Pediatric Constipation: Pediatric Constipation Maria I. Clavell, M.D. Department of Pediatrics Division of Gastroenterology


Background: Background 10% of children seeks medical attention because of constipation 2nd most referred condition to pediatric gastroenterologists Defecation patterns in health vary with age and is hard to define Fecal impaction with soiling is a common complication of chronic constipation Up to 5% of children suffer from soiling at time of entrance to school Rappaport LA, Levine MD. The prevention of constipation and encopresis: a developmental model and approach. Pediatr Clin North Am 1986; 33: 859-69.


ETIOLOGY: ETIOLOGY 95% 5% FUNCTIONAL ORGANIC ANATOMIC METABOLIC NEUROPATHIC ENDOCRINE CONNECTIVE TISSUE D/O DRUGS LEAD INTOXICATION OR BOTULISM


Symptom based criteria for childhood defecation disorders - ROME II : Symptom based criteria for childhood defecation disorders - ROME II Infant Dyschezia Functional Constipation Functional Fecal Retention ROME II: A multinational Consensus Document on Functional Gastrointestinal Disorders. Gut 1999; Suppl: II60-68.


Infant Dyschezia: Infant Dyschezia Under 6 months of age Otherwise healthy 10 minutes of straining/ crying Several times a day Successful passage of soft or liquid stools ROME II: A multinational Consensus Document on Functional Gastrointestinal Disorders. Gut 1999; Suppl: II60-68.


Functional Constipation: Functional Constipation Infants and Pre-school 2 weeks duration Pebble-like, hard stools Firm stools <2 times/week No evidence of structural, endocrine, or metabolic disease ROME II: A multinational Consensus Document on Functional Gastrointestinal Disorders. Gut 1999; Suppl: II60-68.


Functional Fecal Retention: Functional Fecal Retention Most common cause of chronic constipation Associated with fear and toilet refusal From infancy to 16 years old 12 weeks or longer Passage of large diameter stools < 2 times/week Retentive posturing ROME II: A multinational Consensus Document on Functional Gastrointestinal Disorders. Gut 1999; Suppl: II60-68.


Physiology of Colon in defecation: Physiology of Colon in defecation segmental, non-propagated phasic and tonic contractions -mixing and churning powerful high-amplitude propagated contractions- forward motion changes in colonic tone after a meal (gastro-colonic reflex) and upon awakening moving stools to the rectosigmoid region


DIFFERENTIATING FEATURES OF FUNCTIONAL FECAL RETENTION (FFR) AND COLONIC NEUROMUSCULAR DISORDERS (CNMD): DIFFERENTIATING FEATURES OF FUNCTIONAL FECAL RETENTION (FFR) AND COLONIC NEUROMUSCULAR DISORDERS (CNMD) History FFR CNMD Starting at Birth Never Common Retentive Posturing Common Unusual Soiling/Encopresis Common Rare Large Caliber Stools Common Unusual History of Obstruction Rare Common Physical Exam Failure to thrive Unusual Common Distended abdomen Common Occasional Stool in Ampulla Common Rare Rectal Ampulla Dilated Narrow


Physiology of defecation : Physiology of defecation rectal wall is distended reflex contraction of the rectum with relaxation of the internal anal sphincter, pushing fecal material into the anal canal :“the firing position” sensitive lining of the anoderm perceives the stool decision to expel or to postpone defecation by contracting the external anal sphincter and the puborectalis muscle


To go or not to go ?: To go or not to go ? children who have had an unpleasant experience with a bowel movement last step of the defecation process becomes disrupted concrete way of thinking, react to unpleasant activities with vigorous, and often successful, attempts to avoid repeating those experiences at almost any cost Is this one going to hurt ?


Stool Withholding Behavior: Stool Withholding Behavior anxious body becomes stiff face turns pale begins to cross the legs hops up and down hides to a corner


Consequences of Functional Fecal Retention: Consequences of Functional Fecal Retention rectum becomes dilated and filled with large amounts of fecal material soiling occurs when liquid stool arrives in the rectum, encounters impacted stool, and begins to seep around it liquid stool is passed into the undergarment of the child without his/her awareness


Impaction: Impaction hard mass in the lower abdomen on physical exam a dilated rectum filled with a large amount of stool on rectal exam excessive stool in the colon on radiography


North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition: North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Determine if fecal impaction is present Treat impaction if present prior to maintenance therapy When oral medication is used, it should be a softener not a stimulant Parental education Close follow up with behavior modification Baker SS et al. Constipation in Infants and Children: Evaluation and Treatment. J Pediatr Gastroenterol Nutr 1999; 612-626.


Goal of therapy: Goal of therapy Evacuation of stools without pain


Management strategy for treatment of chronic constipation : Management strategy for treatment of chronic constipation DISIMPACTION maintenance therapy monitoring and behavior modification


Disimpaction: Disimpaction Prior to the initiation of maintenance therapy Oral, rectal route or combination Oral route is non-invasive and gives the child sense of power Rectal route is faster but invasive No randomized studies comparing the effect of one to the other


Disimpaction using oral medication: Disimpaction using oral medication Mineral oil and polyethylene glycol solution have been shown to be effective No controlled studies in magnesium citrate, lactulose, senna, and bisacodyl but reported to be effective Problems include large volumes and bad taste leading to poor compliance


Commonly Used Medications: Commonly Used Medications AGENTS DOSAGES SIDE EFFECTS OSMOTIC: Lactulose/ 1-3 ml/kg/day ÷ BID bloating, cramps, diarrhea Sorbitol Magnesium citrate 1-3 ml/kg/day ( 12y) secondary hypocalcemia Magnesium hydroxide 1-3 ml/kg of 400mg/5 ml hypermagnesemia available as liquid hypophosphatemia and secondary hypocalcemia LUBRICANT: Mineral Oil 1-3 ml/kg/day (maintenance) aspiration risk 15-30 ml/year of age (disimpaction) LAVAGE: Polyethylene Glycol (PEG) 5-10 ml/kg/day nausea, vomiting, cramps, risk for aspiration 25 ml/kg/hr via nasogastric tube STIMULANTS: Senna 2.5 –7.5 ml/day (2-6y) melanosis coli, hepatitis 5-15 ml/day (6-12y)


In conclusion…: In conclusion… Childhood constipation is common Painful defecation and fear are contributing factors Fecal impaction and subsequent soiling are usually associated Disimpaction prior to starting maintenance medication is highly recommended