Constipation in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dushka Riaz, MD

Synonyms and keywords: Constipation in kids

Overview

Constipation in childhood is the delay or difficulty in passing stool for more than two weeks. It is one of the most common pathologies that presents to a pediatrician. The diagnosis is based on history, physical exam, and a constipation log. As a comparison, normal average stooling patterns are detailed below:

• Newborns pass meconium within the first 24 hours of life.
• First week of life:
  • Infants pass up to four stools per day with breastfed babies developing bowel movements more slowly as the mother's milk is produced.
• First 3 months of life:
  • Formula-fed infants passing two stools per day.
  • Breastfed infants passing three stools per day.
• Toddlers at age two with under two stools per day.
• Children under age four with 1-2 stools per day.

Historical Perspective

There is no historical perspective concerning constipation in children.

Classification

• Constipation in children may be classified according to the cause into two subtypes/groups:

• Functional - This is the most common type of constipation in children where there is no anatomic or systemic cause. The predilection is for preschool-aged children. This is further classified according to duration:
  • Recent onset where symptoms are present within a two month period.
  • Chronic duration is considered for patients with symptoms for three months or more.
• Organic - the most common causes being celiac disease, hypothyroidism, and cow's milk protein allergy.
  • Care must be taken to exclude urgent causes such as Hirschsprung's disease, cystic fibrosis, lead poisoning, infantile botulism, obstruction, and malformations of the spine.

Pathophysiology

• The pathogenesis of constipation in children is most often characterized by painful stools causing the child to withhold to avoid the pain developing a vicious cycle of constipation. Withholding behavior causes the rectum to absorb and retain water from the fecum further creating a harder stool. The eventual defecation of the fecum is difficult and can create anal fissures exacerbating withholding behavior. Repeated accumulation of the fecum can result in dilation of the colon with a loss of sensation leading to a slow transit time.

Causes

Constipation in children may be caused by functional or organic causes.

• Functional causes include:
  • Fecal retention to avoid a painful stool.
  • Developmental disorder component ie ADHD, Autism.
  • Psychological, as in the case of new toilet training or sexual abuse.
  • Genetic predisposition.
  • Poor fiber intake, low fluid intake, or malnutrition.
  • Introduction of formula or cow's milk.

• Organic causes include:
  • Neuromuscular disorders such as congenital megacolon, cerebral palsy, neurofibromatosis.
  • Anatomic lesions such as gastroschisis.
  • Systemic diseases such as cystic fibrosis, diabetes mellitus, hyper or hypothyroidism, Down syndrome.
  • Drug exposure such as narcotics, codeine, antidepressants, and lead poisoning.
  • Other causes such as cow's milk allergy or celiac disease.

Differentiating Constipation in Children from other Diseases

Constipation must be differentiated from infantile dischezia, Hirschsprung’s disease, and cystic fibrosis.

• Infantile dischezia is a pelvic floor dysfunction that results in diarrhea or constipation presenting in the neonatal period. It is caused by the child not being able to coordinate the increased pressure in the abdomen with the relaxation of the pelvis. The disorder is self resolving as the child learns muscle coordination and does not require any intervention.
• Hirschsprung's disease can present with difficulties in passing stool in the neonatal period because of colonic agangliosis. However, Hirschsprung's disease would also present with bilious vomiting, refusal to feed, and a fever caused by severe enterocolitis. On digital rectal examination, there would be a "squirt sign" with relief of gas with stool.
• Cystic fibrosis patients will present with meconium ileus in the neonatal period as well as abdominal distention. These patients can present with constipation but would also have recurrent pulmonary infections and pancreatic insufficiency.

Epidemiology and Demographics

Prevalence

• The prevalence of constipation in children is between 10% and 23% in North and South America, with lower values of 0.7% to 12% in Europe. Asian populations have a prevalence of between 0.5% and 29.6%.

Age

• Constipation in children is more commonly observed among patients aged two to four years old because of the learning process of toilet training.

Gender

• Constipation in children affects boys and girls equally before the age of 5 followed by girls having increased incidence after age 13.

Race

• There is no racial predilection for constipation.

Risk Factors

• Common risk factors in the development of constipation in children are low fiber intake, stressful events such as bullying and familial changes, cow's milk protein allergy, sedentary lifestyle, low birth weight and the consumption of processed foods.

Natural History, Complications and Prognosis

• If left untreated, constipation in children may progress to develop bowel bladder dysfunction, where the chronic constipation with withholding can lead to decreased voiding and recurrent urinary tract infections.
• Common complications of constipation in children include anal fissures, encoparesis, and withholding behavior.
• Prognosis is generally excellent for patients under five. Patients who don't do well are suspected to have noncompliance of medications.
• Prognosis for full recovery is 48%. Those with symptoms early in their life, family history of constipation and a history of sexual abuse are associated with a poor prognosis.

Diagnosis

Diagnostic Criteria

• In the Paris Consensus Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met for more than 8 weeks:

• Less than 3 bowel movements per week.
• More than one fecal leakage episode per week.
• Rectal obstruction caused by large diameter stools.
• Withholding behavior.
• Painful defecation.

• In the Rome III Criteria, the diagnosis of constipation in children is made when at least two of the following diagnostic criteria are met; with children over four years old requiring to have the symptoms for a minimum of two months:

• Less than 2 bowel movements per week.
• Fecal incontinence episode after achieving complete bowel control.
• Rectal obstruction caused by large diameter stools.
• Withholding behavior.
• Painful defecation.
• Large fecal mass seen in digital rectal examination.

Symptoms

• Symptoms of constipation in children may include the following:

• Straining.
• Crying.
• Bleeding per rectum.
• Anal tears.
• Withholding behavior.
• Nocturnal fecal soiling in response to a loss of sensation.
• Abdominal pain.
• Nausea.
• Decreased appetite.
• Enuresis.
• Urinary tract infections because of hard fecum obstructing urinary flow.
• Hard stools.

• Alarm symptoms point to an organic cause:

• Ribbon stools.
• Blood in stools without anal fissures.
• Fever.
• Bilious vomiting.
• Failure to thrive.
• More than 48 hours to pass meconium.
• Occult blood in the stool.
• Fear when the anus is being examined due to pain.
• Sacral dimple, agenesis.
• Perianal scars, fistula.
• Pilonidal dimple with hair tuft.
• Abnormal anus position.
• Thyroid gland abnormalities.
• Family history of Hirschsprung's disease.
• Fecal mass with an empty rectum.
• Air or fluid release on digital rectal examination.
• Absence of an anal wink, anal reflex, or cremasteric reflex.
• Delayed lower extremity deep tendon reflexes.
• Decreased lower extremity tone, strength, and sensation.

Physical Examination

• Patients with constipation usually appear pale and fatigued.
• Physical examination may be remarkable for:

• Mouth ulcers.
• Blood or mucus in the stools.
• Perianal skin tags or fistulae.
• Hypotonia.
• Absent lower extremity reflexes.
• Fever.
• Exopthalmos and lid lag for hypothyroidism.
• Abdominal distension or mass.
• Lumbar abnormalities or hair tufts.

• Digital rectal examinations are not routinely done but may assist in diagnosis for the following patients:

• Symptoms of constipation since infanthood.
• Alarm signs present suggesting organic causes.
• Patients not fully meeting the diagnostic criteria with the continuance of symptoms.

Laboratory Findings

• If the patient does not respond to initial treatment, testing must be done for celiac disease (IgA antibodies to tissue transglutaminase), lead levels, CBC, serum electrolytes, thyroid function test, urinalysis, urine culture, sweat test, fecal occult blood test, and allergy testing.
• If lab results are negative with no response to treatment, organic causes must be further investigated through a radiograph, barium enema, anorectal manometry and rectal biopsy to exclude Hirschsprung's disease, and a MRI of the lumbosacral spine.

Electrocardiogram

There are no ECG findings associated with constipation in children.

X-ray

An abdominal x-ray may be helpful in the diagnosis of constipation in children. Findings on an x-ray suggestive of constipation include retained stool. However, these are not routinely done and the diagnosis should be approached through history and physical examination primarily. A spinal radiograph can be considered if there are findings to suggest an organic cause with neurological impairment.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with constipation in children.

CT scan

There are no CT scan findings associated with constipation in children.

MRI

MRI may be helpful in the diagnosis of constipation in children. Findings on MRI suggestive of lumbosacral spine abnormalities may be helpful to identify neuropathic causes of dysfunction

Other Imaging Findings

A contrast enema may be helpful in excluding Hirschsprung's disease as the cause for constipation. This should be completed without measures to clean out the stool. Findings on an barium enema diagnostic of Hirschsprung's disease include a transition zone where the normal rectum transitions to a dilated portion that is aganglionic. This is always confirmed by a rectal biopsy.

Other Diagnostic Studies

• Constipation in children can also be evaluated by parents giving a symptom and dietary history log including frequency of bowel movements, pain and description of the stool.
• Radiopaque marker studies can be considered in patients who are not responding to treatment with an unclear diagnosis. This is used primarily to diagnose slow transit constipation or outlet obstruction.

Treatment

Medical Therapy

• Treatment for constipation in children depends on the age group:
  • Infants 3 months to 1 year are offered sorbitol containing juices diluted with water, a trial of avoiding cow's milk, breastfed children with a trial of the mother avoiding cow's milk. Glycerin suppositories and laxatives can be used for children 6 months and older if needed. Infants older than 6 months should also increase the consumption of fruits and vegetables.
  • In children treatment consists of three phases:

1. Disimpaction of the hard fecum through osmotic laxatives (lactulose, bisacodyl suppository, magnesium citrate, magnesium hydroxide, paraffin oil, sorbitol, or senna) for 1-3 days.
2. Restoring muscle tone through stool softeners for 2-6 months.
3. Restore normal bowel movements by increasing fiber and water intake and reducing laxative use gradually for 4-6 months.

• Treatment also includes behavior modification of re-toilet training with routine scheduled toilet visits. Possible psychological issues must be addressed and a star reward system can be helpful in tracking improvement.

Surgery

• Patients who are refractory to medical management may require an anal sphincter release through myectomy.

Prevention

• Effective measures for the primary prevention of constipation in children include anticipatory guidance with parents with respect to proper nutrition, diet and toilet training. Parents should be advised that children are likely to experience constipation in transition phases such as entering school, starting cow's milk or during toilet training. If parents are aware of forthcoming episodes they can quickly move to the treatment phase. Once children are introduced with solid foods, parents should be advised to also increase their fluid intake. Parents should also encourage routine use of the toilet after meals to begin toilet training measures while keeping a close monitor of their bowel habits. Parents can be on the lookout for withholding behaviors, possible anal fissures exacerbating the withholding behavior, and the overuse of cow's milk.
• Toilet training of children should begin when they display developmental, physical, and behavioral signs of being ready. Parents should indicate proper vocabulary for the child to express having to go to the bathroom and encouragement to use a potty chair. Parents should not punish the child if accidents occur. A proper routine should be established according to the child's pace and understanding.