Contipation

Question 1

What is constipation in a child < 1 year old?

Answer 1

Fewer than 3 complete stools per week
Hard large stool
Rabbit droppings

Question 2

What is constipation in a child > 1 year?

Answer 2

Fewer than 3 complete stools per week
Overflow soiling
Rabbit droppings
Large, infrequent stools that can block the toilet

Question 3

What are symptoms associated with defection in constipation in child < 1 year old?

Answer 3

Distress on passing stool
Bleeding associated with hard stool
Straining

Question 4

What are symptoms associated with defaecation in constiaption in child > 1 year old?

Answer 4

Poor appetite that improves with passage of large stool
Waxing and waning of abdominal pain with passage of stool
Retentive posturin straight legged, tiptoed
Straining
Anal pain

Question 5

Wha are causes of constipation in children?

Answer 5

Dehydration
Low fibre diet
Medications - opiates
Anal fissure
Hypothyroidism
Hirschsprung's disease
Hypercalcaemia
Learning disabilities
Over-Enthusiastic potty training

Question 6

What are red flags suggesting underlying disorder?

Answer 6

Reported from birth or first few weeks of life
Passage of meconium > 48 hours after birth
Ribbon stools
Faltering growth is amber flag
Previously unknown or undiagnosed weakness in legs
Abdominal distension

Question 7

What features indicate idiopathic constipation?

Answer 7

Starts after few weeks of life
Obvious precipitating factor - fissure, change of diet, potty training, acute events
Meconium passage < 48h after birth
Growth is generally good
Active
No neurological problems in legs
Changes in infant formula
Insufficient fluid intake

Question 8

What are factors suggesting faecal impaction?

Answer 8

Symptoms of severe constipation
Overflow soiling
Faecal mass palpable in abdomen

Question 9

What is manamgen if faecal impaction is present?

Answer 9

Polyethelene glycol 3350 + electrolytes (Movicol Paediatric Plan)
Excalating dose regimen

If no disimpaction after 2 weeks:
Add stimulant laxative - sodium picosulphate or senna

Substitue stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plan is not tolerated

Question 10

What is maintenance therapy for constipation?

Answer 10

Movicol Paediatric Plan - polyethylene glycol + electrolytes
Add a stimulant laxative if no response
Substitute a stimulant laxative if Movicol Paediatric Plan is not tolerated
Add lactulose if stools are hard

Continue medication at maintenance dose for several weeks after regular bowel habit is established then reduce dose gradually

Question 11

What is management of infants not yet weaned <6m

Answer 11

Bottle fed infants: give extra water between feeds
Gentle abdominal massage and bicycling infants legs

Breast fed infant: constiaption is unusual - organic causes considered

Question 12

What is the concern in failure to pass meconium within 24h?

Answer 12

Hirschsprung disease

Question 13

What is the concern with faltering growth?

Answer 13

Hypothyroidism

Coeliac disease

Question 14

What is the concern with perianal fistulae, abscesses or fissures?

Answer 14

Perianal Crohn’s disease

Question 15

What conservative management for constipation?

Answer 15

Ensure adequate oral fluid intake

Encourage good toileting habits

Question 16

What is Hirschsprug disease?

Answer 16

Absence of ganglion cells from the myenteric and submucosal plexuses of part of the large bowel resulting in narrow, contracted segment.

Mostly confined to rectosigmoid

Question 17

How does Hirschsprung present?

Answer 17

Intestinal obstruction with failure to pass meconium in first 24h of life

Rectal examination may reveal a narrowed segment and withdrawal of the examining finger often releases a gush of liquid stool and flatus

Question 18

How is Hirschsprung diagnosed?

Answer 18

Suction renal biopsy demonstrating absence of ganglion cells

Question 19

Management of Hirschsprung?

Answer 19

Surgical excision + colostomy