Constipation resident survival guide (pediatrics)

Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Samah Obaiah, MD[2]

Constipation resident survival guide (pediatrics) Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Overview

Constipation occurs when waste or stool moves too slowly through the digestive tract, causing the stool to become hard and dry. It is a common pediatric problem (prevalence rates up to 32.2%) that requires primary care management. Children and their families should be included in the treatment regimen to prevent recurrences and promote health maintenance. Chronic (functional) constipation is a source of anxiety for parents who worry that a serious disease may be causing the symptom.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Atropine poisoning
• Hypokalemia
• Lead poisoning
• Opium poisoning
• Severe dehydration
• Spinal cord injury
• Superior mesenteric artery occlusion

Common Causes

The most common factors that can contribute to constipation in children include:

• Ignoring

A child may ignore the urge to have a bowel movement or uncomfortable using public toilets.

• Painful bowel movements caused by large, hard stools also may lead to avoiding a repeat of the distressing experience
• Toilet training issues

• Diet

Not enough fiber-rich fruits and vegetables or fluid in a child's diet may cause constipation.

• Changes in routine

Any changes in routine — such as travel, hot weather, stress, or start school — can affect bowel function

• Medications

Certain antidepressants and various other drugs can contribute to constipation

• Cow's milk allergy

• Family history

• Medical conditions
  • Irritable bowel syndrome
  • Hirschsprung disease
  • Hypothyroidism
  • Cystic fibrosis

Complete Diagnostic Approach

The most common kind is functional constipation and not life-threatening. Diagnosed with history one of these symptoms:

• Hard stools

• Pain or trouble passing stool

• Less than three stools per week

Many children with an impaction have a loss of appetite and are less interested in physical activity. After passing the stool, the child feels better, and symptoms improve. Shown below is an algorithm summarizing the diagnosis of [[constipation]] according to the the [Rome III Diagnostic Criteria] guidelines.

Diagnosing Functional Constipation in Children

At least two of the following in a child with a developmental age younger than four years* Symptoms suggestive of constipation: ❑2 or less bowel movements per week ❑At least one episode of incontinence per week after the acquisition of toileting skills ❑History of 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 At least two of the following in a child with a developmental age of four years or older with insufficient criteria forirritable bowel syndrome:- ❑Two or fewer bowel movements in the toilet per week ❑At least one episode of fecal incontinence per week ❑History of retentive posturing or excessive voluntary 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 —Criteria must be fulfilled for at least one month. Accompanying symptoms may include irritability, decreased appetite, and/or early satiety, and they may disappear immediately following the passage of a large stool. —Criteria must be fulfilled at least once a week for at least two months.

Treatment

Treatment of constipation in children functional constipation focuses on three main areas:

-Increasing fiber in the diet and more fluids.

-Regular Exercise and bowel habit training.

Medicine is often needed to help children have regular, soft bowel movements, and disimpaction.

Medicines Help Constipation in different ways. Osmotic laxatives (Polyethylene glycol without electrolytes, magnesium hydroxide, magnesium citrate, lactulose, sorbitol, phosphate sodium enema), stimulant laxatives(senna, bisacodyl ), and lubricant laxatives(mineral oil, glycerin suppository).

Oral medications regimen for disimpaction if indicated:

• Polyethylene glycol 3350 + electrolytes, using an escalating dose regimen, as the first-line treatment. Polyethylene glycol 3350 + electrolytes may

be mixed with a cold drink.

• Add a stimulantlaxative if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks.
• Substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if polyethylene glycol 3350 + electrolytes is not

tolerated.

• Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain.

Laxatives: recommended doses are those recommended by the British National Formulary for Children (BNFC) 2009

Laxatives	Recommended doses
Polyethylene glycol 3350 + electrolytes	Paediatric formula: oral powder: macrogol 3350 (polyethylene glycol 3350)a 6.563 g; sodium bicarbonate 89.3 mg; sodium chloride 175.4mg; potassium chloride 25.1 mg/sachet. Disimpaction Child under 1 year: ½ to 1 sachet daily (non-BNFC recommended dose) Child 1–5 years: 2 sachets on 1st day, then 4 sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily (non-BNFC recommended dose) Child 5–12 years: 4 sachets on 1st day, then increased in steps of 2 sachets daily to a maximum of 12 sachets daily (Non-BNFC recommended schedule) Ongoing maintenance (chronic constipation, prevention of fecal impaction) Child under 1 year: ½ to 1 sachet daily (non-BNFC recommended dose) Child 1–6 years: 1 sachet daily; adjust the dose to produce regular soft stools (maximum 4 sachets daily) (for children under 2, non-BNFC dose) Child 6–12 years: 2 sachets daily; adjust the dose to produce regular soft stools (maximum 4 sachets daily) Adult formula: oral powder: macrogol 3350 ([[polyethylene glycol 3350]]) 13.125 g; sodium bicarbonate 178.5 mg; sodium chloride 350.7 mg; potassium chloride 46.6 mg/sachet (unflavoured). Disimpaction Child/young person 12–18 years: 8 sachets daily Ongoing maintenance (chronic constipation, prevention of fecal impaction) Child/young person 12–18 years: 1–3 sachets daily in divided doses usually for up to 2 weeks; maintenance, 1–2 sachets daily
Lactulose	* Child 1 month to 1 year: 2.5 ml twice daily, adjusted according to response Child 1–5 years: 2.5–10 ml twice daily, adjusted according to response (non-BNFC recommended dose) Child/young person 5–18 years: 5–20 ml twice daily, adjusted according to response (non-BNFC recommended dose)
Sodium picosulfate	Non-BNFC recommended doses Elixir (5 mg/5 ml) Child 1 month to 4 years: 2.5–10 mg once a day Child/young person 4–18 years: 2.5–20 mg once a day
Bisacodyl	Non-BNFC recommended doses By mouth Child/young person 4–18 years: 5–20 mg once daily By rectum (suppository) Child/young person 2–18 years: 5–10 mg once daily
Senna	Senna syrup (7.5mg/5ml) Child 1 month to 4 years: 2.5–10 ml once daily Child/young person 4–18 years: 2.5–20 ml once daily Senna (non-proprietary) (1 tablet = 7.5 mg) Child 2-4 years: ½ to 2 tablets once daily Child 4-6 years: ½ to 4 tablets once daily Child/young person 6–18 years: 1–4 tablets once daily
Docusate sodium	Child 6 months–2 years: 12.5 mg three times daily (use pediatric oral solution) Child 2–12 years: 12.5–25 mg three times daily (use pediatric oral solution) Child/young person 12–18 years: up to 500 mg daily in divided doses

FRIST ALGORITHM:- Shown below summarizing the treatment of [[Constipation]] according the the [ North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Constipation] guidelines.

Constipation in Infants Younger than Six Months

Children under 1 year: . Delayed passage of meconium (more than 48 hours after birth) . Fewer than three complete stools a week ( this does not apply to exclusively breastfed babies after six weeks of age) . Hard large stools, "rabbit droppings" or "nuts," distress on defecating, bleeding associated with hard stools . Straining, previous episode(s) of constipation, and previous or current anal fissure

Physical and laboratory examination should includ:- . Growth parameters . An abdominal examination . Occult blood test . An external examination of the perineum and perianal area . An evaluation of the thyroid and spine . And a neurologic evaluation for appropriate reflexes (cremasteric, anal wink, patellar). . A digital examination of the anorectum recommended to assess for perianal sensation, anal tone, rectum size, anal wink, and amount and consistency of stool in the rectum

If Onset before one month of age . Delayed passage of meconium (more than 48 hours after birth) . Failure to thrive . Abdominal distension . Intermittent diarrhea and explosive stools . Empty rectum . Tight anal sphincter . Pilonidal dimple covered by a tuft of hair . Midline pigmentary abnormalities of the lower spine . Abnormal neurologic examination (absent anal wink, absent cremasteric reflex, decreased lower extremity reflexes and/or tone) . Occult blood in the stool . Extraintestinal symptoms (vomiting, fever, ill-appearance) . Gushing of stool with rectal examination . No history of withholding or soiling . No response to conventional treatment

If no alarm symptoms,the treatment will be:- incrased fluid oral rehydration with breastfed closed followup

Suggested diagnoses will be one of these; congenital malformation of anorectum or spine, Hirschsprung disease, allergy, metabolic/endocrine condition

Functional constipation

More evaluation according to physical examination and history finding by one of those:- . Barium enema . Spinal magnetic resonance imaging . Thyroid studies . Serum calcium and potassium levels . Fasting glucose level . Serum and urine osmolarity .Anorectal manometry, rectal suction biopsy . Colonic manometry . History, drug level . Lead level . Tissue transglutaminase . IgA, total IgA . Endoscopy . Sweat test . Cow's milk elimination

Functional constipation without impaction

Improvement with Education, diet, fluid , medication, dairy, close follow up.

Failure of improvement with treatment and family education

Continue treatment

Re-evaluation

Second ALGORITHM is:-

Constipation in children older than one year

Child with history of consitpation

No alarm signs as, fever, vomiting, abdominal distinction,...

Diagnosis of functional constipation provide

Education for cild and his or her parents :-diet, exercises,toilet training, increase fluid,and close follow up

If there is impaction should use rectal or oral medication to disimpaction

If the impaction improved, cotinus tretment with education family

If the impaction not improved should re evaluation

Do's

• It is important to increase fiber slowly over two to three weeks with a current constipation.
• Make sure the child drinks more water and juice when eating more fiber.
• If a child becomes very upset when taken to the toilet or holding stool more or constipation is getting worse, or their history of tantrums or aggression with toileting should refer the child to a psychotherapy expert.
• Increased the dose of medicine, if there are one of these signs, stools are small and hard, or a stool, not every day, or there complain of a hard time passing stool, or pain.
• Decreased the dose of medicine if there, loose or watery stool, history of belly pain or cramps.
• Length of treatment of disimpaction and functional constipation usually at least 6 months

Don'ts

• Don't stop the medicine until make sure the child continues to have a soft stool each day and the colon and rectum have returned to normal.
• Don't use abdominal ultrasound, gastrointestinal endoscopy, plain abdominal radiography, transit studies to diagnose functional constipation.
• Don't do a rectal biopsy if there is not clinical future of Hirschsprung disease or family history.
• Don't use manometry to diagnose Hirschsprung disease in children with chronic constipation.
• Don't stop the medication suddenly: gradually reduce the dose over a period of months in response to stool consistency and frequency.