Constipation in children

Last updated
Constipation in children
Specialty Pediatrics

Constipation in children refers to the medical condition of constipation in children. It is a functional gastrointestinal disorder.

Contents

Presentation

Children have different bowel movement patterns than adults. In addition, there is a wide spectrum of normalcy when considering children's bowel habits. [1] On average, infants have 3-4 bowel movements/day, and toddlers have 2-3 bowel movements per day. At around age 4, children develop an adult-like pattern of bowel movements (1-2 stools/day). The median onset of functional constipation in children is at 2.3 years old, with girls and boys being similarly affected. [2] Children benefit from scheduled toilet breaks, once early in the morning and 30 minutes after meals. [3] [4] The Rome III Criteria for constipation in children can help to define and diagnose constipation for various age groups. [5] Constipation in children may present as encopresis, or the inappropriate passage of stool (usually involuntarily) in inappropriate places. [2] Stool can build up in the rectum, leading to rectal dilation and decreased gastric emptying. This can present as nausea, vomiting, abdominal distention, loss of appetite and pain. [2] Children may also have stool retentive behaviors and aversion to using the toilet as bowel movements are painful. [2] Chronic constipation in children has been associated with urinary stasis and urinary tract infections. [2]

Causes

While it is difficult to assess an exact age at which constipation most commonly arises, children frequently experience constipation in conjunction with life-changes. Examples include: toilet training, starting or transferring to a new school, and changes in diet. [1] Especially in infants, changes in formula or transitioning from breast milk to formula can cause constipation. 95% of cases of constipation in children are thought to be functional constipation (without a structural or biochemical cause). [2] Treatment of these functional causes can be focused on simply relieving the symptoms. [6]

Studies have shown a link between diets low in dietary fibres and high in processed foods, such as fast food, and childhood constipation. [7] Certain medications such as antacids, anticholinergics and opiates are also known to cause constipation in children. [2]

Congenital causes

A number of diseases present at birth can result in constipation. They are as a group uncommon with Hirschsprung's disease (HD) being the most common. [8] HD is more common in males than females, affecting 1 out of 5000 babies. In people with HD, specific types of cells called 'neural crest cells' fail to migrate to parts of the colon. This causes the affected portion of the colon to be unable to contract and relax to help push out a bowel movement. The affected portion of the colon remains contracted, making it difficult for stool to pass through. [9] Concern for HD should be raised in a child who has not passed stool during the first 48 hours of life. Milder forms of HD, in which only a small portion of the colon is affected, can present later in childhood as constipation, abdominal pain, and bloating. [9] Similar disorders to HD include anal achalasia and hypoganglionosis. In hypoganglionosis, there is a low number of neural crest cells, so the colon remains contracted. In anal achalasia, the internal anal sphincter remains contracted, making it difficult for stool to pass. However, there is a normal number of neural crest cells present. [6]

There are also congenital structural anomalies that can lead to constipation, including anterior displacement of the anus, imperforate anus, strictures, and small left colon syndrome. [6] Anterior displacement of the anus can be diagnosed on physical exam. [10] The disease causes constipation because the inappropriate positioning of the anus which make it difficult to pass a bowel movement. Imperforate anus is an anus that ends in a blind pouch and does not connect to the rest of the person's intestines. Small left colon syndrome is a rare disease in which the left side of the babies colon has a small diameter, which makes it difficult for stool to pass. A risk factor for small left colon syndrome is having a mother with diabetes. [6]

Some symptoms that may indicate an underlying disease include: [1]

Diagnosis

The diameters of different segments of the large intestine can be compared to the width of lumbar vertebra 2 for more consistent reference ranges on abdominal x-rays. Main measuring sites of colon diameter.jpg
The diameters of different segments of the large intestine can be compared to the width of lumbar vertebra 2 for more consistent reference ranges on abdominal x-rays.
Ratios of large intestinal segments compared to lumbar vertebra 2, as 75th percentile, meaning that 25% of children normally have a ratio higher than this. Ratios of large intestinal segments compared to lumbar vertebra 2.png
Ratios of large intestinal segments compared to lumbar vertebra 2, as 75th percentile, meaning that 25% of children normally have a ratio higher than this.

The Rome process suggests a diagnosis of constipation in children fewer than 4 years old when the child has 2 or more of the following complaints for at least 1 month. [6] For children older than 4 years, there must be 2 of these complaints for at least 2 months:

For children, the degree of constipation may be scored by the Leech or the Barr systems:

Areas used for the Leech system of constipation grading. Leech scoring areas.jpg
Areas used for the Leech system of constipation grading.
  • 0: no visible feces
  • 1: scanty feces visible
  • 2: mild fecal loading
  • 3: moderate fecal loading
  • 4: severe fecal loading
  • 5: severe fecal loading with bowel dilatation
These score are assigned separately for the right colon, the left colon and the rectosigmoid colon, resulting in a maximum score of 15. A Leech score of 9 or greater is regarded as positive for constipation. [12]

Treatment

Osmotic laxatives (ex. polyethylene glycol, milk of magnesia, lactulose, etc) are recommended over stimulant laxatives (ex. sennosides, bisacodyl, etc). [14]

Lactulose and milk of magnesia have been compared with polyethylene glycol (PEG) in children. All had similar side effects such as flatulence, watery stools, stomach pain and nausea, but PEG was more effective at treating the symptoms of constipation. [5] [15] [16] Bisacodyl and glycerin suppositories can also be used. [2] After normal bowel movements have been restored, PEG can be continued daily as a maintenance treatment to maintain normal bowel habits. The length of PEG maintenance therapy is not well established, with some advocating continuing PEG for at least 1 months after normal bowel movements have been restored, or until the child is toilet trained. [2] Lactulose and stimulant laxatives are considered second line in the maintenance treatment of constipation. [2] Relapses of constipation symptoms are common. [2]

An increased intake in fibre or fibre supplements have been shown to improve the symptoms of constipation in comparison to placebo; however, the evidence is limited. [7] Fibre helps improve the symptoms of constipation through the action of soluble and insoluble fibres. Soluble fibres facilitate the production of a gel-like substance. [7] This increases stool size, and improves compactness, making it easier to remove the stools from the body. [7] Insoluble fibres also increase the size of the stool, and triggers the gastrointestinal tract to contract, facilitating further movement of gastro-intestinal contents. [7] Sorbitol based juices (such as apple, prune or pear juices) can help in infants or children with constipation as they increase stool water content and frequency. [2]

A structured toileting schedule (such as using the toilet after meals) or a reward system may help with chronic constipation. [2] Consultation to a child psychiatrist may be considered if treatments do not restore normal bowel function within 6 months. [2]

More evidence is needed to evaluate other non-pharmacological interventions. Probiotics are thought to provide healthy bacteria that can aid in stimulating contractions in the gastrointestinal tract to help gastrointestinal contents move forward in the body. [17] Probiotics, increased hydration, and dry cupping were found to be ineffective in the treatment of childhood constipation; however, better studies on these subjects need to be done. [7]

Epidemiology

There is wide variation in the rates of constipation as reported by research in various countries. [18] The variation in research data makes it challenging to describe the true global situation. [18]

Approximately 3% of children have constipation, with girls and boys being equally affected. [6] With constipation accounting for approximately 5% of general pediatrician visits and 25% of pediatric gastroenterologist visits, the symptom carries a significant financial impact upon our healthcare system. [1]

Society and culture

Constipation is often emotionally stressful for children and their caregivers. [19] It is common for parents to bring their children to doctors for this condition. [19] The experience of going to a doctor for this can be stressful. [19]

Too often, children at doctors receive unnecessary health care when they get medical imaging for constipation. [20] Children should only get tests when there is an indication. [20]

Related Research Articles

<span class="mw-page-title-main">Defecation</span> Expulsion of feces from the digestive tract via the anus

Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.

<span class="mw-page-title-main">Constipation</span> Bowel dysfunction

Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

<span class="mw-page-title-main">Laxative</span> Agents that relax and loosen the bowels and stools

Laxatives, purgatives, or aperients are substances that loosen stools and increase bowel movements. They are used to treat and prevent constipation.

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Hirschsprung's disease</span> Medical condition

Hirschsprung's disease is a birth defect in which nerves are missing from parts of the intestine. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, diarrhea and slow growth. Most children develop signs and symptoms shortly after birth. However, others may be diagnosed later in infancy or early childhood. About half of all children with Hirschsprung's disease are diagnosed in the first year of life. Complications may include enterocolitis, megacolon, bowel obstruction and intestinal perforation.

Encopresis is voluntary or involuntary passage of feces outside of toilet-trained contexts in children who are four years or older and after an organic cause has been excluded. Children with encopresis often leak stool into their undergarments.

Functional constipation, known as chronic idiopathic constipation (CIC), is constipation that does not have a physical (anatomical) or physiological cause. It may have a neurological, psychological or psychosomatic cause. A person with functional constipation may be healthy, yet has difficulty defecating.

<span class="mw-page-title-main">Lactulose</span> Treatment for constipation and hepatic encephalopathy

Lactulose is a non-absorbable sugar used in the treatment of constipation and hepatic encephalopathy. It is administered orally for constipation, and either orally or rectally for hepatic encephalopathy. It generally begins working after 8–12 hours, but may take up to 2 days to improve constipation.

<span class="mw-page-title-main">Fecal impaction</span> Medical condition

A fecal impaction or an impacted bowel is a solid, immobile bulk of feces that can develop in the rectum as a result of chronic constipation. Fecal impaction is a common result of neurogenic bowel dysfunction and causes immense discomfort and pain. Its treatment includes laxatives, enemas, and pulsed irrigation evacuation (PIE) as well as digital removal. It is not a condition that resolves without direct treatment.

<span class="mw-page-title-main">Blood in stool</span> Medical condition

Blood in stool or rectal bleeding looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.

<span class="mw-page-title-main">Bristol stool scale</span> Medical system for classifying human faeces

The Bristol stool scale is a diagnostic medical tool designed to classify the form of human faeces into seven categories. It is used in both clinical and experimental fields.

<span class="mw-page-title-main">Distal intestinal obstruction syndrome</span> Medical condition

Distal intestinal obstruction syndrome (DIOS) involves obstruction of the distal part of the small intestines by thickened intestinal content and occurs in about 20% of mainly adult individuals with cystic fibrosis. DIOS was previously known as meconium ileus equivalent, a name which highlights its similarity to the intestinal obstruction seen in newborn infants with cystic fibrosis. DIOS tends to occur in older individuals with pancreatic insufficiency. Individuals with DIOS may be predisposed to bowel obstruction, though it is a separate entity than true constipation.

<span class="mw-page-title-main">Polycarbophil calcium</span> Pharmaceutical drug

Polycarbophil calcium (INN) is a drug used as a stool stabilizer. Chemically, it is a synthetic polymer of polyacrylic acid cross-linked with divinyl glycol, with calcium as a counter-ion.

<span class="mw-page-title-main">Macrogol</span> Medication for constipation, classified as an osmotic laxative

Macrogol, also known as polyethylene glycol (PEG), is used as a medication to treat constipation in children and adults. It is also used to empty the bowels before a colonoscopy. It is taken by mouth. Benefits usually occur within three days. Generally it is only recommended for up to two weeks. It is also used as an excipient.

<span class="mw-page-title-main">Human feces</span> Metabolic waste of the human digestive system

Human feces are the solid or semisolid remains of food that could not be digested or absorbed in the small intestine of humans, but has been further broken down by bacteria in the large intestine. It also contains bacteria and a relatively small amount of metabolic waste products such as bacterially altered bilirubin, and the dead epithelial cells from the lining of the gut. It is discharged through the anus during a process called defecation.

Bowel management is the process which a person with a bowel disability uses to manage fecal incontinence or constipation. People who have a medical condition which impairs control of their defecation use bowel management techniques to choose a predictable time and place to evacuate. A simple bowel management technique might include diet control and establishing a toilet routine. As a more involved practice a person might use an enema to relieve themselves. Without bowel management, the person might either suffer from the feeling of not getting relief, or they might soil themselves.

<span class="mw-page-title-main">Rectum</span> Final portion of the large intestine

The rectum is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. The adult human rectum is about 12 centimetres (4.7 in) long, and begins at the rectosigmoid junction at the level of the third sacral vertebra or the sacral promontory depending upon what definition is used. Its diameter is similar to that of the sigmoid colon at its commencement, but it is dilated near its termination, forming the rectal ampulla. It terminates at the level of the anorectal ring or the dentate line, again depending upon which definition is used. In humans, the rectum is followed by the anal canal which is about 4 centimetres (1.6 in) long, before the gastrointestinal tract terminates at the anal verge. The word rectum comes from the Latin rectumintestinum, meaning straight intestine.

<span class="mw-page-title-main">Anismus</span> Medical condition

Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

<span class="mw-page-title-main">Neurogenic bowel dysfunction</span> Human disease involving inability to control defecation

Neurogenic bowel dysfunction (NBD) is the inability to control defecation due to a deterioration of or injury to the nervous system, resulting in faecal incontinence or constipation. It is common in people with spinal cord injury (SCI), multiple sclerosis (MS) or spina bifida.

References

  1. 1 2 3 4 Colombo JM, Wassom MC, Rosen JM (September 2015). "Constipation and Encopresis in Childhood". Pediatrics in Review. 36 (9): 392–401, quiz 402. doi:10.1542/pir.36-9-392. PMID   26330473. S2CID   35482415.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Mulhem, E; Khondoker, F; Kandiah, S (1 May 2022). "Constipation in Children and Adolescents: Evaluation and Treatment". American family physician. 105 (5): 469–478. PMID   35559625.
  3. Walia R, Mahajan L, Steffen R (October 2009). "Recent advances in chronic constipation". Current Opinion in Pediatrics. 21 (5): 661–666. doi:10.1097/MOP.0b013e32832ff241. PMID   19606041. S2CID   11606786.
  4. Bharucha AE (2007). "Constipation". Best Practice & Research. Clinical Gastroenterology. 21 (4): 709–731. doi:10.1016/j.bpg.2007.07.001. PMID   17643910.
  5. 1 2 Gordon M, MacDonald JK, Parker CE, Akobeng AK, Thomas AG, et al. (Cochrane IBD Group) (August 2016). "Osmotic and stimulant laxatives for the management of childhood constipation". The Cochrane Database of Systematic Reviews. 2016 (8): CD009118. doi:10.1002/14651858.CD009118.pub3. PMC   6513425 . PMID   27531591.
  6. 1 2 3 4 5 6 Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, et al. (February 2014). "Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN". Journal of Pediatric Gastroenterology and Nutrition. 58 (2): 258–274. doi: 10.1097/mpg.0000000000000266 . PMID   24345831. S2CID   13834963.
  7. 1 2 3 4 5 6 Wegh CA, Baaleman DF, Tabbers MM, Smidt H, Benninga MA (January 2022). "Nonpharmacologic Treatment for Children with Functional Constipation: A Systematic Review and Meta-analysis". The Journal of Pediatrics. 240: 136–149.e5. doi: 10.1016/j.jpeds.2021.09.010 . PMID   34536492. S2CID   237564332.
  8. Wexner S (2006). Constipation: etiology, evaluation and management. New York: Springer.
  9. 1 2 Wesson D (November 9, 2016). "UpToDate: Constipation". UpToDate. Retrieved March 15, 2017.
  10. "Congenital Anterior Displacement of Anus". Pediatrics in Review. American Academy of Pediatrics. 8 (2): 38–62. 1986-08-01. doi:10.1542/pir.8-2-38. ISSN   0191-9601.
  11. 1 2 Koppen IJ, Yacob D, Di Lorenzo C, Saps M, Benninga MA, Cooper JN, et al. (March 2017). "Assessing colonic anatomy normal values based on air contrast enemas in children younger than 6 years". Pediatric Radiology. 47 (3): 306–312. doi:10.1007/s00247-016-3746-0. PMC   5316394 . PMID   27896373.
  12. 1 2 Leech SC, McHugh K, Sullivan PB (April 1999). "Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children". Pediatric Radiology. 29 (4): 255–258. doi:10.1007/s002470050583. PMID   10199902. S2CID   9542750.
  13. Catto-Smith AG, McGrath KH (2012). "The Role of Diagnostic Tests in Constipation in Children". Constipation - Causes, Diagnosis and Treatment. doi:10.5772/29213. ISBN   978-953-51-0237-3.
  14. Naheed N (9 November 2007). Jenner R (ed.). "Osmotic laxative are preferable to the use of stimulant laxatives in the constipated child". BestBETs.
  15. Naheed N (16 July 2007). Jenner R (ed.). "Is PEG (Polyethylene Glycol) a more effective laxative than Lactulose in the treatment of a child who is constipated?". BestBETs.
  16. Candy D, Belsey J (February 2009). "Macrogol (polyethylene glycol) laxatives in children with functional constipation and faecal impaction: a systematic review". Archives of Disease in Childhood. 94 (2): 156–160. doi:10.1136/adc.2007.128769. PMC   2614562 . PMID   19019885.
  17. Wallace C, Sinopoulou V, Gordon M, Akobeng AK, Llanos-Chea A, Hungria G, et al. (March 2022). Cochrane Gut Group (ed.). "Probiotics for treatment of chronic constipation in children". The Cochrane Database of Systematic Reviews. 2022 (3): CD014257. doi:10.1002/14651858.CD014257.pub2. PMC   8962960 . PMID   35349168.
  18. 1 2 Boronat AC, Ferreira-Maia AP, Matijasevich A, Wang YP (June 2017). "Epidemiology of functional gastrointestinal disorders in children and adolescents: A systematic review". World Journal of Gastroenterology. 23 (21): 3915–3927. doi: 10.3748/wjg.v23.i21.3915 . PMC   5467078 . PMID   28638232.
  19. 1 2 3 Ferrara LR, Saccomano SJ (July 2017). "Constipation in children: Diagnosis, treatment, and prevention". The Nurse Practitioner. 42 (7): 30–34. doi:10.1097/01.NPR.0000520418.32331.6e. PMID   28622255. S2CID   32386388.
  20. 1 2 Ferguson CC, Gray MP, Diaz M, Boyd KP (July 2017). "Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric Emergency Department". Pediatrics. 140 (1): e20162290. doi: 10.1542/peds.2016-2290 . PMID   28615355.