Constipation

Question 1

What constitutes constipation in childhood?

Answer 1

Constipation is defined as a delay or difficulty in defecation, present for 2 or more weeks and sufficient to cause distress in the patient. Normal stool frequency varies from several times a day to three stools per week. In children, constipation should be considered when the normal stooling pattern becomes more infrequent, when stools become hard or are difficult to expel, or when the child exhibits withholding patterns or behavioral changes toward moving his or her bowels. Soiling (encopresis) can be a sign of constipation

Question 2

What features suggest an organic etiology for constipation?

Answer 2

History of weight loss or inadequate weight gain
• Lumbosacral nevi or sinus
• Multiple café-au-lait spots
• Abnormal neurologic examination (decreased tone, strength; abnormal reflexes)
• Anal abnormalities (anteriorly displaced, patulous, or tight)
• Gross or occult blood in stool
• Abdominal distention with or without vomiting

Question 3

What are some common triggers of constipation in healthy infants and children?

Answer 3

• Introduction of solid foods or cow milk : Diet may be low in fiber and not provide adequate fluid intake.
• Inadequate toilet training : Toddlers may not respond appropriately to the need to defecate or may not have adequate foot support needed for effective evacuation of stool if using an adult-sized toilet. If passage of stool is painful, toddlers can begin to withhold stool. If stool is not made softer by increasing fiber and/or fluids in the diet or by stool softeners, this pattern can continue.
• School entry: Children may be reluctant to use the toilet at school, leading to a pattern of stool withholding, painful stools, and constipation.

Question 4

How should children with chronic constipation and encopresis be managed?

Answer 4

• The rectosigmoid colon should be aggressively cleansed of fecal material. Manual disimpaction is sometimes required. Multiple enemas over multiple days are commonly needed. Adult enemas should be used in children who are older than 3 years.
• Medications that act as an osmotic laxative by drawing fluid into the intestine to promote the passage of soft stools include polyethylene glycol powder and lactulose (a nonabsorbable sugar). Other osmotic agents, such as sorbitol and magnesium citrate, can be considered. For cases of long-standing functional constipation, osmotic laxatives should be continued for a minimum of several months while the dilated rectum returns to normal size.
• An oral lubricant , such as mineral oil, can help promote the continued passage of stool but can contribute to accidental soiling. In difficult cases, stimulant medications , such as bisacodyl or senna, can be substituted for short-term use.
• It is extremely important to educate patients and parents about the mechanics of the disorder. A high-fiber diet, possible limitation of dairy and complex carbohydrates, defined periods of toilet sitting (2 to 3 times daily for 10 minutes after meals), and a behavior modification system that rewards normal bowel movements are essential for eventual success. Integrative approaches of biofeedback, relaxation strategies, and mental imagery have been used for children who have severe “defecation anxiety.” A goal is one to two soft bowel movements a day. Relapses are common.