Constipation resident survival guide (pediatrics)

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

Constipation resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
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 that needs primary care management. The North American Society for Pediatric Gastroenterology and Nutrition has formulated clinical practice guidelines for the management of pediatric constipation.

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 factors can contribute to constipation in children, including:

• 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 avoid 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’s disease
  • hypothyroidism
  • cystic fibrosis

FIRE: Focused Initial Rapid Evaluation

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 impaction have a loss of appetite and are less interested in physical activity. After passing the stool, the child feels better and symptoms improve.

Complete Diagnostic Approach

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 for irritable 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 passage of a large stool. —Criteria must be fulfilled at least once a week for at least two months.

Treatment

Shown below is an algorithm 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 6 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 is 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

Improvement with trial of fiber and/or laxatives

Failure of improvement with trial of fiber and/or laxatives

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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