Functional Constipation, by Piyawat Sukijthamapan and Dr. Daniel Kamin.
Learning Objectives.
By the end of this video, the viewer will be able to explain the basic pathophysiology
of pediatric constipation, recognize its clinical presentation, discuss how to diagnose constipation,
and understand the management for constipation.
Introduction.
Constipation is a common health problem in pediatric patients.
It affects up to 30% of children and accounts for 3% to 5% of all visits to pediatricians.
Constipation is defined as difficulty in defecation for at least one month.
About 95% of cases of constipation in healthy children one year and older are functional
disorders due to voluntary withholding with no identifiable pathologic condition.
Organic constipation is more likely to present in the first month of life.
Pathophysiology.
Functional constipation is caused by painful bowel movements that lead to the child voluntarily
withholding stool.
The child will contract the anal sphincter or gluteal muscles by stiffening the body,
rocking back and forth, or fidgeting with each urge to defecate.
Prolonged fecal stasis can lead to excessive reabsorption of fluid causing stools to become
harder, larger, and more painful to pass.
Over time, the rectum stretches and may cause diminished rectal sensation.
Liquid stools may leak around the retained firm stools and cause incontinence.
Retained fecal masses may obstruct the urethra causing urinary stasis and urinary tract infections.
Some organic etiologies of constipation include, Hirschsprung's disease, cystic fibrosis, hypothyroidism,
electrolyte abnormalities, celiac disease, milk protein allergy, anatomic malformations
of the colon and rectum, spinal cord lesions, and medications.
The possibility of child abuse should also be considered, particularly when history is
not typical.
Clinical Presentation.
A child must present with at least one month of difficulty in defecation showing at least
two signs including two or fewer defecation per week for a toilet trained child, one or
more episodes of fecal incontinence per week, retentive posturing or volitional stool retention,
painful or hard bowel movements, large fecal mass in the rectum, or large diameter stools.
The child may also have abdominal pain or symptoms of urinary tract infection.
Diagnosis.
A history and physical exam is usually sufficient to diagnose functional constipation.
Relevant history includes detailed newborn history, as well as recent stooling history,
including stool size, consistency, appearance, and leakage events.
A thorough dietary history should also be performed noting milk intake, carbohydrate
quality, and vegetable or fruit intake.
The examination focuses on signs of abnormal growth, abdominal distension, hepatosplenomegaly,
fecal mass, as well as signs of trauma and neuromuscular or spinal abnormalities.
It is important to look for signs that may suggest an organic cause including abdominal
distension or mass, neurologic abnormality, such as loss of cremasteric reflex, or anal
wink, blood in stool, abnormal anal position, or an explosive stool on withdrawal of finger
from the anus.
If an organic etiology is suspected, perform an appropriate diagnostic workup, which may
include, when appropriate, thyroid studies, a calcium level, a celiac disease panel, sweat
chloride test, abdominal X-ray or barium enema, anorectal manometry, and rectal suction biopsy.
Management.
Treatment of pediatric constipation involves initial disimpaction, maintenance therapy,
and behavioral and dietary modifications.
Disimpaction, or a clean out, can be done with oral and/or rectal therapies.
Oral treatments include osmotic agents, such as polyethylene glycol, magnesium citrate,
lubricant mineral oil, and stimulants such as Senna or bisacodyl.
If unsuccessful, rectal glycerin suppository can be used.
Enemas with phosphate soda, saline, or mineral oil can also be used for more rapid treatment.
Use caution when administering phosphate enemas to patients with renal impairment.
Following disimpaction, a maintenance therapy should be given and gradually tapered until
resolution of symptoms.
A combination of any osmotic, stimulant, and lubricant agents can be used.
A diet rich in fiber, non-dairy fluids, and some sorbidal based juices can play a role
in preventing constipation.
Techniques such as documentation of bowel movements, toileting routines with proper
body mechanics, and positive reinforcement are helpful behavioral support through toilet
training.
Organic constipation can be treated based on the underlying cause and usually involves
a specialist to manage.
Treatment over organic constipation is beyond the scope of this video.
Summary.
Constipation in toddlers and preschool-aged children is most often a functional disorder.
However, organic etiology should be ruled out, especially in younger infants and anyone
with red flag symptoms or abnormal physical exam.
Management includes disimpaction, a maintenance stool regimen, and dietary and behavioral
modifications.
Thank you for watching this video on constipation.