1. Constipation in Infants and Children
Jason Dranove, MD
Levine Children’s Hospital
Carolinas Medical Center
Division of Pediatric Gastroenterology, Hepatology, and Nutrition
2011

3. 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

4. Delayed passage of meconium
Intestinal Obstruction / Anatomical Malformation
Hirschsprung’s Disease
Meconium Ileus
Functional Ileus
Small left colon
Maternal Drugs
Hypothyroidism

5. Normal Frequency of Bowel Movements
The gradual decrease in bowel movement frequency with advancing age correlates with shorter transit time and varying patterns of colonic motility. The mean total gastrointestinal transit time is 8.5 hours at 1 to 3 months of age, 16 hours at 4 to 24 months, 26 hours at 3 to 13 years of age, and 30 to 48 hours after puberty [4].
Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
Journal of Pediatric Gastroenterology & Nutrition. 43(3):e1-e13, September 2006.

6. Constipation in Infants and Toddlers
At least two of the following present for at least
one month
Two or fewer defecations per week
At least one episode of incontinence 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
Constipation is generally defined as a delay or difficulty in passage of stool
This is very subjective, so over the years investigators have tried to make a more objective criteria so that constipation is not over or under diagnosed.

7. 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
Resolves spontaneously
No interventioni required
Reassurance is key
Laxatives and osmotic agents can lead to more gas

8. Constipation in Children 4-18 YO
Children with developmental age of at least 4 to 18 years
Two of the following present for at least two months
Two or fewer defecations per week
At least one episode of fecal incontinence per week
History of retentive posturing or excessive volitional 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

9. Nonretentive Fecal Incontinence
Must include all of the following in a child
with a developmental age at least 4 years
Defecation into places inappropriate to the
social context at least once per month
No evidence of an inflammatory, anatomic,
metabolic, or neoplastic process that explains
the subject’s symptoms
No evidence of fecal retention

10. Functional vs. Organic -- Functional
Over 95% of Constipated children has functional constipation
Functional: persistent, difficult, infrequent, or seemingly incomplete defecation without evidence of underlying structural or metabolic defect
Most commonly due to with-holding after a painful bowel movement
Presents most commonly at three age periods
At introduction of cereals and solid foods
At toilet training
At the start of school

11. Functional Constipation
Classic History
Child has a painful bowel movement
When urge to have a bowel movement happens, the child consciously withholds stool by contracting their external anal sphincter and gluteal muscles
The child might rise on their toes, rock back and forth, stiffen their buttocks and legs, assume unusual postures, and often will hide in a corner
Eventually, the rectum habituates to the stimulus of the enlarging fecal mass, the urge to defecate subsides, and the retentive behavior becomes almost second nature or subconscious
Can develop soiling (encopresis)

12. Functional vs. Organic -- Organic
Accounts for less than 5% of all constipation
Anatomic malformations
Metabolic causes
Neuropathic conditions
Intestinal nerve and muscle disorders
Drugs
Hypotonia
Miscellaneous

13. Distinguishing Functional vs. Organic -- History
Presentation in neonatal period more likely to be organic as compared to older children
Clues from history (red flags)
Delayed growth
Delayed passage of meconium
Urinary incontinence or bladder disease
Passage of blood (unless attributable to an anal fissure)
Constipation from birth or very early infancy
Acute onset of constipation
Vomiting
Signs of systemic illness, multisystem involvement
Recurrent respiratory infections
History of sexual, physical, or emotional abuse

14. Functional vs. Organic – Physical exam clues
Abdominal distension
Findings of spinal dysraphism
Patulous anus
Absent cremasteric reflex (boys)
Absent anal wink
Pigmentation, dimples, or tufts of hair over lumbosacral region
Anorectal malformation
Anteriorly displaced anus
Sensory or motor defects of the lower extremities
Inability to insert a pinky in the anal canal
Gush of stool after a rectal exam upon which no stool is felt in the rectal vault

15. Clues to Hirschsprung’s disease
Aganglionic bowel extending for variable lengths from the internal anal sphincter
75-80% confined to rectosigmoid
Incidence about 1:5000
Male to female 4:1
Almost exclusively a disease of full term infants
80-90% diagnosed within first 3 years
Mean age of diagnosis is 2.6 months

16. Barium enema for Hirschsprung’s
Transition zone

17. Other Metabolic Causes of Constipation
Celiac disease
Hypothyroidism
Spinal dysraphism
Cystic Fibrosis
Botulism
Hypokalemia / Hypercalcemia
Lead poisoning

18. Evaluation of Constipation
Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
Journal of Pediatric Gastroenterology & Nutrition. 43(3):e1-e13, September 2006.

19. Overall approach to management
Determine whether fecal impaction present
Treat impaction if present
Initiate treatment with oral medications
Provide parental education
Close follow up
Adjust medications as necessary

20. Management and Treatment of Constipation -- > 1 YO
Red Flags Present
Yes – Evaluate further
No – Presume and treat functional
constipation
Is a fecal impaction present (mass of stool felt on abdominal exam or large rectal fecal mass on DRE)
If not comfortable performing rectal exam – KUB can help
Yes – Disimpact with oral or rectal medication, then move to maintenance medication
If fail disimpaction, refer to Pediatric GI
No – Start maintenance treatment with with education, diet, medication
Continued …..

21. Management and treatment of Constipation > 1 YO
Maintenance therapy
Effective – Attempt to wean after several months of success
Ineffective – Reassess, re-educate, increase or change medications
If effective on second try – go into maintenance phase and attempt to wean again in future
If ineffective on second trial of treatment
T4, TSH, Calcium, Celiac panel (total IgA and anti ttG IgA antibody), lead level
If abnormal, treat as indicated
If tests normal, refer to pediatric GI

22. Pediatric GI After referral is made Determine appropriate workup
Vast majority of referral patients can be managed without much diagnostics
When refractory to treatment, consider further workup
Anorectal manometry
Barium enema
Spine MRI
Radio-opaque marker studies
Full thickness rectal biopsy
Colonic manometry

23. Management and treatment of Constipation -- < 1 YO
Similar to that of Children > 1 YO
Differences
If delayed passage of meconium
Refer to Pediatric GI or Surgery for rectal biopsy
If rectal biopsy normal – sweat test
1st line treatment can be diet alone
Prune or apple juice, 2-4 ounces a day

24. Education Family friendly explanation of constipation
Reassure that this is not a willful or defiant behavior
Maintain consistent, positive, supportive attitude
Avoid punishment
Establish a reward system

25. Toilet Hygiene
Twice a day for minutes after breakfast and dinner
Gastrocolic reflex
Sit up straight
Thighs parallel to ground
Good foot support
Valsalva maneuver to increase abd pressure
Blow up balloon
No distractions
Reasonable reward system

26. Disimpaction Impaction Disimpaction
a hard mass in the lower abdomen identified during physical examination, or
A dilated rectum filled with a large amount of stool on rectal exam, or
Excessive stool in the colon identified by radiography
Disimpaction
Oral
Rectal
Oral and Rectal
Best determined after discussion with family
Manual

27. Disimpaction LCH approach High dose Polyethylene Glycol (Miralax)
Age 1-2
2 teaspoons of Miralax with 4 oz of clear liquid and drink repeat every hour until stool is clear
Age 3-5
4 capfuls of Miralax in 24 ounces of Gatorade given 4 oz q 30 – 60 minutes until gone
Age 6-11
6 capfuls of Miralax in 32 oz of Gatorade given 4 oz q minutes until gone
Age 12 and older
8 capfuls of Miralax in 32 oz of Gatorade given 4 oz q minutes until gone
Stimulant laxative
Age 3-11
Bisacodyl 5 mg at beginning and end of cleanout
Age 12 and up
Bisacodyl 10 mg at beginning and end of cleanout

28. Enema Fleets Phosphosoda enema Retention of enema
< 2 YO not recommended
2 – 4 YO = ml (1/2 of a Pediatric Fleets enema <Pedia Lax>)
5-11 YO = 67.5 ml (full Pediatric Fleets enema <Pedia-Lax>)
12 YO and up – 118 ml (adult Fleet enema)
Retention of enema
Hyperphosphatemia
Hypocalcemia
Never give more than one enema per day
If enema not evacuated, do not give a second enema

29. Goals of treatment
1 to 2 soft (mashed potato or soft ice cream) consistency stools per day
Resolution of soiling
Return of rectal sensation
Empowerment of child
Make defecation a positive experience

30. Non absorbed sugars Juices OK to use after roughly 2 mo of age Prune
Apple
White grape juice
Increase osmotic load and draw water into bowel
OK to use after roughly 2 mo of age

31. Lactulose Second line in infants < 6 mo not responding to juice
Limited role in those over 6 mo secondary to success of PEG 3350
Comes 10 g / 15 ml
Dose = 1-3 ml/kg/day in single or divided doses
Usually start ½ to 1 teaspoon a day and increase as needed
Side effects
Cramps, flatulence, “colicky” behavior

32. PEG 3350 Safe for use down to 6 months of age Comes 17 grams in a cap
Roughly 4 teaspoons is in one cap (1 teaspoon = roughly 4 to 5 grams of PEG 3350
Easier to dose by teaspoon in infants
Typical dose for maintenance is roughly 0.7 g/kg/day
In older children typically start at max of 17 grams twice a day but can increase if needed
Technically no max dose
If not responding to 34 grams a day in older child or roughly 1 g/kg/day in younger child, consider adding a stimulant laxative, re-education, or referral

33. Sample Treatment regimen for older child (non infant)
Start Miralax at discussed doses
Increase or decrease dose by small amounts until desired effect is reached
Follow up within 1 month
Aggressive Approach
After 8 weeks of soft daily bowel movements, begin to taper by small amounts every couple of weeks (1/4 of dose at a time is a good guide) until BM achieved without laxative
If stools become hard again during taper, increase to the last effective dose and maintain for another 8 weeks
Conservative approach
Continue laxatives for 6 months of soft daily bowel movements, then wean slowly

35. Stimulants Senna Bisacodyl Comes 8.8 mg/5ml or 8.8 mg tabs
2-6 YO – 2.5 to 7.5 ml a day
6-12 YO – 5-15 ml a day
Try to limit to periodic dosing
With regular use drug can lose effectiveness
Anecdotal evidence
Bisacodyl
0.2 mg/kg/dose, max 10 mg per dose
Comes in 5 and 10 mg tabs
Use intermittently or for short periods
Has very high side effect profile
Cramping, diarrhea, abdominal pain, nausea

36. Others Mineral oil Magnesium citrate Magnesium hydroxide Karo Syrup
Do not use for < 1 YO due to aspiration risk
Magnesium citrate
Magnesium hydroxide
Karo Syrup
Suppositories

37. Diet Controversial whether dietary changes can treat constipation
Mild constipation
Increase fluid intake
Increase fiber intake
Goal is age + 5 in grams per day
Mild to severe constipation
Diet alone unlikely to treat constipation
Role of excessive cow’s milk intake
controversial

38. Inpatient bowel cleanout
Polyethylene Glycol Electrolyte solution
100 ml / kg up to max of 4 liters
Likely will need Nasogastric administration
Can run at rates up to 1 L per hour
Personal experience
Run in over 8 hours
If stool not clear may repeat
If severe impaction not responding
Consult Pediatric Gastroenterology
Manual Disimpaction under anesthesia

39. Treatments Not recommended
Milk and Molasses enema
Soap suds enema
Tap water enema
Oral Phosphosoda
Nephropathy
FDA warning

40. Non retentive encopresis
Soiling in the absence of fecal impaction or constipation
Cause unknown
High correlation with attention deficit and psychological comorbidities
Up to 40% were never fully toilet trained
Treatment
Unfortunately limited
Psychologist
Regimented toileting schedule

41. Colonic Manometry

42. Colonic Manometery

43. Anorectal Manometry

44. Anorectal Manometry

45. Case 1
3 YO male with infrequent, hard bowel movements. Stools can clog the toilet. He has a normal physical and is thriving?
--What is the diagnosis
--Is any workup indicated
--What is the treatment?

46. Case 2
18 month old female
Constipation, abdominal distension, poor growth, frequent wheezing and chronic cough
Mom can not remember if she passed meconium within 1st day of life
What is the differential diagnosis?
Would you do any workup?

47. Case 3 3 month old male, full term infant
Abdominal distension, poor growth, has developed vomiting
Rectal exam – can not get pinky into anal canal
Differential diagnosis?
Workup?

48. Case 4
3 YO female. Was doing well until about 9 months of age, then started to fall off growth curve. Has distended abdomen, extremity wasting, no history of respiratory infection.
Differential diagnosis
Workup?

49. Case 5 2 YO female with constipation since birth
Did pass meconium on day of life 1
No abdominal distension, normal growth
Physical exam reveals a pit over the lumbosacral area with hair covering it?
Differential diagnosis
Workup

50. Question 1 What is the appropriate screening test for celiac disease
A. Anti gliadin antibody
B. HLA DQ2-DQ8 genotype
C. Ttg IgG and serum IgA
D. Ttg IgA and serum IgA
E. TgG Iga alone

51. Question 2
Infantile dyschezia is straining with passage of soft bowel movements in babies up to _____ months old.
A. 3
B. 6
C. 9
D. 12
E. 15

52. Question 3 The presence of meconium ileus is almost pathognomonic for
A. Hirschsprung’s disease
B. Infant of diabetic mother
C. Ileal atresia
D. Cystic Fibrosis
E. Hypothyroidism

53. Question 4
Which of the following home remedies is strongly discouraged for fecal disimpaction
A. Milk and Molasses enema
B. Soap Suds enema
C. Tap Water enema
D. All of the above
E. None of the above

54. Question 5
The following tests should be routinely performed in all constipated children
A. TSH
B. Sweat test
C. Basic metabolic panel
D. All of the above
E. None of the above