case: A 2-year-old child presents with painful defecation for 1 week. - Hard stools, straining - No bleeding, no withholding behavior - Diet: high cow’s milk intake, low fiber ❓ Question: What is the best initial management? A) Start PEG 3350 immediately B) Increase fiber intake and fluids C) Use glycerin suppositories daily D) Order abdominal X-ray