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Evaluation
When thorough and complete, the history and PE findings are usually
sufficient to allow the healthcare professional to decide if the child has
functional constipation or needs further evaluation. The younger the infant,
the higher the risk of an anatomic or organic cause of constipation.
Establishing whether constipation is functional or organic helps direct
diagnostic tests and treatment plan. Organic causes of constipation in infants
have warning signs or “red flags”.
“Red Flag” Signs Indicative of Organic Constipation
In the perianal area, look for abnormal
appearance, position, patency of the anus; observe for fistulae, bruising,
multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal
wink, pilonidal dimple. In the abdomen, look for gross abdominal distention,
tight and empty rectum in presence of a palpable fecal mass. In the spine, lumbosacral
region, and gluteal exam, look for abnormal symmetry or flattening of the
gluteal muscles, evidence of sacral agenesis, discolored skin, naevi or sinus,
hairy patch, central pit, and scoliosis. Lastly, in the lower limb
neuromuscular examination, look for deformity (eg talipes), decreased lower
extremity and/or strength, and abnormal reflexes (eg absent cremasteric reflex,
absence or delay in relaxation phase of lower extremity deep tendon reflexes).
Principles of Therapy
A normal fiber and fluid intake, and normal physical activity, in
combination with education and demystification, is the recommended initial
treatment strategy for functional constipation. Toilet training should coincide
with the above for the management of children ≥4 years old. If education,
demystification, lifestyle and diet changes with toilet training are
insufficient, pharmacological therapy should follow. Pharmacological therapy
consists of 3 phases, disimpaction, maintenance treatment, and weaning, if
possible. Maintenance therapy should be evaluated 2 weeks after initiation and
should be continued for at least 2 months. Maintenance medications are
continued in children who are being toilet trained until toilet training is
learned. Lastly, weaning may be initiated if the child has been under treatment
for at least 2 months and symptoms decreased or are absent for at least 1
month.
Specialist Referral
Consultation with a pediatric gastroenterologist
is indicated if the child’s history or exam findings suggest an organic cause,
when the child fails therapy, or for complex management. Symptoms not improving
after 6 months of good compliance to therapy warrants a pediatric gastroenterology
consult. The pediatric gastroenterologist further evaluates the child for
underlying organic problems, does specialized tests, and gives counseling. A
review of previous treatment regimen may lead to adjustment of medications.
Referral to a pediatric surgeon may be considered for patients unresponsive to
extensive medical management.
Pharmacological therapy
Disimpaction
If fecal impaction is present, the initial therapy is to evacuate the
colon. Fecal impaction is identified through PE finding of palpable stool on
abdominal and rectal exam and excessive stool on abdominal X-ray. Disimpaction
may be done with oral or rectal medications or a combination of these 2, and in
uncontrolled clinical trials, these had been effective. It is important to
discuss options with family regarding treatment choice. Disimpaction improves
response to maintenance therapy.
Oral Disimpaction
Example drugs: High-dose Mineral oil, Polyethylene glycol (PEG)
electrolyte solutions, high-dose Magnesium citrate, Sodium picosulfate,
Magnesium hydroxide, Sorbitol, Lactulose, Senna, Bisacodyl
Oral disimpaction is preferred due to its non-invasiveness but
adherence may be difficult. PEG is the recommended first-line therapy for
children presenting with fecal impaction.
Rectal Disimpaction
Rectal disimpaction is considered only when oral medications have
failed or are unavailable and only with the child or family’s consent. It may
be done with saline or phosphate soda enema or a mineral oil enema followed by
a phosphate enema. Glycerin suppositories in infants is recommended but enema is
to be avoided. Bisacodyl suppositories in older children are used. Soap suds,
tap water, and Magnesium are potentially toxic and are not recommended.
Digital disimpaction is not recommended or discouraged. Follow-up is
needed within 1 week for children undergoing disimpaction.
Constipation in Children_Management 2Maintenance Therapy
Following disimpaction, maintenance therapy is then started and may be needed for several months. Monitoring is essential during this time to ensure the child does not become reimpacted and to address issues such as adherence and toileting. Frequency of clinic visits is individualized based on the child’s needs and of the family’s. It is recommended that the same person or team perform the reassessment. Laxatives are advantageous in children until they can maintain regular toilet habits. Clear evidence is lacking as to which laxative is superior. Discontinuation of maintenance therapy may be considered if the child has developed regular bowel habits (bowel movement of at least 3 times per week).
Bulk-forming Laxatives
Example drugs: Ispaghula (Psyllium), Methylcellulose
Bulk-forming laxatives are used for the treatment and prolonged prophylaxis of patients with constipation without outlet obstruction. They are often used as first-line treatment and only used if increased dietary fiber is ineffective. Water-absorbing organic polymers that can increase fecal mass and make it softer and easier to pass, adequate intake of fluid is important.
Enemas
Example drugs: Glycerol, Sodium chloride, Sodium docusate, Sodium lauryl sulfoacetate, Sodium phosphate, Phosphate enemas
Enemas are not recommended for infants and patients with or suspected Hirschsprung disease or renal insufficiency. Enemas increases the risk for mechanical trauma to the rectal wall, abdominal distention, and vomiting. Disimpaction with enemas is a recommended option for children. Phosphate enemas are used after disimpaction with the use of another enema.
Lubricants
Example drugs: Mineral oil, liquid paraffin
Lubricants are considered safe in children but not recommended in children <3 years old and those with coagulation disorders. They are used for managing acute or subacute constipation. They soften stool and ease its passage by decreasing water absorption from the gastrointestinal tract.
Osmotic Laxatives
Example drugs: Poorly absorbed electrolytes (eg Magnesium hydroxide [milk of magnesia], Magnesium citrate, Magnesium sulfate) and poorly absorbed disaccharides (eg Lactulose, Lactitol and Sorbitol, and PEG 3350/4000)
Magnesium citrate, Magnesium sulfate, Magnesium hydroxide (milk of magnesia) are poorly absorbed electrolytes that are used for the long-term treatment of constipation that is difficult to manage. Low-dose PEG electrolyte solution may also be used. PEG with or without electrolytes is recommended as first-line maintenance therapy. Lactulose should be considered if PEG solutions are not available.
Lactitol is a lactulose-like derivative with the same function as a Lactulose-derived prebiotic and has the same therapeutic effect as Lactulose. Lactulose and Sorbitol are used in infants as stool softeners. Magnesium citrate is predominantly used for pediatric patients needing bowel cleansing prior to colonoscopy. It produces an osmotic effect in the colon, resulting in distention and peristalsis promoting bowel emptying. Osmotic laxatives change the water distribution in the stool causing fluid retention in the colon through osmosis. It must be noted that good fluid intake is essential.
Secretagogues (Prosecretory Agents)
Example drugs: Linaclotide, Lubiprostone, Plecanatide
Linaclotide is a guanylate cyclase receptor agonist that was recently approved in the United States for children ≥6 years old with functional constipation. Mild adverse effects were reported and include nausea, vomiting, abdominal pain, and diarrhea.
Serotonin Agonist
Prucalopride, a dihydro-benzofuran-carboxamide derivative and novel serotonin 5-HT4 agonist is an off-label option for pediatric patients with refractory constipation to be used as an adjunct to high-dose stimulant laxative. Studies have shown that toilet-trained patients with functional constipation tolerate Prucalopride therapy.
Stimulant Laxatives
Example drugs: Anthroquinones (Senna, Cascara, Danthron), Castor oil, diphenylmethanes (Bisacodyl, Sodium picosulfate), Glycerol or Glycerin
In the maintenance period, it is not recommended to use stimulant laxatives for a prolonged time. It is also not recommended in infants. It is used as an additional or second-line therapy in children with functional constipation when osmotic laxatives alone are ineffective. They are used as a “rescue therapy” when taken intermittently or for short periods. They directly stimulate colonic nerves, increase peristalsis in the GI tract, and induce water and salt secretion in the colon by stimulation of the enteric nervous system.
Stool Softeners
Example drugs: Docusate sodium, Liquid paraffin
Stool softeners may be combined with a stimulant. While softening the stool, the stimulant increases peristaltic activity in the GI tract. Stool softeners are used for prophylaxis in acute and subacute settings. They are surface-active agents that allow absorption of fat and water into the stool making it softer and easier to pass.
Investigational Agents
Various agents used in adults with functional constipation are being studied for pediatric use which include cholinesterase inhibitor (eg Pyridostigmine), and botulinum toxin injection.
Nonpharmacological
Treatment
goals in general include evacuation, pain-free bowel movement, and formation of
regular bowel habits.
Parental
Education
Family
education includes providing information on the mechanisms of constipation.
Parents are encouraged to have a consistent, positive, and supportive attitude
during treatment. Knowing the precipitating factors of constipation helps
remove anxiety of parents and caregivers and encourages them to be involved in
its management. Parents are educated on the proper timing and techniques of
toilet training. Toilet training should only be started when the child is
developmentally ready or shows signs of readiness and using a relaxed approach.
A potty chair or foot support (if adult-sized toilet is used) should be
provided. Treatment may be long and irregular and characterized by improvement
alternating with relapses.
Behavioral Modifications
Behavioral
Therapy
Behavioral
therapy aims to regularize toilet habits, discourage stool withholding, and
improve understanding of defecation dynamics. To establish a regular bowel
habit, scheduled toileting is recommended appropriate for the child’s
developmental stage, with adequate time for bowel movement. The child is
encouraged to sit on the toilet for 5-10 minutes after meals; when in school,
it is alright for the child not to go to the toilet. Ensure that a foot support for sitting is provided for the child’s
comfort when on the toilet.
The
parent is advised to give the child enough time to spend in the toilet when the
child shows signs of withholding stool. Straining techniques such as relaxation
of legs and feet, taking a deep breath then pausing while pushing while holding
one’s breath, should be taught to the child. A bowel diary of stool frequency
and consistency which can be discussed during clinic visits is maintained. For
positive reinforcement, the child’s efforts should be encouraged and rewarded,
not the results. It may be of benefit to refer to a mental health provider for
intervention if behavioral problems interfere with treatment, but it is
discouraged to do it routinely.
Biofeedback
Therapy
Biofeedback
therapy uses devices (electrical or mechanical) in order to increase awareness
of physiological functions of the anal sphincter by providing the patient with
visual, verbal, and/or auditory information and enhances self-control on body
functions. With the rise of rectal pressure, patients are taught external anal
sphincter relaxation. This demonstrated efficacy in correcting abnormal
defecation dynamics in previous studies but failed to show additional benefit
in the treatment of chronic childhood constipation. It is currently used only
for children with pelvic floor dyssynergia and short-term treatment of
intractable constipation. It is not to be used for ongoing treatment of
children with functional constipation.
Dietary Modification
Although
dietary modification is commonly recommended for the treatment of functional
constipation, it is discouraged to use dietary modification alone as first-line
treatment.
For
infants, it is recommended to continue breastfeeding. For formula-fed infants,
partially or extensively hydrolyzed infant formulas with prebiotics offer a
good alternative for managing functional constipation. It is helpful for
infants to have complex carbohydrates (eg carob bean gum,
galacto-oligosacharides [GOS], inulin) and sorbitol present in some juices (eg
apple, prune, pear) which increase stool frequency and fecal water content.
Barley malt extract or corn syrup can be used as stool softeners.
A
high-fiber diet is encouraged to help form soft bulky stools in children. A
0.5g/kg body weight intake of fiber is recommended in children > 2 years of
age. For infants and children <2 years of age, 5
g/day of fiber intake is preferred. A balanced diet with fruits, vegetables, and whole grains is appropriate
in children >2 years of age.
A
double-blind crossover study demonstrated that intolerance to cow’s milk may
result in constipation. However, withholding milk from the diet should be done
only on the advice of a specialist, as it is not a common occurrence. Elimination
of cow’s milk protein for at least 2 weeks may be considered in patients
unresponsive to other interventions especially if with atopic symptoms.
Probiotics
(eg Lactobacillus sp, Bifidobacteruim sp) may help improve stool
frequency and consistency. However, studies are limited, and further trials are
needed to support the use of probiotics in children with functional
constipation. Increasing intake of fluids is also recommended, especially if there are signs of dehydration. However, studies
have shown that doing so only increased urine output and had no effect in
output or consistency of stool and did not improve stool frequency. Increasing
intake of absorbable and non-absorbable carbohydrates, especially sorbitol,
found in some juices like prune, pear, and apple juice is recommended.
Constipation in Children_ManagementSurgery
Surgical management of refractory functional constipation may include anal procedures (eg botulinum toxin injection, sphincter myectomy), anterograde continence enema, colorectal resection, and intestinal diversion.