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Constipation in Children

Responding to this common concern

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Constipation is a common complaint among children, accounting for approximately 3% of general pediatric outpatient visits and 25% of pediatric gastroenterology visits.1-3 NPs and PAs in primary care settings routinely treat pediatric patients with complaints of constipation.

Clinical Practice Guidelines

Current practice guidelines for treating constipation in children are based on available evidence and expert opinions.2,4-6 However, the lack of quality studies performed in children means that existing guidelines are based more on authority than on evidence.6 These guidelines do provide a framework for treatment initiation, and each provider can adjust treatment as necessary based on the patient's needs.

Three published guidelines guide the discussion in this article. The American Academy of Nurse Practitioners guidelines, published in 2010,4 are based on recommendations from the Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (CGCNASPGHAN), which published its document in 2006.2 The National Institute for Health and Clinical Excellence (NICE) published guidelines for constipation in 2010.5

Methods

In addition to reviewing the guidelines listed above, I performed a comprehensive literature search of the Cumulative Index to Nursing and Allied Health, PubMed, Cochrane Library, Agency for Healthcare Research and Quality, Institute for Clinical Systems Improvement, National Guideline Clearinghouse, and reference lists. Search keywords included: constipation, encopresis, fecal incontinence, treatment, therapy, drug therapy, diet therapy, laxatives and cathartics. Limits included age (0 to 18 years), publication date (January 2006 through December 2012), and English language.

Defining Constipation

This literature search identified variations for the definition of constipation, but a common central idea. CGCNASPGGAN has defined constipation as "a delay or difficulty in defecation, present for 2 or more weeks, and sufficient to cause significant distress to the patient."2 Other definitions include specific signs, symptoms and time frames, but all are similar to this one.

Constipation can be organic or functional. Functional constipation has no medical cause.3 In many cases, functional constipation is the result of withholding behavior brought on by a previous painful bowel movement.3 Other contributing factors include medication use, stress, illness, or dietary changes.7

More than 90% of pediatric constipation cases having no organic cause.1 In the few cases that do, organic constipation can be caused by Hirschsprung disease, cerebral palsy, hypothyroidism, sacral agenesis, cystic fibrosis, and others.2-5 This article focuses on the treatment of functional constipation, since organic constipation management would treat the causative medical condition.

Constipation becomes chronic when it lasts for more than 8 weeks. Chronic constipation can cause adverse health effects including colonic distention, anal fissures, involuntary soiling and abdominal discomfort.3 It may also hinder growth and development.3 Encopresis or fecal incontinence is caused by chronic constipation and is involuntary.7 Encopresis is the liquid stool that leaks around the hard stool retained in the colon; the psychological ramifications for the child can be significant.

Diagnosis

A thorough history and physical examination are essential and usually sufficient to diagnose functional constipation.2,4-6 According to CGCNASPGHAN, a constipation history should include the following components:2

  • frequency and consistency of stools
  • pain or bleeding with passing stools
  • abdominal pain
  • waxing and waning of symptoms
  • age at onset
  • toilet training status
  • fecal soiling
  • withholding behavior
  • change in appetite
  • nausea or vomiting
  • weight loss
  • perianal fissures
  • dermatitis, abscess or fistula
  • current treatment and previous treatment

The available clinical guidelines have differing suggestions for the physical examination. CGCNASPGHAN recommends at least one digital rectal examination (DRE).2 This guideline also recommends a fecal occult blood test for every infant presenting with constipation.2 NICE recommends that a DRE only be performed by a provider "competent to interpret features of anatomical abnormalities or Hirschsprung disease."5

Any of the history and physical findings listed in Table 1 are considered red flags and suggest an organic cause for the constipation. These findings warrant additional workup and possible referral to a pediatric gastroenterologist.2

Management

Education is an essential component of managing pediatric constipation. Parents need to understand what a normal bowel movement is for their child. Frequency changes throughout childhood and differs from child to child. Infants younger than 1 year have bowel movements two to five times per day.9 In children ages 1 to 4, bowel movements can occur once or twice per day to once every 2 or 3 days.2,4,8,9

The caliber (shape, texture, color) and consistency of stool also require attention. An explanation of the basic pathophysiology of evacuation can help parents understand why constipation occurs and minimize blame and guilt. Diet, exercise and toilet training advice should also be provided. Strategies include encouraging toilet time 5 to 10 minutes after meals to utilize the gastrocolonic reflex, positive reinforcement with stickers or other measures, and ensuring the child is ready for toilet training.1,2,4,7-10

 If a child has a fecal impaction, it must be evacuated in order for treatment to be successful. If the rectum is not cleared of the retained stool, oral laxative treatment at maintenance dosing may cause increased fecal incontinence and abdominal pain.1,3

NICE recommends using oral medications before advancing to rectal medications; these guidelines also recommend against manual disimpaction unless all other treatment options have been exhausted.5 CGCNASPGHAN recommends oral medications, rectal medications or a combination of both, depending on the patient. The rectal approach is faster but invasive; the oral approach is not invasive but carries a risk for decreased adherence.2 The two organizations couldn't reach a consensus on manual disimpaction and therefore neither recommend nor discourage it.2

Oral medications used for disimpaction include high-dose polyethylene glycol (PEG) 3350 (MiraLax), polyethylene glycol/electrolytes (GoLytely) and high-dose mineral oil.2,9 Other osmotic and stimulant laxatives have been used with success, however, no controlled trials support their use.2

Laxatives may be used alone or in combination with rectal therapy. CGCNASPGHAN recommendations for rectal therapy include saline enemas, phosphate soda enemas or a mineral oil enema followed by a phosphate enema.2 Tap water, soap suds and magnesium enemas may cause toxicity and should not be used for disimpaction.2 If oral, rectal or combination therapy are not successful within 7 days, inpatient oral lavage is warranted.9

Maintenance therapy should begin as soon as the impaction has been resolved. Diet, behavior modification and stool softeners or laxatives are all important components in preventing reoccurrence. Providers should stress the importance of a balanced diet with sufficient fluids, fruits and vegetables.

A balanced diet requires an adequate amount of fiber to maintain regular bowel movements. High-fiber foods include whole grains, raisins, prunes, berries, kidney beans, lima beans, cabbage, spinach, broccoli and cauliflower. There are conflicting opinions on fiber supplementation in this population; increased fiber should not be added to the diet until the constipation has resolved.7,9

Behavior modification includes scheduled toilet times and positive reinforcement with a calendar, diary or reward system. Stool softeners or laxatives should be used to prevent relapse; Table 2 provides a list of commonly used medications.

Issues in Infants

Constipation in neonates and infants younger than 1 year requires special consideration. It is appropriate to increase fluid intake, including fruit juices containing sorbitol (apple, pear and prune).2 In infants older than 6 months, rice cereal may be replaced by barley cereal.9 The use of glycerin suppositories is also appropriate. Mineral oil, simulant laxatives and enemas should be avoided.2,9

After Disimpaction

In the patient with chronic constipation, the overstretched rectal wall desensitizes to the sensation of being full and the patient doesn't recognize the need to empty the bowels.1,7 Once the rectum has been successfully disimpacted, laxatives may be needed for an extended period of time to prevent relapse and allow proper size and function to return.7 Several treatment options are available, and they should be discussed with the family. Adherence to therapy is crucial for successful treatment, and if one treatment doesn't work, another should be chosen.   

Among laxatives, PEG appears to be most effective for chronic constipation.6,9,11,12 However, the other drugs listed in Table 2 are all comparable to each other.9 There is a lack of high-quality studies to support the definitive recommendation of one agent over another.

When discussing laxative options with the family, several points should be made. PEG is flavorless, which makes it more palatable to children. However, it is expensive.9 Mineral oil is inexpensive, but it presents an aspiration risk and it has poor palatability.9 Stimulant laxatives may cause bowel dependence and are usually reserved for "rescue" therapy. They can be used for 1 to 3 days to prevent impaction.1,9 Probiotics, prebiotics, fiber supplements and fluid supplements all lack high-quality studies to confirm efficacy.13-15

Medication doses should be titrated to achieve desired effect. This can range from a minimum of three soft, easily passed stools per week to one bowel movement daily.7,13 Treatment should continue for several weeks past the return of normal bowel habits and may need to continue for 6 months or more.5,7 Treatment should be tapered gradually until discontinued.5,7

Improving Adherence

Constipation in children is a common problem treated in primary care settings. Most cases of constipation in infants and children are functional and have no organic cause. A thorough history and physical examination are essential for accurate diagnosis. Management includes a combination of education, disimpaction and maintenance therapy. Managing constipation in infants requires special consideration. Education of parents is crucial for treatment success. Treatment options should be planned with the family to improve adherence.

Brandy A. Warmsbecker is a family nurse practitioner who specializes in orthopedics at Mercy Medical Center in Williston, ND. She has completed a disclosure statement and reports no relationships related to this article.

                                                             

References

1. Jurgens H, et al. Management of chronic functional constipation in children: a review of the literature. Neonatal, Paediatric & Child Health Nursing. 2011;14(2):23-28.

2. Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):e1-e13.

3. Walia R, et al. Recent advances in chronic constipation. Curr Opin Pediatr. 2009;21(5):661-666.

4. Greenwald BH. Clinical practice guidelines for pediatric constipation. J Am Acad Nurs Pract. 2010;22(7):332-338.

5. National Collaborating Centre for Women's and Children's Health (UK). Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: RCOG Press; 2010. (NICE Clinical Guidelines, No. 99.)

6. Pijpers MA, et al. Currently recommended treatments of childhood constipation are not evidence based: a systematic literature review on the effect of laxative treatment and dietary measures. Arch Dis Child. 2009;94(2):117-131.

7. Philichi L. When the going gets tough: pediatric constipation and encopresis. Gastroenterol Nurs. 2008;31(2):121-130.

8. Biggs W, Dery W. Evaluation and treatment of constipation in infants and children. Am Fam Physician. 2006;73(3):469-477.

9. Blackmer AB, Farrington EA. Constipation in the pediatric patient: an overview and pharmacologic considerations. J Pediatr Health Care. 2010;24(6):385-399.

10. Plunkett A, et al. Management of chronic functional constipation in childhood. Paediatr Drugs. 2007;9(1):33-46.

11. Gordon M, et al. Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Datab Syst Rev. 2012;(7): CD009118.

12. Candy D, Belsey J. Macrogol (polyethylene glycol) laxatives in children with functional constipation and faecal impaction: a systematic review. Arch Dis Child. 2009;94(2):156-60.

13. Rogers J. Assessment, prevention, and treatment of constipation in children. Nurs Stand. 2012;26(29):46-52.

14. Chmielewska A, Szajewska H. Systematic review of randomised controlled trials: probiotics for functional constipation. World J Gastroenterol. 2010;16(1):69-75.

15. Tabbers MM, et al. Nonpharmacologic treatments for childhood constipation: systematic review. Pediatrics. 2011;128(4):753-761.

 




     

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