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Pediatric Constipation
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Pediatric Constipation
, Constipation in Children
See Also
Constipation in Adults
Constipation in Infants
Epidemiology
Responsible for 3% of pediatric primary care visits (and 10-25% of pediatric gastroenterology visits)
Definition
Decrease in stool frequency
Fewer than 3 stools per week
Decreased fluidity of
Bowel Movement
s
Most stools are hard, pebble-like or scybalous
Physiology
See
Defecation
Mean stool frequency varies by age
Breast
fed infants under age 3 months: 2.9 stools/day (but healthy
Breast
fed infants may go days without a stool)
Formula-fed infants under age 3 months: 2 stools/day
Age 6 to 12 months: 1.8 stools per day
Age 1 to 3 years: 1.4 stools per day
Age over 3 years: 1.0 stools per day
References
Baker (1999) J Pediatr Gastroenterol Nutr 29:612-26 [PubMed]
Etiologies
See
Constipation Causes in Children
See
Constipation Causes in Newborns
Functional Constipation
(non-organic) causes are most common
Often caused by stool witholding due to painful
Bowel Movement
s
History
Stool
characteristics
Time of passage of first meconium
Delayed >48 hours in
Hirschsprung's Disease
Age of onset of stool problems
Neonatal (especially under age 1 month) onset suggests congenital cause
Onset under age 1 year suggests dietary cause
Onset after 18 months suggests behavioral cause (
Functional Constipation
)
Timing of stool problems
Acute Constipation
suggests organic cause
Chronic Constipation
suggests functional cause
Older children will often have
Colicky Abdominal Pain
after eating in
Functional Constipation
Frequency of stools
Infants without stool in 2 days or even up to 7 days may be normal pattern (especially in
Breast
fed infants)
Normal stool frequency may suggest
Irritable Bowel Syndrome
Size of
Bowel Movement
s
Large caliber stools suggests functional cause (especially stool witholding)
Small caliber stools suggest
Hirschsprung's Disease
Associated symptoms and conditions
Abdominal Pain
Relieved with
Defecation
may suggest
Irritable Bowel Syndrome
Exclude other causes of
Abdominal Pain
Presence of pain with
Defecation
Consider
Anal Fissure
s (May also present with blood on stool)
Presence of
Rectal Prolapse
Systemic symptoms (see red flags below)
Suggests organic cause
Bowel
control
Age of
Toilet Training
Presence of
Encopresis
or fecal soiling (suggests
Fecal Impaction
)
Presence of
Enuresis
Stool
withholding (see below)
Prior and current management (medications, diagnostics)
Review medication dosages to date
Diet Diary (7 day history of foods and symptoms)
Family History
Constipation
Hirschsprung's Disease
Celiac Disease
Cystic Fibrosis
Thyroid
disease
Parathyroid
disease
Colon Cancer
or
Colonic Polyp
s
Past medical and developmental history
Psychosocial history (emotional stressors)
May have triggered behavior change including stool witholding
History
Reassuring suggestive of functional cause
Infrequent, hard, large-caliber stools
Encopresis
recurs after completing
Toilet Training
Pain on passing stool
Perianal fissures (may causes blood on stool surface)
Benign abdominal exam
Stool
witholding behaviors
Child stiffens body to contract buttocks or anal sphincter
Child hides in corner while stooling in diaper, crosses legs, rocks back and forth or fidgets with each urge to defecate
Results in fecal stasis with hardening and enlarging of distal stool, that becomes more difficult to pass
Ultimately stretches
Rectum
, decreases
Defecation
urge sensation and results in
Stool Incontinence
History
Red flag symptoms suggestive of organic cause
See
Hirschprung's Disease
See
Spinal Dysraphism
No meconium by 48 hours old
Hirschprung's Disease
Cystic Fibrosis
Congenital malformation of anorectum
Spinal Dysraphism
Failure to Thrive
Hirschprung's Disease
Malabsorption
Cystic Fibrosis
Metabolic disorder
Abdominal Distention
Hirschprung's Disease
Fecal Impaction
Pseudoobstruction or other neuroenteric condition
Occult blood in stool
Hirschprung's Disease
Food Allergy
Onset of
Constipation
symptoms under age 1 month
Small-caliber stools
Fever
Bloody
Diarrhea
Bilious Vomiting
Weight loss
Abdominal Pain
Nausea
or
Vomiting
(especially
Bilious Emesis
)
Exam
Growth evaluation for
Growth Delay
Malabsorption (
Cystic Fibrosis
,
Celiac Disease
)
Abdominal exam
Abdominal Distention
Abdominal mass (Suprapubic fecal mass may be felt)
Hepatomegaly
or
Splenomegaly
Anal inspection
Anterior anus
Hemorrhoid
s
Anal Fissure
s
Rectal Examination
Assessment of anal sphincter
Retained stool
Fecal Occult Blood Test
ing
Back Inspection
See
Cutaneous Signs of Dysraphism
Sacral sinuses or sacral hair tufts
Neurologic Exam
Lower extremity reflexes and
Motor Exam
Anal Wink
Cremasteric Reflex
Diagnosis
Rome III Criteria for
Functional Constipation
<4 years old (at least 2 criteria present for one month)
Two or less
Bowel Movement
s per week
One or more
Stool Incontinence
episodes per week (after
Toilet Training
is complete)
Excessive stool retention history
Painful or hard
Bowel Movement
history
Large rectal fecal mass
Large diameter stools (may plug the toilet)
Diagnosis
Rome III Criteria for
Functional Constipation
>4 years old (at least 2 criteria present weekly for 2 months)
Insufficient criteria for
Irritable Bowel Syndrome
Two or less
Bowel Movement
s per week
One or more
Stool Incontinence
episodes per week (after
Toilet Training
is complete)
Excessive voluntary stool retention history (or retentive posturing)
Painful or hard
Bowel Movement
history
Large rectal fecal mass
Large diameter stools (may plug the toilet)
Differential Diagnosis
See
Constipation Causes in Children
See
Constipation Causes in Newborns
See
Medication Causes of Constipation
Labs (consider if suggested by history)
Thyroid Function Test
Blood Urea Nitrogen
Serum
Electrolyte
s
Serum Calcium
Serum Magnesium
Blood lead level
Celiac panel (e.g. Tissue Transglutaminase)
Sweat Test
Imaging (indicated for red flags above)
Abdominal XRay (KUB)
No benefit in
Constipation
(diagnosis is clinical)
Berger (2012) J Pediatr 161(1):44-50 +PMID:22341242 [PubMed]
Associated with increased risk of missing serious diagnosis (
Intussusception
,
Appendicitis
)
Freedman (2014) J Pediatr 164(1): 83-8 +PMID:24128647 [PubMed]
Unprepped
Barium Enema
Indications
Suspected anatomic abnormalities
Hirschsprung's Disease
Colonic strictures from
Necrotizing Enterocolitis
Rectal manometry
Hirschsprung's Disease
Anismus
Paradoxical external anal sphincter contraction
Rectal suction biopsy by surgery
Assess for
Hirschsprung's Disease
Transit study
Administer radiopaque marker rings over 3 days
Perform Abdominal XRAy (KUB) on third day
Consider
Spinal Dysraphism
evaluation (
L-Spine MRI
)
Evaluation
Initial evaluation in all patients
Careful history and examination as above
Consider Constipation in Children causes
Red flag symptoms or signs present
Pediatric Gastroenterology referral
Diagnostic testing as directed by history
No red flag symptoms or signs
Empiric management for functional causes (see below)
If no improvement with empiric therapy
Consider Lab testing above
Consider pediatric gastroenterology
Management
Pediatric Constipation Management
Pediatric Constipation Dietary Management
References
Bergeson (1996) Med J Allina 5(2):6-10
Arce (2002) Am Fam Physician 65(11):2283-96 [PubMed]
Leung (1996) Am Fam Physician 54(2):611-18 [PubMed]
Nurko (2014) Am Fam Physician 90(2): 82-90 [PubMed]
Rasquin-Weber (1999) Gut 45(suppl 2):1160-8 [PubMed]
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