Constipation in Infants and Children: Evaluation and Treatment

BACKGROUND A normal pattern of stool evacuation is thought to be a sign of health in children of all ages. Especially during the first months of life, parents pay close attention to the frequency and the characteristics of their children's defecation. Any deviation from what is thought by any family member to be normal for children may trigger a call to the nurse or a visit to the pediatrician. Thus, it is not surprising that approximately 3% of general pediatric outpatient visits and 25% of pediatric gastroenterology consultations are related to a perceived defecation disorder (1). Chronic constipation is a source of anxiety for parents who worry that a serious disease may be causing the symptom. Yet, only a small minority of children have an organic cause for constipation. Beyond the neonatal period, the most common cause of constipation is functional and has been called idiopathic constipation, functional fecal retention, and fecal withholding. In most cases the parents are worried that the child's stools are too large, too hard, painful, or too infrequent. The normal frequency of bowel movements at different ages has been defined (Table 1). Infants have a mean of four stools per day during the first week of life. This frequency gradually declines to a mean average of 1.7 stools per day at 2 years of age and 1.2 stools per day at 4 years of age (2,3). Some normal breast-fed babies do not have stools for several days or longer (4). After 4 years, the frequency of bowel movements remains unchanged.TABLE 1: Normal frequency of bowel movements Functional constipation-that is, constipation without objective evidence of a pathologic condition-most commonly is caused by painful bowel movements with resultant voluntary withholding of feces by a child who wants to avoid unpleasant defecation. Many events can lead to painful defecation such as toilet training, changes in routine or diet, stressful events, intercurrent illness, unavailability of toilets, or the child's postponing defecation because he or she is too busy. Withholding feces can lead to prolonged fecal stasis in the colon, with reabsorption of fluids and an increase in the size and consistency of the stools. The passage of large hard stools that painfully stretch the anus may frighten the child, resulting in a fearful determination to avoid all defecation. Such children respond to the urge to defecate by contracting their anal sphincter and gluteal muscles, attempting to withhold stool (5). They rise on their toes and rock back and forth while stiffening their buttocks and legs, or wriggle, fidget, or assume unusual postures, often performed while hiding in a corner. This dance-like behavior is frequently misconstrued by parents who believe that the child is straining in an attempt to defecate. Eventually, the rectum habituates to the stimulus of the enlarging fecal mass, and the urge to defecate subsides. With time, such retentive behavior becomes an automatic reaction. As the rectal wall stretches, fecal soiling may occur, angering the parents and frightening the child (6). After several days without a bowel movement, irritability, abdominal distension, cramps, and decreased oral intake may result. Although constipation is a common pediatric problem, no evidence-based guidelines for its evaluation and treatment currently exist. Therefore, the Constipation Subcommittee of the Clinical Guidelines Committee was formed by the North American Society for Pediatric Gastroenterology and Nutrition (NASPGN) to develop a clinical practice guideline. METHODS The Constipation Subcommittee, which consists of two primary care pediatricians, a clinical epidemiologist, and five pediatric gastroenterologists, addressed the problem of constipation in infants and children who had no previously established medical condition. Neonates less than 72 hours old and premature infants of less than 37 weeks' gestation were excluded from consideration. This clinical practice guideline has been designed to assist primary care pediatricians, family practitioners, nurse practitioners, physician assistants, pediatric gastroenterologists, and pediatric surgeons in the management of children with constipation in both inpatient and outpatient settings. Constipation was defined as a delay or difficulty in defecation, present for two or more weeks, and sufficient to cause significant distress to the patient. The desirable outcome of optimal management was defined as a normal stooling pattern, with interventions that have few or no adverse effects, and with resultant resumption of functional health. To develop evidence-based guidelines, articles on constipation published in English were found using Medline (7). A search for articles published from January 1966 through November 1997, revealed 3839 articles on constipation. The Cochrane Center has designed a search strategy for Medline to identify randomized controlled trials. This strategy includes controlled vocabulary and free-text terms such as randomized controlled trial, clinical trial, and placebo (8). When this search strategy was run with the term constipation, 1047 articles were identified, 809 of which were in English and 254 of which included children. After letters, editorials, and review articles were eliminated, 139 articles remained. Forty-four of these were studies in special populations, such as children with meningomyelocele or Hirschsprung disease, and were eliminated. Ninety-five articles remained and were reviewed in depth. A second search strategy was used to identify articles on constipation that related to treatment, including drug therapy (75 articles), surgery (64 articles), and "therapy" (144 articles). This added 148 new articles, in which the abstracts were reviewed. If the abstract indicated that the article might be relevant, the article was reviewed in depth. Seven additional articles were identified from the reference listings of the articles already cataloged. In total, 160 articles were reviewed for these guidelines. Articles were evaluated using written criteria developed by Sackett et al. (9,10) These criteria had been used in previous reviews (11,12). Five articles were chosen at random and reviewed by a colleague in the Department of Pediatrics at the University of Rochester (New York, U.S.A.) who had been trained in epidemiology. Concordance using the criteria was 92%. Using the methods of the Canadian Preventive Services Task Force (13), the quality of evidence of each of the recommendations made by the Constipation Subcommittee was determined and is summarized in Table 2. The Subcommittee based its recommendations on integration of the literature review combined with expert opinion when evidence was insufficient. Consensus was achieved through Nominal Group Technique, a structured, quantitative method (14).TABLE 2: Summary of recommendations and the quality of the evidence The guidelines were critically reviewed by numerous primary care physicians in community and academic practices, including members of several committees of the American Academy of Pediatrics. In addition, the guidelines were distributed to the NASPGN membership for review and comment and finally were officially endorsed by the society's Executive Council. Two algorithms were developed (Figs. 1 and 2). The initial discussion is based on the algorithm for children 1 year of age and older. The second algorithm is for children less than 1 year of age. In this article, the first algorithm is discussed in detail, and the second algorithm is discussed only when it diverges from the first.FIG. 1: (Continued)FIG. 1: An algorithm for the management of constipation in children 1 year of age and older. T4, thyroxine; TSH, thyroid-stimulating hormone; Ca, calcium; Pb, lead; Rx, therapy; PEG, polyethylene glycol electrolyte; psych, psychological management; MRI, magnetic resonance imaging.FIG. 2: (Continued)FIG. 2: An algorithm for the management of constipation in infants less than 1 year of age. T4, thyroxine; TSH, thyroid stimulating hormone; Ca, calcium; Pb, lead; Rx, therapy; PEG, polyethylene glycol electrolyte; psych, psychological management; MRI, magnetic resonance imaging.MEDICAL HISTORY Based on clinical experience, a thorough history is recommended as part of a complete evaluation of a child with constipation (Table 3). There are no well-designed studies that determine which aspects of a history are pertinent. Important information includes the time after birth of the first bowel movement, what the family or child means when using the term "constipation," (15) the length of time the condition has been present, the frequency of bowel movements, the consistency and size of the stools, whether defecation is painful, whether blood has been present on the stool or the toilet paper, and whether the child experiences abdominal pain. Fecal soiling may be mistaken for diarrhea by some parents. A history of stool-withholding behavior reduces the likelihood that there is an organic disorder. Medications are an important potential cause of constipation (Table 4).TABLE 3: History in pediatric patients with constipation TABLE 4: Differential diagnosis of constipation Fever, abdominal distension, anorexia, nausea, vomiting, weight loss, or poor weight gain could be signs of an organic disorder (Table 4). Bloody diarrhea in an infant with a history of constipation could be an indication of enterocolitis complicating Hirschsprung disease. A psychosocial history assesses the family structure, the number of people living in the child's home and their relationship to the child, the interactions the child has with peers, and the possibility of abuse. If the child is in school it is important to learn whether the child uses the school restrooms and if not, why. The caregiver's assessment of the child's temperament may be useful in planning a reward system for toilet behavior. PHYSICAL EXAMINATION Based on clinical experience, a thorough physical examination is recommended as part of a complete evaluation of a child with constipation (Table 5). No well-designed studies have been conducted to determine the aspects of the physical examination that are most important. External examination of the perineum and perianal area is essential. At least one digital examination of the anorectum is recommended. The anorectal examination assesses perianal sensation, anal tone, the size of the rectum, and the presence of an anal wink. It also determines the amount and consistency of stool and its location within the rectum. It is recommended that a test for occult blood in the stool be performed in all infants with constipation, as well as in any child who also has abdominal pain, failure to thrive, intermittent diarrhea, or a family history of colon cancer or colonic polyps. Detection of a physical abnormality could lead to the identification of an organic disorder (Table 6).TABLE 5: Physical examination of children with constipation TABLE 6: Physical findings distinguishing organic constipation from functional constipation A thorough history and physical examination is generally sufficient to allow the practitioner to establish whether the child requires further evaluation (Fig. 1, box 4) or has functional constipation (Fig. 1, box 5). MANAGEMENT OF CHILDREN WITH FUNCTIONAL CONSTIPATION The general approach to the child with functional constipation includes the following steps: determine whether fecal impaction is present (Fig. 1, box 6), treat the impaction if present (Fig. 1, box 7), initiate treatment with oral medication, provide parental education and close follow-up, and adjust medications as necessary (Fig. 1, box 10). Education The education of the family and the demystification of constipation, including an explanation of the pathogenesis of constipation, are the first steps in treatment. If fecal soiling is present, an important goal for both the child and the parent is to remove negative attributions. It is especially important for parents to understand that soiling from overflow incontinence is not a willful and defiant maneuver. Parents are encouraged to maintain a consistent, positive, and supportive attitude in all aspects of treatment. It may be necessary to repeat the education and demystification processes several times during treatment (16). Disimpaction Fecal impaction is defined as a hard mass in the lower abdomen identified during physical examination, a dilated rectum filled with a large amount of stool found during rectal examination, or stool in the colon identified by abdominal Disimpaction is necessary of It may be with oral or rectal (Fig. 1, box In clinical by the oral the rectal or a of the two has been to be (Table There are no randomized studies that the of one with the The oral approach is not and a of to the child, to the treatment may be a The rectal approach is is The of treatment is determined after the with the family and Medications for in treatment of constipation Disimpaction with oral has been to be when of polyethylene glycol or both are used Although there are no controlled the of or for initial these have been used in that It is recommended that oral or the be used or in for initial when the oral is may be performed with or by a These are used and are The of and is not recommended because of their potential has also been performed with in infants and in children. The Subcommittee discussed the of digital in constipation in the primary care there was literature on the and the Subcommittee could not on whether to or its the impaction has been the treatment on the of In the child who has no impaction (Fig. 1, box or after therapy is This treatment consists of and to that bowel movements at normal with changes are commonly intake of fluids and and as a method to stools. and especially found in some such as and can cause frequency and of stools No randomized controlled studies were found that an on stools of of or in children A that includes and is recommended as part of the treatment for constipation in children. of is An important of treatment includes behavior and toilet time on the toilet after is recommended. As part of the treatment of constipation, with or without overflow it is often to have children and their of stool This can be combined with a reward a child can a with to each stool that is in the The can be on visits with the and can as both a and a for In cases in which or are with treatment, to a for behavior or may be The treatment of constipation, especially with overflow requires a family that is well can complete and is to and by and by visit is recommended. Some may to this problem It is often necessary to to children bowel movements (Table A randomized that the of medications to behavior management in children with constipation is who medications achieved than children who The of was most for children were to maintain toilet When is necessary in the treatment of constipation, or or a of and is recommended. At this in the treatment of constipation, the prolonged of is not recommended. with of and or has been studies that these are and The and potential adverse of these medications are found in Table or to be the these is based on the child's of and the (Fig. 1, box A may be necessary for to avoid of an impaction (Fig. 1, box In this the of is therapy may be necessary for when the child has been bowel movements without difficulty is care and be that are common and that difficulty with bowel movements may studies have that a significant number of children to therapy to maintain bowel movements WITH A with a pediatric becomes necessary when the therapy when there is that an organic disease or when management is (Fig. 1, box A can the child with constipation, an organic and The pediatric (Fig. 1, can review previous using different or additional medications or of the and previous management additional studies (Fig. 1, box A review by the primary care practitioner of the diagnosis (Table 4) of the organic of constipation may be at this time to determine which are indicated to a It is recommended that the primary care physician whether the children who evaluation by a have blood to identify evidence of disease, and lead (Fig. 1, box these by the primary care to a pediatric patients who are found to have a medical problem that requires evaluation by a different can be to the a child with can be to a pediatric and An abdominal is not indicated to establish the presence of fecal impaction if the rectal examination the presence of large of A in children that a to large amount of stool found on rectal examination has and than for fecal determined by abdominal using the the and negative were or When the system developed by et al. was used for the presence of fecal on the of to large of stool on rectal examination to and the was the remained at only and the negative was only This when there is whether the is a abdominal is in the presence of fecal in the child who is or a rectal examination, or in there are psychological that the rectal examination too It may also be in the child with a history for constipation who not have large of stool on rectal examination (Fig. 1, box In a the of the was with the colonic The was to be with and and there was no with of time Some patients have a history of bowel movements have no objective findings of constipation. The history from the parents and child may not be In these patients an evaluation of colonic time with may be (Fig. 1, box The of time whether constipation is present and an objective evaluation of bowel If the time is the child not have constipation. If the time is normal and there is no the child no further evaluation (Fig. 1, box In children who have soiling without evidence of constipation, the have been achieved with behavior in some psychological evaluation and treatment may be necessary (Fig. 1, box If the is or fecal impaction is present, further evaluation is (Fig. 1, box When there is objective evidence of constipation and it is to treatment, it is important to Hirschsprung disease (Fig. 1, box Hirschsprung Hirschsprung disease is the most common cause of lower in and is a cause of constipation in and children It is by of in the and of the colon, resulting in of the The at the anal in a In of the disease is to the The bowel to the becomes dilated because of the The of Hirschsprung disease is approximately 1 in The most common abnormality is than of normal and less than of children with Hirschsprung disease in the first hours of Thus, a passage of by a infant the of Hirschsprung disease. Hirschsprung disease can have of vomiting, abdominal distension, and to all of which are of Hirschsprung disease may children have stools, a failure to In cases constipation is the only symptom. Fecal soiling is more and only when the is the most of Hirschsprung disease, may be its initial has initial of of abdominal distension, and and at times diarrhea most often during the second and months of life, it is with a of The of enterocolitis can be by a diagnosis of Hirschsprung disease. The mean age at diagnosis decreased from months in the to months in the because of anorectal and in to of Hirschsprung disease remains after the age of years Physical examination a abdomen and a anal sphincter and rectum in most children. The rectum is of stool in cases of As the is there may be an of stools, with of the normal In the child with constipation, a history and a thorough physical examination are sufficient to Hirschsprung disease from functional constipation in most Hirschsprung disease is (Fig. 1, box it is recommended that the be evaluated at a medical in which a pediatric and a pediatric are and studies can be in diagnosis the of with examination and rectal are the only that can Hirschsprung disease. the of in the are of Hirschsprung disease The approximately the anal be to is when special in colonic there is both an of and an of are not and a is (Fig. 1, box the of the anal sphincter to of a in the anal sphincter When the rectal is there is a of the anal In Hirschsprung disease this is there is no or there may be of the anal In a child, anorectal a and test for Hirschsprung disease. It is useful when the is and of or pathologic studies are If sphincter is Hirschsprung disease can be In the presence of a dilated rectum, it is necessary to the with large to normal sphincter In the child with retentive there may be caused by voluntary of the anal sphincter and the gluteal which not with the may be used in and children. If are diagnosis be with a Although a is often performed as the initial test to Hirschsprung disease, it is When stool is present in the rectum to the of the the no more useful information than can be with a after the diagnosis of Hirschsprung disease has been the may be useful in the location of the that or have not been the to the The may not a in cases of colonic Hirschsprung disease, or may be from cases of functional constipation when Hirschsprung disease is Medications and If constipation is not with the and Hirschsprung disease has been may be (Fig. 1, box treatment may be necessary for an or can be added for There is with and is no longer in the because of its The of for the treatment of constipation is In some studies and it to be in had no glycol have been used to bowel and it has been that the of lower may be useful in therapy has been evaluated in studies in which it was found to be in some controlled not may be for the treatment of a small of patients with constipation At times may be with therapy may be Many can cause constipation (Table 4). children who to the may be indicated (Fig. 1, box resonance of the can such as a or such as anorectal rectal colonic and a psychological evaluation can be by objective evidence of colonic can the presence of or can be useful to the presence of or of a rectal can be useful to or including Hirschsprung disease. such as or thyroid can of constipation 1 OF The evaluation of infants in some aspects from that of children. in most constipation is when treatment when there is passage of (Fig. box or when are present (Fig. of Hirschsprung disease and is Hirschsprung disease has been in In a infant with passage of if Hirschsprung disease has been it is recommended that a test be performed to (Fig. box Constipation can be an of in the of failure to and also be to breast-fed infants in the first year of life. in stool frequency breast-fed infants than in infants of Hirschsprung disease is present, management of a breast-fed infant requires only and close if the infant is and and has no signs or of or Some important in treatment of constipation in infants intake of of such as and which is recommended within the of a or can be used as stool and are not to be potential of and are not recommended. and of are more common in there is a of of which can can be and are to be