“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
    • Note that checking abdominal XR to assess constipation in children is a Thing We Do For No Reason

*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.

Key points on the above criteria: 

• 80% of children with fecal incontinence have underlying constipation. Conversely, fecal incontinence ultimately develops in up to 50% of children with chronic refractory constipation. 
• Abdominal pain is often associated with functional constipation, but is NOT among the diagnostic criteria. ~90% of children presenting with recurrent abdominal pain have a functional etiology such as constipation or IBS!

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