“Farfrompoopen” (A 5-year-old Told Me It’s German for Constipation)

Constipation in Kiddos

Evaluation: 

  • Subjective: baseline diet/fluid intake (including any recent changes), stooling pattern (frequency, consistency, etc.), any prior constipation, current/prior medications, and possible infectious exposures
    • Common times for young kids to get constipated:
      • After the introduction of cereals and solid food into the diet (age 4-6mo to 1yr)
        • Constipation tends to develop in this context because the transitional diet often includes inadequate amounts of fiber and fluid
      • Transitioning to cow’s milk (1yo)
      • During toilet training (age 2-3yo)
      • During the start of school (age 3-5yo) 
  • Objective: hydration status, abdominal exam, quantification of stools relative to normal output
    • Consider labs (metabolic or electrolyte derangements) and imaging in patients with atypical features or for those who fail to respond to a systematic and carefully administered intervention program

*Key point: Almost all childhood constipation is functional without an organic etiology. 

Potential complications of constipation:

  • Progressive stool withholding
  • Hemorrhoids
  • Anal fissures
  • Incontinence
    • Beware of overflow incontinence with rectal impaction!

Functional Constipation

Rome IV diagnostic criteria are similar for all children, but vary slightly according to age and toilet-training.

Source: UpToDate

Key points on the above criteria: 


But wait! It can’t all be functional, right?

Organic causes account for fewer than 5% of cases of constipation in children. Consider the following potential “can’t miss” issues:

  • Constipation associated with new stool incontinence, decreased genitourinary sensation, and/or lack of response to traditional stimulant laxatives?
    • May suggest spinal cord abnormality
  • Progressive symptoms, no flatus, increasing distention, and/or increasing pain?
    • May suggest cystic fibrosis, malignancy, volvulus, intussusception, or incarcerated hernia
  • Occult blood, empty rectum, gushing stool with rectal exam, and/or no meconium within first 48h of life?
    • May suggest Hirschsprung disease

Prevention

In thinking about preventing constipation, let’s first differentiate “recent onset” (≤8 weeks) from “chronic” (>3 months).

  • “Recent” is often amenable to short-term interventions whereas “chronic” may require
    longer-term behavioral and environmental modifications

Dietary modifications:

  • Fluid intake: goal is maintenance fluid requirement
  • Addition of pear, apple, or prune juice (sorbitol), which must be titrated:
    • Infants <4 months: 1-2 oz/day of diluted juice (1:1 ratio)
    • Infants >4 months: 2-4 oz/day of full strength juice
    • Infants taking purees: sorbitol-containing pureed foods
    • Beware of sugar and calorie content!
  • Dairy: Try limiting cow’s milk (slows intestinal motility) to 24 oz/day (475-700 mL) or try calcium-fortified soy milk
  • Fiber goals:
    • Infants and toddlers <2yo: 5 g/day
    • Children ≥2yo: (age + 5-10) g/day
      • Usually 7-15 g/day
    • Most vegetables and fruits supply approximately 1 g of fiber per serving, but prunes and peas can supply up to 2 g. Rice infant cereal supplies a negligible amount of fiber, whereas whole wheat, barley, and multigrain cereals supply 1 to 2 grams per serving

Toilet training:

  • Relaxed approach
  • Provide foot support for sitting on the toilet (for comfort and to relax the pelvic floor)
  • Ensure adequate fiber intake
  • Avoid excessive cow’s milk in diet

Stool withholding:

  • Try to minimize 1) pain, and 2) stress
  • Check for presence of anal fissures
    • Consider topical petroleum jelly, occasional topical analgesics, and stool softeners as needed
  • Is school a low- or high-stress environment?
    • Encourage caregivers to inquire about bathroom patterns
  • Address psychosocial contributors

Treatment

Rectal therapies:

  • Rectal thermometer stimulation (lubricated)
    • Note that tolerance can develop
  • Glycerin suppositories
  • Older children: consider trial of mineral oil or enemas (NOT recommended in infants)

Laxatives (infants >6 months):

  • Osmotic (Miralax, lactulose, sorbitol)
  • Short-term use of Senna
  • Older children: can trial milk of magnesia or bisacodyl (NOT recommended in infants)

Additional anticipatory guidance: 

  • Manage expectations
    • If functional constipation, anticipate a chronic relapsing course
  • Maintenance of regular schedule (including medications)
  • Educate families about warning signs

Blog post based on Med-Peds Forum talk by Emily Kruse, PGY1