Childhood constipation

Dr.Khalid Hama salih

Ass.prof. of Pediatrics

Regular pattern of defecation is

considered by many to
be a sign of good health

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Table Of Contents:

• Prevalence
• Definition
• Classification
• Etiology
• Pathogenesis Of Functional Constipation
• Evaluation
• Risk factor
• Investigation
• Management

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Newborns:
• First meconium stool usually within the first 36 hours of birth in normal
newborns
• 90% pass stool within 24 hours

• This may happen later in preterm infants without underlying structural defects

• First week of life normal newborn has 4 stools per day, with some variability
• Breastfed infants can stool with each feeding or only once every 7 to 10 days
• Formula fed infants tend to stool more regularly than breastfed infants
• Soy formulas known to cause harder stools
• Protein Hydrolysate and Elemental formulas associated with looser stools

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Epidemiology:
–Constipation affects up to 30 percent of children
–3 to 5 percent of all visits to pediatricians
–10-25% visits to pediatric GI
–Functional constipation is responsible for more than
95 percent of cases of constipation in healthy children
one year and older
• Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2018.
van den Berg MM, Benninga MA, Di Lorenzo C. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol 2006; 101:2401.

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Definition of constipation:
• Constipation is a disorder in which a child passes
infrequent bowel movements (two or fewer per week),
has painful defecation, or passes large caliber and hard
stools that may require excessive straining.
• Some children may have rectal impaction and overflow
fecal incontinence.

1Merriam-Webster dictionary
*Formal NASPGHAN definition specifies minimum 2 week duration

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Classification of Constipation

Constipation

Functional/Idiopathic Pathological Constipation

Constipation

Medical Surgical
No objective evidence of Anatomical
a pathological condition malformations
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 Pathogenesis Of Functional constipation

Painfull
defication

Voluntary with
holding
Change in routine
Change in diet
Stressfull event
Postponding defication
More pain Too early toilet training

Prolong feccal stasis

reabsorption of fluid and
increase insize and
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consistency
Causes : constipation
Non-organic
A.Developmental
– Infant dyschezia
– Attention-deficit disorders
B.Situational
– Toilet training
– Toilet phobia
– School bathroom avoidance
– Sexual abuse
C.Constitutional
– Genetic predisposition
D.Reduced stool volume and dryness
– Low fiber in diet
– Dehydration
– Underfeeding or malnutrition
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Organic causes of • Abnormalities of the colon
constipation and rectum
• Chronic intestinal pseudoobstruction
 Systemic disorders • Anal stenosis
 Celiac disease • Anal/colonic stricture –post NEC/IBD
 Cystic fibrosis • Ectopic anus
 Diabetes mellitus • Spinal cord lesions
 Panhypopituitarism • Spina bifida, Meningomyelocele
• Sacral agenesis
 Lead toxicity
• Tethered cord
drug • Tumors

 Analgesics
• Neuropathic lesions
• Hirschsprung disease
 Anticholinergics • Intestinal neuronal dysplasia
 Iron
 Antacids (esp Ca2+ containing) • Metabolic
• Hypothyroidism
 NSAIDs
• Hypo/hyper-calcemia
 Psychotropics • Hypokalemia
• Uremia

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 Evaluation of an infant or child with constipation
Onset of constipation:
present from birth or early infancy? organic cause (eg, Hirschsprung disease)

preceding change in diet or diarrheal illness?

onset around the time of toilet training, or around a precipitating event? functional
Were there problems with toilet training? (eg, child resistance, fear)
constipation
Stool quality and appearance:

Is defecation painful?
Are the stools hard or soft?
If the child is toilet trained, does he or she have "accidents" in the functional constipation
underwear?
Does the child have stool withholding behavior?
Dietary issues: Low fluid intake occasionally
Is the diet unusual? Are there sources of fiber? Is there adequate fluid? contributes to constipation
Did the constipation coincide with a change in diet? (eg, transition to solid Suggests functional
foods in infants, or to milk) constipation, possibly cow’s
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 Consider neurogenic causes of
constipation; some congenital syndromes are
Are there underlying medical problems, associated with Hirschsprung disease (eg,
congenital anomalies, abnormal growth, Down syndrome).
or developmental delay? Congenital malformations, such as kidney and
urinary tract anomalies, also raise concerns for
anorectal, sacral and spinal abnormalities,
which can interfere with defecation.

Is there a family history of functional

constipation, Hirschsprung disease, or Each of these causes has some
celiac disease? familial patterns

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Abdominal distension Severe distension raises concern for organic disease

Palpable stool mass Consistent with constipation from any cause, but lack of
palpable stool does not rule out constipation

Mass in suprapubic area Common finding in patients with rectal stool impaction, but can also
suggest sacral teratoma

Cutaneous changes in the lumbosacral area (dimple, hair tuft,

Suggests spinal dysraphism
lipoma, or deviation of the gluteal cleft)

Soiled underwear In the presence of rectal stool impaction, suggests overflow

(fecal incontinence) incontinence and functional constipation

Absent anal wink or cremasteric reflex, decreased lower

Suggests neurologic dysfunction
extremity tone or strength

Anteriorly displaced anus, or perianal fistula Suggests anorectal anomaly

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Digital rectal examination
Hirschsprung disease
Anal sphincter tone
neurogenic constipation

Impacted stool Soft stool suggests possibility of anorectal

(hard or soft) dysfunction, including Hirschsprung disease

Explosive expulsion of stool after the

examination (squirt sign)
Suggests Hirschsprung disease

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 Alarm signs
Chronic :
Constipation present from birth or early
Acute : infancy, Ribbon stools
Delayed passage of meconium Urinary incontinence
Fever, vomiting, or diarrhea Weight loss or poor weight gain Delayed
Rectal bleeding growth
Extraintestinal symptoms (especially
Severe abdominal distension neurologic deficits)

Physical findings:
Severe abdominal distension Pelvic mass .
Lumbosacral dimple, hair tuft or lipoma, or deviation of the gluteal cleft, Lower spine
abnormalities.
Anal scars Perianal fistula Tight anal canal with empty rectum.
Explosive expulsion of stool after DRE
Absent cremasteric reflex ,hypotonia ,Abnormal lower limb reflex
Extreme fear during the anal inspection
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© 2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Rome IV criteria for the diagnosis of functional constipation in children
infants and toddlers up to 4 years old
At least 2 of the following present for at least 1 month:
2 or fewer defecations per week
History of excessive stool retention
History of painful or hard bowel movements
History of large-diameter stools
Presence of a large fecal mass in the rectum
In toilet-trained children, the following additional criteria may be used:
At least 1 episode/week of incontinence after the acquisition of toileting skills
History of large-diameter stools that may obstruct the toilet
Children and adolescents (developmental age ≥4 years)
At least 2 of the following present at least once per week for at least 1 month:*
2 or fewer defecations in the toilet per week
At least 1 episode of fecal incontinence per week
History of retentive posturing or excessive stool retention
History of painful or hard bowel movements
Presence of a large fecal mass in the rectum
History of large-diameter stools that may obstruct the toilet
The symptoms cannot be fully explained by another medical
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Ass.prof.khalid 17
 Category Risk factors

Patient Related Male sex

Poor Sleep
Obesity

Dietary Low fiber

Consumption of junk food
Cow’s milk protein allergy

Psychological Home/School-related stresses

Adverse life event including abuse
Depression
Autistic spectrum disorders

Social Living in war-affected areas

Lower social class
Hostile and aggressive family environment
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Approach to Constipation 6
when constipation is likely to occur?

●The introduction of solid foods or cow's milk

●Toilet training

●School entry

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Diagnostic Testing
• Routine laboratory testing is not
recommended
• If suspected, test for:
• Thyroid dysfunction: TSH, T-4
• Metabolic dysfunction:
• Celiac disease: Celiac panel, IgA
• Food allergy:
• Inflammatory markers: ESR, CRP,
Sweat test.
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Diagnostic Testing
• Digital rectal exam: perform based on history
• X-ray (KUB): only needed if fecal impaction is
suspected or physical exam (DRE) is not
possible
• Anorecal manometry: only useful in evaluation
of HD. suction biopsy should be performed to
evaluate for HD.
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Diagnostic Testing
• Colonic manometry: evaluates colonic
dysmotility.
• MRI of the spine: if tethered cord or
other neurologic abnormalities suspected.
• Colonic Scintigraphy: useful in
measuring colonic motility in children
with slow transit constipation.
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Why Treat Constipation?

• Risk of recurrent urinary tract infections

• Can worsen gastro-oesophageal reflux
• Abdominal cramps, pain and irritability
• Painful anal fissures

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Management of Constipation:

Medications

Diet

Behavior

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Behavioral modification

• 1- unhurried toilet sitting for child’s age

• 2-two to three times a day 10-15 minutes after meals (Gastrocolic reflex).

• 3-Good foot support (footstool) is often helpful in maximizing Valsalva

maneuver.

• 4- Parents should understand the basic pathophysiology of constipation and be

taught to provide consistent positive reinforcement

• 5.A simple reward system such as stickers on a calendar can be effective.

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Diet modification

1- Increased intake of fluids

2- High-residue foods (e.g. bran, whole wheat, fruits,
and vegetables.

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 FRUITS
 Banana

OTHER FOOD ITEMS

 Tea
Coffee
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 CHOOsE

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Medical management

Disimpactation
A.Enema :hypertonic sodium Mainteneance :
,mineral oil Polyethylene glycol
B.Oral: polyethylene glycol electrolyte free,
electrolyte free or with lactulose, senna syrup
electrolyte
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Treatment: recommendation last updated: Mar 21, 2023.

Infants with severe or recurrent constipation, and especially from birth, should be carefully
evaluated for possible organic causes,
For infants younger than four months, one to two ounces of diluted prune juice is a reasonable
starting dose. Alternatively, lactulose (about 1 mL/kg daily) can be added to the formula.
For infants four months and older, two to four ounces of 100-percent fruit juice per day.
Glycerin suppositories or rectal stimulation with a lubricated rectal thermometer can be used
occasionally if there is very hard stool in the rectum.
For children one year and older with hard stools and straining but minimal pain and no
withholding behavior, bleeding, or anal fissure, only diatry change .
Those with stool withholding behavior, pain while defecating, rectal bleeding or anal fissure, initial treatment
with polyethylene glycol (PEG) if PEG is not available, lactulose should be the laxative of choice, and is safe for
all ages.
Stimulant laxatives (eg, senna, bisacodyl), mineral oil, and enemas should be
avoided in infants because of their potential adverse effects.
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Infantile Dyschezia

In children less than 6 months old

• At least 10 minutes of straining and crying

• Successful passage of a soft stool

• Otherwise healthy and thriving

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Take home massage
Functional constipation is responsible for more than 95 % of cases of
constipation
Organic causes are responsible for fewer than 5 %
Infant dyschesia self-limited disorder no need for medication.
Signs and symptoms suggestive of Hirschsprung disease include delayed passage
of meconium (after 48 hours of life), failure to thrive or delayed growth,
vomiting, abdominal distension, a tight anal canal with an empty ampulla, with +
(squirt sign).
Cow's milk may cause constipation in infants and young children.
Celiac disease is common and occasionally is associated with constipation.
Laboratory and radiographic testing should be selectively performed .
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THANK YOU

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