FEATURE ARTICLE

Constipation in Children: A Practical

Review
Shailender Madani, MD; Lisa Tsang, BS; and Deepak Kamat, MD, PhD

ABSTRACT constipation also costs the US health ing and/or pain without an organic eti-
care system an estimated $3.9 billion ology. Although there are a number of
Pediatricians and other child care pro- per year.3 Moreover, 25% of children definitions, the Rome III definition is
viders manage a large number of chil- who present with functional constipa- the most accepted definition of func-
dren with constipation, a recurrent medi- tion will continue to have bowel prob- tional constipation.7 For a child young-
cal problem that is frustrating to patients, lems as adults.4 In addition to the health er than age 4 years, at least two of the
their care givers, and the health care implications, the social ramifications following criteria must be present for
providers themselves. Most often the of constipation include self-esteem is- 1 month: two or fewer defecations per
constipation in children is functional in sues, social isolation, and family dis- week, at least one episode of inconti-
nature, and only a very small percentage ruption.3,5,6 Thus, the long-term health, nence per week, history of excessive
of patients have an organic cause for it. In social, and economic implications of stool retention, history of painful or
this review, we discuss the epidemiology, childhood constipation should provide hard bowel movements, presence of
causes, evaluation, and management of enough impetus for the primary care large fecal mass in the rectum, or his-
children with functional constipation. physician to learn a practical, goal- tory of large-diameter stools that may
[Pediatr Ann. 2016;45(5):e189-e196.] oriented approach for its evaluation and obstruct the toilet.7 For a child at age
management. 4 years or older without evidence of ir-
ritable bowel syndrome, at least two of

C
onstipation is one of the most WHAT IS CONSIDERED the previously mentioned criteria must
common conditions for which CONSTIPATION? be present for at least 2 months.7 Aside
children are brought to health Constipation occurs when there is from the small minority of children
care facilities. It accounts for 3% of an abnormally delayed or infrequent who have an organic cause of constipa-
all visits to primary care physicians passage of hard feces accompanied by tion, which is usually discovered dur-
and up to 25% of referrals to pediat- excessive straining and or pain.7 Func- ing the neonatal period, the majority
ric gastroenterologists.1,2 Not only is tional constipation is an abnormally of children have functional constipa-
it a common symptom that distresses delayed or infrequent passage of hard tion.2,8
parents and children alike, childhood feces accompanied by excessive strain-
WHAT IS CONSIDERED A NORMAL
BOWEL PATTERN?
Normal bowel pattern varies de-
Shailender Madani, MD, is an Assistant Professor of Pediatrics, Wayne State University School of pending on the age of the child. An
Medicine, Division of Pediatric Gastroenterology, Children’s Hospital of Michigan. Lisa Tsang, BS, is a infant in the first week of life on an
fourth-year Medical Student, Wayne State University School of Medicine. Deepak Kamat, MD, PhD, is a average passes four stools per day.1,2
Professor of Pediatrics, Wayne State University School of Medicine, Department of Pediatrics, Children’s At age 2 years, the average frequency
Hospital of Michigan. is closer to two stools per day. Around
Address correspondence to Shailender Madani, MD, Wayne State University School of Medicine, Di- age 4 years, the frequency of bowel
vision of Pediatric Gastroenterology, Children’s Hospital of Michigan, 3901 Beaubien Street, Detroit, MI movements is similar to adult pat-
48201; email: smadani@dmc.org. terns (from 3 times per day to 3 times
Disclosure: The authors have no relevant financial relationships to disclose. per week).1,2 In healthy breast-fed
doi: 10.3928/00904481-20160323-01
babies, bowel movements may not

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 FEATURE ARTICLE

occur for several days, which can be patient and caregivers define constipa- test for fecal occult blood in the stool
alarming to parents who are unaware tion, what is the frequency of bowel is recommended in all infants with
that this pattern is considered normal as movements, what are the consistency constipation, significant abdominal
long as the baby does not show signs of and size of stools, whether there is pain pain, failure to thrive, family history
distress with defecation.8,9 or blood upon defecation, and if there of colon cancer, or colonic polyps.1,2
is a history of stool-withholding be-
WHAT IS THE MECHANISM OF havior in the child.2 Additional impor- WARNING SIGNS OF ORGANIC
FUNCTIONAL CONSTIPATION? tant information includes medication CONSTIPATION
Functional constipation can oc- use; dietary, family, and social history; Although most cases of constipa-
cur when a child experiences dietary incidence of stressful life events such tion presenting for evaluation are func-
changes or stressful events; during toilet as a death in the family; parental di- tional constipation, there is a small
training, illness, or dehydration; or if the vorce; school problems; sexual abuse; minority of organic cases in which
child has a busy schedule.10 Other fac- and if there is a history of treatment the practitioner must quickly act in to
tors include neurodevelopmental disor- for constipation.12 prevent complications and decreased
ders of any kind, autism spectrum dis- In evaluating a patient with consti- quality of life for the patient and even
orders, and prescription medications.11 pation, a thorough physical examina- for family members. If clinical mani-
In these situations, the child fights the tion is a simple but important tool that festations include delayed meconium
urge to defecate and contracts the anal the physician can use to further eluci- passage (>48 hours after birth), failure
sphincter and gluteal muscles, fidgeting date the cause of constipation. Impor- to thrive, abdominal distention, empty
in a dance-like behavior with each urge tant aspects of this include the abdom- rectum, and tight anal sphincter, a di-
to defecate.10 Parents may misinterpret inal examination, perianal inspection, agnosis of Hirschsprung disease must
this “stool dance” as the child straining anorectal digital examination, thyroid be considered.1,2 The health care pro-
to defecate.1,2 Withholding of stool can examination, and spinal evaluation.1,12 vider must consider the possibility of
lead to stagnant stool in the colon, which The abdominal examination can pro- congenital malformation of the ano-
can become harder, larger, and more dif- vide any indication of gas or fecal ac- rectum or spine, milk protein allergy,
ficult to pass as more fluid reabsorption cumulation, whereas inspection of the cystic fibrosis, and metabolic or endo-
occurs. Over time, these children experi- perianal region can provide clues to crine conditions causing hypercalce-
ence fecal incontinence due to overflow sexual abuse and show skin tags, fis- mia.1
caused by stretching and desensitization sures, or dermatitis.12 A routine digital Physical examination results that
of rectum by fecal impaction.1,10 Table 1 anorectal examination for the diagno- signal an organic cause of constipa-
shows common risk factors for constipa- sis of functional constipation is not tion include pilonidal dimple covered
tion. recommended by the National Insti- by a hair tuft, abnormal neurologic
tute for Health and Care Excellence, examination, and abnormal pigmenta-
A QUICK AND EASY METHOD FOR the European Society for Paediatric tion near the lower spine.1 With these
EVALUATING CONSTIPATION Gastroenterology Hepatology and findings, one must consider evaluation
A simple goal-directed history and Nutrition, or the North American So- for spinal cord abnormalities such as
physical examination is all that is nec- ciety for Pediatric Gastroenterology, tethered cord. Also, one has to be alert
essary to efficiently diagnose consti- Hepatology and Nutrition.7,11 How- when the following clinical manifesta-
pation. Answers to two questions hold ever, the digital anorectal examination tions are present: occult blood in stool,
the key to diagnosis: (1) What was the is indicated when there are worrisome perianal skin tags, fistulas, anterior
age when constipation first started? symptoms and signs such as deep anal displacement of the anus (ie, the ano-
and (2) What were the circumstances/ fissure(s), unexplained anemia, poor genital index, which is the distance in
events around the initial constipation growth/weight loss or encopresis/en- centimeters from the vagina or scro-
event? Refer to Table 2 and Table 3 uresis. Digital anorectal examination tum to the anus, divided by the dis-
for a quick diagnosis and management can assess for the presence of anal tance from the vagina or scrotum to the
based on answers to these two ques- wink, perianal sensation, anal tone, coccyx [the normal anogenital index
tions. and size of the rectal vault.1 However, in females is 0.39 cm + 0.9 cm and in
Other information that is useful this should be avoided when children males is 0.56 cm + 0.2 cm]). One also
includes whether or not there was de- present with clear withholding behav- has to be alert if there is vomiting, fe-
layed passage of meconium, how the ior or when trauma is suspected.1,2 A ver, bladder dysfunction, or decreased

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 FEATURE ARTICLE

lower extremity strength.12,13 Being TABLE 1.

aware of these signs and symptoms al-
lows one to identify organic causes of Common Associations with Constipation
constipation.
Type of Risk Factor Example
TREATMENT OPTIONS Dietary Transition from breast-milk to formula or to cow’s milk

The treatment of functional con- Starting rice cereal

stipation is a four-pronged approach: Lack of fiber

education, disimpaction, maintenance Psychosocial Toilet training

therapy, and long-term follow up. All of Birth of sibling
these are vital for success in the long run Starting school
in the backdrop of a strong partnership Parental strife/divorce
between the physician, parent, and child. Toilet phobia
Table 4 lists common medications used Sexual abuse
to treat constipation. Depression/anxiety
Medications Antidepressants
Education ADD/ADHD medications
The first and most important step in Opiates
educating the parent and child (in an Anatomic or medical conditions Anal stenosis
age-appropriate manner) is to explain Anterior displacement of the anus
the pathophysiology of constipation and Spinal cord abnormalities
fecal incontinence. In this discussion, it Hirschsprung disease
is crucial to emphasize that fecal soiling Cow’s milk protein intolerance
happens because of involuntary over- Celiac disease
flow of the stool and not because of de- Cystic fibrosis
liberate defiance.2,10 Remember, parents Irritable bowel syndrome
and patient can feel ashamed, guilty, Perianal lesions due to Crohn’s disease
and helpless in their own way. During Lead ingestion
this conversation, the physician should Hypercalcemia
encourage parents to be supportive and Abbreviations: ADD, attention-deficit disorder; ADHD, attention-deficit/hyperactivity disorder.
to maintain a positive attitude through- Adapted from Auth et al.10 and Greenwald.11

out the treatment process as it can be

frustrating for the child as well. Remem-
ber to set clear and realistic expecta- A major task to ensure success is for On the other hand, rectal disimpac-
tions that relapses do occur and that the the physician to dispel this miscon- tion has been shown to be faster, but
proper management of constipation is ception and offer unambiguous reas- it is invasive. 2 The method of choice
a long-term process.8,12,14 At this time, surance regarding the use and safety should be determined with a discus-
recommend the use of a footstool so that of laxatives. 8 sion among the physician, parent,
the child can use their legs to increase and child. The first-line therapy for
intra-abdominal pressure and effectively Disimpaction oral fecal disimpaction is polyeth-
use their pelvic muscles to defecate.8 A When there is a palpable fecal ylene glycol (PEG) 3350 solution
major setback to success in treatment is mass on abdominal examination or in adequate doses. 7 Alternatively,
the parents’ commonly held belief about hard stool is felt in a dilated rectum magnesium citrate given orally and
“dependence on” or “addiction” to laxa- on a digital rectal examination, dis- repeated again after 4 to 6 hours if
tives. This results in parental under- impaction is warranted. Disimpac- response is inadequate, is effective
dosing in which parents administer dos- tion can be done via oral therapy, therapy. PEG 3350 administered via
es intermittently or only as needed. Of- rectal therapy, or a combination of nasogastric tube can be considered
ten times parents may even prematurely both. Children tolerate the oral route as a third option.
discontinue treatment before a pain-free better because it is not invasive and When rectal disimpaction is
bowel movement pattern is established. it gives children a sense of control. 2 deemed necessary, a phosphate en-

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 FEATURE ARTICLE

TABLE 2.

Answers to the Two Cardinal Questionsa that Are Key to Diagnosis and Management

Age Clinical Scenario Diagnosis Next Step

Newborn Otherwise healthy newborn who has distressed Idiopathic constipation Use corn syrup or lactulose
defecation since birth with no delay of meconi-
um passage, no clinical evidence of obstruction,
with or without a family history of constipation
10 days Breast-fed baby with no bowel movements since Breast-milk constipation Offer effective parental reassurance
discharge 5 days prior. Baby is comfortable but
mother is distressed
2 weeks Breast-fed baby presents with no bowel move- Formula constipation Treat with lactulose
ments for 3 days since starting formula supple- Can consider adding 1 tsp/oz of infant
mentation. Baby cries, turns red in the face, and oatmeal to formula
passes hard small stools every 1-2 days for past
few days
4 months Formula-fed baby, previously healthy, presents Rice cereal constipation (rice Advise parent to add infant oatmeal cereal
with 2 weeks of constipation. Baby was recently blocks chloride channel) 1-2 tsp/oz 2-3 times per day
started with rice cereal supplementation Lactulose use is another effective option
1-6 months Otherwise well breast-fed/bottled-fed infant Infantile dyschezia Provide education and reassurance (eg, this
with bowel movement 1-2 times per day, who is a self-limited condition that improves
screams and strains for 10 minutes before with maturation of muscle coordination)
evacuating soft stool Oatmeal supplementation can help
1 year Healthy child who is growing normally with Whole milk constipation (due Treat with lactulose, or PEG 3350 solution
previously normal bowel movements presents to higher protein to carbohy- and supplemental fiber in diet
with a 2-week history of constipation. Stools are drate ratio) Routine advice to introduce whole milk
described as “rock hard” (with or without bright gradually at age 1 year
red blood on the surface). Child has history of
whole milk consumption
4 years Otherwise healthy child with previously normal Psychosocial constipation Educate family on the role of psychosocial
bowel movements who presents with recent factors (autonomy vs shame and doubt)
onset of constipation for 3-4 days. There is as- Provide reassurance to patient and parent
sociated excessive straining and crying. Patient Treat with PEG 3350 solution for as long as
recently started toilet training and showed with- required (months to years)
holding behavior
5 years Otherwise healthy child with previously normal Functional constipation Educate regarding constipation and regu-
bowel movements, except for occasional irregu- lar toileting habits with foot support
lar stools, now presents with constipation Treat with PEG 3350 solution for as long as
required (months to years)
Promote high-fiber diet
7 years Otherwise healthy child presents with no bowel Functional constipation Establish rapport with patient and patient’s
movements for 10 days and a history of consti- (remember that after establish- family
pation since birth and multiple past emergency ing regularity, an inability to Treat with an adequate dose of PEG 3350
department visits. History of passing wide- wean off a laxative is a “red solution daily for as long as required (reas-
caliber hard stool that plugs the toilet flag” for an organic cause like sure safety of long-term use)
Hirschsprung disease) Promote high-fiber diet
Educate regarding constipation and regu-
lar toileting habits with foot support

ema is a good choice, but phosphate dren younger than age 2 years. 3,10,14 effective and safe choice, especially
enemas are contraindicated in chil- Glycerine suppositories are also an in infants. 14

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 FEATURE ARTICLE

TABLE 2. (continued)

Answer to the Two Cardinal Questionsa that Are Key to Diagnosis and Management

Age Clinical Scenario Diagnosis Next Step

12 years Healthy child with a history of constipation Functional fecal retention with Rule out neurologic problems on neuro-
during infancy who presents with leakage of overflow logic examination. If abnormal, X-ray and
feces into underwear. Child may or may not have or MRI of lumbosacral spine should be
bowel movements in the toilet and fecal lumps considered
are felt per abdomen Rule out potential psychosocial issues
Educate family
Reassure child
Implement regular toilet schedule
Treat with PEG 3350 and stimulant laxative
(senna herb)
13 years Previously well teenager who presents with con- Sexual abuse constipation Obtain history from child with sensitivity
stipation and encopresis starting 6 weeks prior Give perspective to child and parent
During examination, patient appears detached Make appropriate referrals (social work and
and often replies, “I don’t know” to inquiries psychiatry)
May be afraid of physical examination or anal
inspection

Abbreviations: MRI, magnetic resonance imaging; PEG, polyethylene glycol.

a
The two cardinal questions are (1) when did constipation first start (and at what age) and (2) what were the circumstances/events around the initial constipation event?

Maintenance Therapy tion with laxatives.15 Behavioral modi- Rescue Therapy

When fecal disimpaction has been fication includes scheduled toilet time Rescue therapy should be considered
accomplished, the goal thereafter for 5 to 10 minutes after meals com- when there is recurrence of impaction
should focus on preventing recur- bined with a reward system when the for any reason (missed dose, ran out of
rences with use of maintenance ther- constipated child uses toilet time.1,2,12 medication) or when osmotic laxatives
apy. Maintenance therapy consists of Additionally, caretakers should also are ineffective.1,2 Stimulant laxatives,
laxatives in adequate doses for requi- keep diaries of stool frequency, which such as senna (an herb), should be used
site duration, dietary supplementation can be taken to the health care provid- intermittently or for short periods in
with fiber, and behavioral modifica- er and serve as positive reinforcement these situations.1,2 Be aware that further
tions.2 PEG 3350 is the recommended for the child.2,8 In some cases, referral evaluation is necessary when a child re-
laxative to be used for maintenance for counseling may be helpful when quires long-term stimulant laxatives.1
therapy, with lactulose as the prefer- there are motivational or behavioral
able alternative.7,11 Experts agree that issues. Besides laxatives and behav- WHAT ARE SOME OF THE
laxative treatment should last for at ioral modification, dietary changes can CHALLENGES TO SUCCESSFUL
least 2 months and that regular bowel play a role in decreasing symptoms TREATMENT?
movements should occur for at least of constipation. Although probiotics, The following are phrases or messag-
1 month before discontinuing laxa- prebiotics, and fiber supplementation es that have been found to be effective for
tive treatments.7 In some cases, laxa- are not recommended for treatment of the parent to hear to ensure adherence.
tives may need to be used for months functional constipation in children,7 If there is parental prejudice about
or years. When providing instructions increased intake of fluids and carbo- the term “laxative” and concern for be-
to parents, advise them that laxatives hydrates, especially sorbitol (which is coming “laxative dependent,” then these
can be titrated to treatment response.1,8 found in juices) can increase the fre- sentences can be helpful: “A laxative is
Along with laxative use, behavioral quency and water content of stools.8,16 a medication that encourages a bowel
modification should be implemented. Moreover, a balanced diet that includes movement but it has a negative connota-
Such an approach has been shown to be fruits, whole grains, and vegetables is tion in society. However it is what your
more effective when used in combina- recommended for treatment.2,8 child needs to get better.” Other messag-

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TABLE 3.

Organic Causes of Constipation

Age Clinical Scenario Diagnosis Next Step
Newborn Newborn presents with abdominal distention with or Hirschsprung disease Refer to surgery or gastroenterologist
without vomiting, and no meconium passage after 48 Needs rectal biopsy and or rectal manom-
hours of life etry
7 months Infant who previously defecated normally presents with Celiac disease Order TTG IgA antibody and quantitative
constipation for 1 month after introduction of weaning IgA level to screen
foods. History of negative occult blood test Refer to gastroenterologist if positive
5 years Child with a history of cerebral palsy/shunted hydro- Functional outlet Consider enema with or without digital
cephalus who presents with 7-day history of no bowel obstruction with impaction
movements. Bowel movements usually occur every decreased propulsive Change to a different laxative
3-4 days with laxative only. Fecal lumps per abdominal forces and impaired Consider PEG 3350 solution administered
examination rectal sensation via NGT or gastrostomy tube
Any age child Child, with history of slow growth and anorexia who Celiac disease Order TTG IgA antibody and quantitative
presents with constipation and abdominal distension IgA level to screen
with or without pain. Occult blood test is negative Refer to gastroenterologist if positive
Any child >5 Child with history of slow weight gain, anemia, and posi- Crohn’s disease Order CBC, ESR, CRP, albumin
years tive occult blood test who presents with constipation Refer to gastroenterologist for upper
and abdominal pain. Look for perianal lesions endoscopy and colonoscopy
10-12 years Child with history of chronic constipation, poor weight Hirschsprung disease Refer to surgery or gastroenterologist
gain, intermittent diarrhea, fecal lumps, and inability Needs rectal biopsy and or rectal manom-
to wean off PEG 3350 solution who presents with etry
discharge of foul-smelling liquid stools/gas after with-
drawal of finger from rectal examination
Abbreviations: CBC, complete blood count; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IgA, immunoglobulin A; NGT, nasogastric tube; PEG, polyethylene glycol; TTG, tissue transglu-
taminase.

TABLE 4.

Medications Used to Treat Pediatric Constipation

Type of Therapy Medication Dosage Side Effects

Disimpaction Magnesium citrate Age <6 years: 1-3 mL/kg/day Magnesium poisoning (infants)
Age 6-12 years: 100-150 mL/day (single or Hypermagnesemia, hypophosphatemia, and
divided dose) secondary hypocalcemia
Polyethylene glycol 3350 1-1.5 g/kg/day for 3 days Limited, occasional abdominal pain, bloating,
loose stools

Maintenance Polyethylene glycol 3350 Starting dose 0.4-1.0 g/kg/day Limited, occasional abdominal pain, bloating,
loose stools
Lactulose 1 mL/kg/day (single or two divided doses) Flatulence, abdominal cramps, anaphylaxis

Rescue Senna Age 2-6 years: 2.5-7.5 mL/day Idiosyncratic hepatitis, melanosis coli, hypertro-
Age 6-12 years: 5-15 mL/day phic osteoarthropathy, analgesic nephropathy

Adapted from Nurko and Zimmerman,1 Baker et al.,2 Rowan-Legg,8 and Auth et al.10

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 FEATURE ARTICLE

es are that “Laxatives are safe when used If the parents ask about the safety of TABLE 5.
under medical guidance” and “What PEG 3350 use, you can tell them that
looks like dependence when medication “Some families have reported concerns Take-Home Messages
is withdrawn is not a dependence but a to the US Food and Drug Administra- • Always ask the two cardinal questions:
sign that the gut is not ready to function tion (FDA) that some neurologic or 1. When did constipation first start
(and at what age)?
on its own without assistance.” behavioral symptoms in children may
2. What were the circumstances/
If the parents complain that the medi- be related to taking PEG 3350. It is un-
events around the initial onset of
cation is not working and they stopped clear whether these side effects are due constipation?
giving it, you can tell them that “PEG to PEG 3350. The FDA is presently in- • A goal-directed history and physi-
3350 is best given in 6 to 8 ounces of wa- vestigating this. Until the FDA releases cal examination specifically related to
ter/juice/milk in the morning when the the results of is findings, this is the po- constipation is all that is required to help
child is relatively thirsty and most likely sition statement of the North American differentiate between functional and
to finish it at one sitting. You will see the Society for Pediatric Gastroenterology, organic causes in almost all cases

difference. If added to a 16-ounce ‘sippy Hepatology and Nutrition Neurogastro- • Laboratory and imaging studies are rarely
required with this approach
cup’, and consumed over the course of enterology and Motility Committee.”
• Constipation is very common in children
the day it does not function optimally.” Generally speaking, you should let
with neurodevelopmental disorders such
If the parents observe that a full the parents know that if their child has as autism spectrum disorders, attention-
dose of laxative helps but still the stool been prescribed PEG 3350 as part of deficit/hyperactivity disorder, and use of
is somewhat hard, then you should tell the treatment plan, and the medicine psychopharmaceutic agents
them that “In our experience, using provides benefit, then they should feel • Education is important at each visit to
white grape juice to make PEG 3350 safe continuing PEG 3350. You can let help the parent and child to improve
compliance and outcome
solution, gives better results. This has them know that at this time that PEG
• Encourage parents to remain positive
an additive effect without increasing the 3350 appears to be safe based on cur-
and patient throughout the treatment
dose of PEG powder.” rent medical literature. Tell the parents process
If the parents say something like “I that you are willing to discuss their • Deliver hope and positive messages to
gave this medicine as you suggested, concerns about the safety of PEG 3350, the child and parent at every visit
but my child got the runs. So, I stopped. and if they prefer to discontinue it, • Regular follow-up visits are important to
Now there has been no bowel movement other options can be discussed before ensure success of treatment
for the last 3 days!” then you should tell stopping PEG 3350 therapy. Although • Combination therapy with behavioral
them that “Some children respond with abruptly stopping PEG 3350 is not modification and medication therapy is
diarrhea to a standard dose. This is not considered dangerous, it could lead to recommended

an illness that will result in dehydration. a relapse/worsening of constipation. • Use 1 to 2 medications routinely for
the disimpaction, maintenance, and
A given dose may give no response,
rescue phases to develop familiarity and
partial response, or an exaggerated re- WHAT TO EXPECT IN THE LONG- confidence
sponse. We always start at a standard TERM • Know that most children require long-
dose. The ‘runs’ your child had can be Successful treatment of chronic term treatment
seen as resolving the dis-impaction. We childhood constipation was shown to • Disimpaction can usually be achieved
need to adjust the dose with a goal of be 60% by age 1 year and 80% by age with oral and/or rectal medications
having bowel movements 1 to 3 times 8 years in a study of children older than •Polyethylene glycol 3350 can be used for
per day to 1 to 3 times per week as long age 5 years.17 Additionally, successful disimpaction and maintenance therapy
(it is easy to administer, noninvasive, and
as the stool is soft and evacuation occurs treatment was seen more in children
well tolerated)
without pain.” with an age of onset at 4 years or older
• Even though anecdotally useful, probiot-
If the parents ask if the constipa- and in children presenting with consti- ics, prebiotics, and fiber supplementation
tion is a “psychological problem” you pation without encopresis.17 In the same are not recommended for treatment of
should tell them “No, it is not. What study, 50% of those treated success- functional constipation in children
you are seeing is merely a reflex pro- fully had at least one relapse.17 More- • Consider referral to a pediatric gas-
tective response of your child. It is as over, another study of children age 4 troenterologist when you suspect an
‘psychological’ as tightening up your years or younger showed that one-third organic cause for constipation or when
constipation is unresponsive to adequate
gut upon seeing a hostile fist coming at of patients still had chronic constipa-
treatment
your belly.’ tion 3 to 12 years after initial evalua-

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 FEATURE ARTICLE

tion and treatment.18 In a Dutch study ganic cause of constipation, most other quality of life: a case controlled study. J Pe-
that evaluated outcomes in adulthood, children will have functional constipa- diatr Gastroenterol Nutr. 2005;41:56-60.
7. Tabbers MM, Di Lorenzo C, Berger MY,
one-fourth of children with functional tion.2,8 Functional constipation requires et al. Evaluation and treatment of func-
constipation were shown to still have a multipronged approach that includes tional constipation in infants and children:
evidence-based recommendations from ES-
symptoms as adults.4 As the evidence education, disimpaction, maintenance
PGHAN and NASPGHAN. J Pediatr Gas-
shows, management of constipation therapy, and long-term follow-up along troenterol. 2014;58(2):258-274.
may be a life-long process that may with a strong relationship among the 8. Rowan-Legg A. Managing functional consti-
require prolonged treatment, lifestyle health care provider, parent, and pa- pation in children. Paediatr Child Health.
2011;16(10):661-665.
changes, and patience from the parent, tient. With this approach and encour- 9. Weaver LT, Ewing G, Taylor LC. The bowel
child (eventually adult), and physician. agement from the physician, the patient habit of milk-fed infants. J Pediatr Gastro-
and the parent have a better chance of enterol Nutr. 1988;7:568-571.
10. Auth MKH, Vora R, Farrelly P, Baillie C.
WHEN TO REFER TO A PEDIATRIC resolving the distress caused by consti- Childhood constipation. BMJ. 2012;345:1-
GASTROENTEROLOGIST pation. Table 5 provides a list of the 11.
Consultation with a pediatric gas- salient points discussed in this article. 11. Greenwald BJ. Clinical practice guidelines
for pediatric constipation. J Am Acad Nurse
troenterologist is necessary when treat-
Pract. 2010;22:332-338.
ment fails or a concern for an organic REFERENCES 12. Mugie SM, Di Loranzo C, Benninga MA.
cause exists.1 “Treatment failure” is de- 1. Nurko S, Zimmerman LA. Evaluation Constipation in childhood. Nat Rev Gastro-
fined as recurrence of constipation after and treatment of constipation in chil- enterol Hepatol. 2011;8:502-511.
dren and adolescents. Am Fam Physician. 13. Agarwal J. Chronic constipation. Indian J
adequate dosing and regularity of use, 2014;90(2):82-90. Pediatr. 2013;80(12):1021-1025.
and after requisite duration of therapy. 2. Baker SS, Liptak GS, Colleti RB, et al. Con- 14. Pashankar DS. Childhood constipation: eval-
The concern for an organic cause arises stipation in infants and children: evalua- uation and management. Clin Colon Rectal
tion and treatment. J Pediatr Gastroenterol Surg. 2005;18(2):120-127.
when there are red flags on history, ex- 15. Brazzelli M, Griffiths P. Behavioral and cog-
Nutr. 1999;29:612-626.
amination, and/or on basic investiga- 3. Liem O, Harman J, Benninga M, Kelleher K, nitive interventions with or without other
tion. The pediatric gastroenterologist Mousa H, Di Lorenzo C. Health utilization treatments for the management of faecel in-
and cost impact of childhood constipation in continence in children. Cochrane Database
re-evaluates the child for underlying
the United States. J Pediatr. 2009;154:258- Syst Rev. 2006;2:CD002240.
organic processes and reviews previous 262. 16. Kneepkens CMF. What happens to fruc-
management strategies before perform- 4. Bongers ME, van Wijk MP, Reitsma JB, tose in the gut? Scand J Gastroenterol.
ing additional studies.2,10 Benninga MA. Long-term prognosis for 1989;24(171):1-8.
childhood constipation: clinical outcomes 17. Van Ginkel R, Reitsma JB, Buller HA, van
in adulthood. Pediatrics. 2010;126(1):e156- Wijk MP, Taminiau JAJM, Benninga MA.
CONCLUSION Childhood constipation: longitudinal fol-
162.
Constipation is a challenging medi- 5. Philichi L. When the going gets tough: pedi- low-up beyond puberty. Gastroenterology.
cal conundrum for not only pediatric atric constipation and encopresis. Gastroen- 2003;125(2):357-363.
terol Nursing. 2008;31(2):121-130. 18. Loening-Baucke V. Constipation in early
patients and their parents, but also
6. Youssef NN, Langseder AL, Verga BJ, childhood: patient characteristics, treat-
medical providers. Besides the small Mones RL, Rosh JR. Chronic childhood ment, and longterm follow up. Gut.
minority of children who have an or- constipation is associated with impaired 1993;34:1400-1404.

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