Paediatric constipation - An approach and evidence-based treatment regimen - RACGP
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CLINICAL
Paediatric constipation
An approach and evidence-based treatment regimen
Harveen Singh, Frances Connor WITHIN THE FIRST three months of life, • What is the form and calibre of motions,
infants can pass anywhere from 5 to 40 frequency and relation to daily activity?
motions per week, decreasing at age • Is there suspicion of an organic cause, or
This article is the second in a series one year to 4–20 motions per week and red flags in the history (Box 1, Box 2)?
on paediatric health. Articles in this at three years to 3–14 per week.1–4 The • Has the child been toilet-trained for
series aim to provide information
Rome IV criteria are applied in order to stooling and/or urination?
about diagnosis and management
of presentations in infants, toddlers formally define functional constipation. • When and how often does the child sit
and pre-school children in general Constipation under these criteria requires on the toilet?
practice. two or more of the following:3 • What is the toileting posture? Are both
• two or fewer defaecations per week feet resting on the ground or footstool
Background
Constipation affects 5–30% of children
• at least one episode of faecal and the child leaning forward with a
incontinence per week relaxed abdomen?
and is responsible for 3% of primary
care visits. General practitioners • history of retentive posturing or • Are there triggering events (eg disrupted
(GPs) are frequently the first medical excessive volitional stool retention routine, entering day care or an episode
encounter for concerned parents • history of painful or hard bowel of painful, hard stools leading to
regarding their child’s bowel habit. movements withholding)?
Objective
• presence of a large faecal mass in the • Are there any neurodevelopmental
The aim of this article is to review
rectum concerns? Children with developmental
the assessment and management of • history of large diameter stools that may delay or behavioural disorders will
children with constipation to empower obstruct the toilet require additional help to be toilet
GPs to initiate treatment and know • symptoms occurring at least once per trained.
when to refer to a paediatrician. month for a minimum of one month, Determine the presence of any
with insufficient criteria to diagnose withholding behaviours. These include:
Discussion
In the absence of organic aetiology, irritable bowel syndrome. • going stiff
childhood constipation is almost Faecal incontinence refers to the passage • clenching buttocks
always functional and often due of stools in an inappropriate place, and • walking on tip toes
to painful bowel movements that may result from chronic retention of stool • crossing legs
prompt the child to withhold stool. with passive overflow during withholding.3 • bracing against furniture
It is important to initiate a clear
management plan for the family, as
Parents can interpret this passage of stool • being in all fours position or curling up
as the child trying to defaecate; it is more in a ball
what is an easily treatable condition
can escalate into a vicious cycle likely that this incontinence is due to • sitting with legs straight out.
of pain if not addressed early. strong colonic contractions attempting to
The medical approach should expel stool while the child is withholding, Could this be allergy?
consider organic disease, the use especially if there is associated retentive
of appropriate toileting habits, and posturing.3 The presence of abdominal Constipation can be associated with food
dietary modifications. Laxatives are
pain, distension, behaviour change and allergy, particularly to cow’s milk. A dietary
often required to re-establish regular,
painless defaecation.
anorexia in these children may indicate history is essential and should include the
a need for disimpaction.3 Organic causes mother if the child is still being breastfed.
of incontinence include spinal cord or Cow’s milk protein can be found in breast
sphincter anomalies (Box 1).3 milk, formula and dairy-containing solids.
Factors that may indicate a cow’s milk
Key points in the history protein intolerance are outlined in Box 3.5–7
For infants agedCLINICAL PAEDIATRIC CONSTIPATION
Box 1. Organic causes of constipation 3 Box 2. Red flags in the history 3 Box 3. Factors associated with cow’s
milk protein intolerance5–7
Allergy – cow’s milk protein intolerance and/ Blood in stools
or other food protein intolerances Onset of symptoms on changing from breast
Systemic symptoms – faltering growth,
to bottle feeds
Coeliac disease weight loss, lethargy
Hypothyroidism Perianal disease Onset of symptoms on starting cow’s milk
Cystic fibrosis Extra-intestinal symptoms suspicious Onset of symptoms on starting solid foods
for inflammatory bowel disease – rashes;
Electrolyte abnormalities – hypercalcaemia, Medication-resistant or medication-
arthritis; red, sore eyes; mouth ulcers
hyperkalaemia dependent constipation
Delayed passage of meconium after the
Drugs – opiates, phenobarbital,
first 48 hours of life, infrequent stools Straining during defaecation, even in the
anticholinergics
with straining and/or thin, strip-like stools presence of soft stools
Neuropathic disorders – Hirschsprung’s (suspicious of Hirschsprung’s disease)
disease, internal sphincter achalasia Atopic disease – eczema, asthma, rhinitis
Urinary symptoms
Spinal cord abnormalities – Rashes/urticarial with milk feeds/food
myelomeningocele, tethered spinal cord, Abnormal lower limb neurology
syringomyelia Irritability in infancy – reflux or vomiting
Patulous anus
• Stooling may occur without sensation or
Voluntary dairy restriction
urge Absent perineal sensation
Anatomic malformations – imperforate anus, Onset of constipation before one month Family history – atopy, food allergy, food
anteriorly displaced anus of age intolerance, autoimmune conditions
calculated on a smartphone app called includes immunoglobulin A (IgA), tissue not IgE mediated.10 A one-month trial of
GIdiApp (gastrointestinal diseases app), transglutaminase (tTG) IgA, thyroid avoidng cow’s milk and soy protein may
which covers assessment and management function, calcium and electrolytes.1–3 be indicated in children with intractable
of functional gastrointestinal symptoms Coeliac disease may be considered if constipation.3 During this period, calcium
in babies.8,9 A three-day diary of diet and constipation arises early on with the intake should be supplemented with
stooling patterns can be useful for parents introduction of gluten, and is associated almond or rice products, or calcium
and general practitioners. with iron deficiency anaemia, abdominal supplementation.11 Dairy intolerance
pain and poor growth.3 Abdominal X-ray is can improve with time in older children
Physical examination not recommended to diagnose functional but data in small children is limited.10
constipation, and magnetic resonance Dairy is tried in the diet every 6 –12
Examination should focus on the imaging of the spine is not required in months as tolerated. Referral should be
following:1 those without neurological abnormalities made to a paediatrician or paediatric
• identify ‘red flags’ in the primary care setting.3 gastroenterologist/allergist if there is
• abdominal exam – assess for faecal In infants agedPAEDIATRIC CONSTIPATION CLINICAL
Table 1. Laxatives and doses3,13
Laxative Dosage Side effects
Osmotic oral
Polyethylene glycol (PEG) 3350 Disimpaction: 1–1.5 g/kg/day for three days Abdominal cramps and nausea
Maintenance: 0.75 g/kg/day
Lactulose 1–3 mL/kg/day in divided doses Flatulence, abdominal cramps; less effective
(3.3 g/5 mL) than PEG or paraffin oil
Liquid paraffin 50% (Parachoc) 12 months–6 years: 10–15 mL/day Pneumonia if aspirated (children with reflux
7–12 years: 20 mL daily or unsafe swallow are at risk)
Stimulants
Senna 2–6 years: 2.5–7.5 mL/day
6–12 years: 5–15 mL/day
Syrup – 7.5 g/5 mL
Tablet – 1 tablet = 7.5 mg
Bisacodyl 4–18 years: 5–20 mg/day oral
2–18 years: 5–10 mg rectally once per day
Picosulfate 1 month – 4 years: 2.5–10 mg/day
4–18 years: 2.5–20 mg once per day
minutes after every meal. This can be or Osmolax; Table 1) is the most effective tolerated, the next most appropriate
used in conjunction with a rewards first-line treatment for disimpaction in laxative is liquid paraffin, available
program such as a star chart. the outpatient setting.1,3,4 PEG has also commercially under a number of brands
been shown to be effective in infants aged (eg Parachoc).3 Schools should be made
Drug therapyCLINICAL PAEDIATRIC CONSTIPATION
of symptoms (less than three months) a stimulant laxative can be added. (www.continence.org.au) provides
and are toilet trained. Children with a Stimulants can also be trialled if support for families with constipated
chronic history will often need at least adequate disimpaction is not achieved children.
six months of treatment.3 Withholding after two weeks on PEG.1
behaviours, an ongoing trigger event and When to refer to the
the absence of toilet training can lead to When to refer to allied health paediatrician
longer treatment.3 Constipation should
be resolved for at least one month before If needing additional help with Consider if constipation is medication-
treatment is ceased.3 toileting, children with a developmental dependent after six months of adequate
age >4 years may benefit from treatment, or if medication resistant or
Stimulants referral to an occupational therapist organic causes have been considered
If a brief period of constipation occurs or continence physiotherapist. The (Figure 1).3 Further management may
while on adequate softener treatment, Continence Foundation of Australia include allergy diets, specialist pelvic
Constipation
Red flags? Yes
Red flags? No
Investigate further and refer
Functional constipation to subspecialty
Faecal impaction? Yes Faecal impaction? No
Commence disimpaction Educate, keep diary, assess
dose PEG toilet training, commence
maintenance PEG
Treatment effective? Yes
Treatment effective? No
Continue maintenance and
Assess compliance, educate,
observe or wean
trial different medication/dose,
check for untreated impaction
Treatment effective? No Treatment effective? Yes
Continue maintenance and
observe or wean
Consider investigation – T4, TSH,
coeliac, calcium and electrolytes
Consider a trial of two weeks dairy-free
Organice cause found/
No improvement/cause found
improvement with diet
Refer to paediatrician
Treat accordingly
Figure 1. Management of constipation3,15
PEG, polyethylene glycol; T4, thyroxine; TSH, thyroid-stimulating hormone
276 | REPRINTED FROM AJGP VOL. 4 7, NO. 5, MAY 2018 © The Royal Australian College of General Practitioners 2018PAEDIATRIC CONSTIPATION CLINICAL
floor training, colonic transit studies, 3. Tabbers MM, DiLorenzo C, Berger MY, et al. 12. Michail S, Gendy E, Preud’Homme D, Mezoff A.
Evaluation and treatment of functional Polyethylene glycol for constipation in children
anal manometry and rectal biopsy.3 constipation in infants and children: Evidence- younger than eighteen months old. J Pediatr
based recommendations from ESPGHAN Gastroenterol Nutr 2004;39(2):197–99.
and NASPGHAN. J Pediatr Gastroenterol 13. Pashankar DS, Bishop WP. Efficacy and optimal
Prognosis and conclusion Nutr 2014;58(2):258–74. doi: 10.1097/ dose of daily polyethylene glycol 3350 for
MPG.0000000000000266. treatment of constipation and encopresis in
Up to 50% of patients referred to a 4. Youssef NN, Peters JM, Henderson W, Shultz- children. J Pediatr 2001;139(3):428–32.
Peters S, Lockhart DK, Di Lorenzo C. Dose 14. Chaussade S. Mechanisms of action of low
paediatrician for constipation will regain response of PEG 3350 for the treatment doses of polyethylene glycol in the treatment
normal function and be off laxatives in six of childhood fecal impaction. J Pediatr of functional constipation. Ital J Gastroenterol
2002;141(3):410–14. Hepatol 1999;31 Supp 3:S242–44.
to 12 months.3 Eighty per cent of children
5. Carroccio A, Scalici C, Maresi E, et al. Chronic 15. Constipation Guideline Committee of the North
treated early in their course will recover constipation and food intolerance: A model American Society for Pediatric Gastroenterology,
without use of laxatives at six-month of proctitis causing constipation. Scand J Hepatology and Nutrition. Evaluation and
Gastroenterol 2005;40(1):33–42. treatment of constipation in infants and children:
follow-up, in comparison with 32% of
6. Carroccio A, Iacono G. Review article: Chronic Recommendations of the North American Society
children with a delay in their treatment.3 constipation and food hypersensitivity – An for Pediatric Gastroenterology, Hepatology
Early therapeutic intervention is beneficial intriguing relationship. Aliment Pharmacol Ther and Nutrition. J Pediatr Gastroenterol Nutr
2006;24(9):1295–304. 2006;43(3):e1–13.
and easy to commence. Close follow-up is 7. El-Hodhod MA, Younis NT, Zaitoun YA, Daoud SD.
important for good results. Cow's milk allergy related pediatric constipation:
Appropriate time of milk tolerance. Pediatr
Allergy Immunol 2010;21(2 Pt 2):e407–12. doi:
Authors 10.1111/j.1399-3038.2009.00898.x.
Harveen Singh MBBS, DCH, paediatric 8. Vandenplas Y, Alarcon P, Alliet P, et al. Algorithms
gastroenterology trainee, Lady Cilento Children’s for managing infant constipation, colic,
Hospital, Brisbane, Qld. Harveen.k.singh1@gmail.com regurgitation and cow’s milk allergy in formula-fed
infants. Acta Paediatr 2015;104(5):449–57. doi:
Frances Connor MBBS, FRACP, Paediatric 10.1111/apa.12962.
Gastroenterologist, Lady Cilento Children’s Hospital,
Brisbane, Qld 9. Vandenplas Y, Steenhout P, Järvi A, Garreau AS,
Mukherjee R. Pooled analysis of the Cow’s
Competing interests: None.
Milk-related-Symptom-Score (CoMiSSTM) as a
Provenance and peer review: Not commissioned, predictor for cow’s milk related symptoms. Pediatr
externally peer reviewed. Gastroenterol Hepatol Nutr 2017;20(1):22–26. doi:
10.5223/pghn.2017.20.1.22.
References 10. Pashankar DS, Bishop WP, Loening-Baucke V.
1. National Institute for Health and Care Excellence Long-term efficacy of polyethylene glycol 3350 for
(NICE). Constipation in children and young people: the treatment of chronic constipation in children
Diagnosis and management. UK: NICE, 2010. with and without encopresis. Clin Pediatr (Phila)
Available at nice.org.uk/guidance/cg99 [Accessed 2003;42(9):815–19.
11 September 2017]. 11. Syrigou EI, Pitsios C, Panagiotou I, et al. Food
2. Nurko S, Zimmerman LA. Evaluation and allergy-related paediatric constipation: The
treatment of constipation in children and usefulness of atopy patch test. Eur J Pediatr correspondence ajgp@racgp.org.au
adolescents. Am Fam Physician 2014;90(2):82–90. 2011;170(9):1173–78. doi: 10.1007/s00431-011-1417-6.
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