According to the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, 3 percent of all visits to a pediatrician are in some way related to constipation. Children's Hospital Boston's Samuel Nurko, MD, MPH, director of the Center for Motility and Functional Gastrointestinal Disorders, sat down with Pediatric Views® to discuss current thinking about diagnosis and treatment.
In the past, constipation was defined essentially by number or frequency of bowel movements. Increasingly, it's being seen as not only the number of bowel movements, but how painful and difficult it is to produce them or how problematic they are perceived by the child or the family.
Children have difficulty with producing bowel movements. It's common for children to experience constipation around toilet-training time. Children who are trying to avoid going to the bathroom may hide in a corner or behind the sofa and exhibit "withholding behavior," such as wriggling, fidgeting, rising on their toes and rocking back and forth while stiffening their buttocks and legs or assuming unnatural postures. They may look like they're pushing, but they're really holding the stool in.
Fecal incontinence is a common complication of constipation. This can happen when so much stool is withheld that it creates a blockage around which stool flows and eventually leaks out. It's important for the family to understand that their child is not doing this on purpose—he or she is likely to be as unhappy about it as they are and needs to feel supported. When the constipation is treated, the incontinence most often clears up, too. In rare cases, fecal incontinence may not be related to stool retention.
Most cases of functional constipation can be diagnosed with a thorough history and physical exam. (removed text from here) The history should include asking about the child's development, diet and psychosocial environment—is he or she in school, and if so, using the restrooms there? Have there been any recent stressors in the child's environment?
It's very rare for constipation in children to be caused by an underlying organic disease, but a pediatrician should check for anatomical malformations, and since some causes of constipation are neurological, he or she should also look for telltale signs of spinal problems, like little dimples or hair over the back of the spine. In severe intractable cases, or in those that started at birth or have other associated problems, Hirschsprung's disease needs to be considered. A stool test for occult blood should be performed in all constipated infants and in children with abdominal pain, failure to thrive, diarrhea or a family history of polyps or colon cancer. A pediatrician might also test thyroid function and screen for possible allergic conditions such as celiac disease.
Unfortunately, X-rays are not the most sensitive and specific way to decide if a patient is constipated. There's a lot of variability, it's not reproducible and, again, the diagnosis can often be made clinically. For objective data, colonic transit studies provide more reliable information than X-rays. In those cases where an X-ray is indicated, it must be read with caution.
Treatment is based on education, behavioral interventions and laxative treatment if there is a stool impaction that needs to be treated first. There are many ways to disimpact, and we're seeing an advent of very safe oral laxatives with high levels of efficacy. Recent studies show that oral disimpaction with high-dose PEG solutions is as effective as rectal disimpaction. Once the stool has been disimpacted, the focus should be on keeping the stool soft with the use of laxatives and on behavioral modification—for example, dedicated time on the toilet after meals. It's important to keep the child comfortable, physically and emotionally. Many families think they toilet train their children, but I think the children train themselves. The timing has to be right.
In infants, constipation is most often related to breastfeeding or diet—many healthy breast-fed infants go through normal periods of having very infrequent bowel movements. As with older children, constipation in infants is rarely a sign that something is medically wrong; however, delayed passage of meconium or failure to grow as expected could be a sign of Hirschsprung's disease or another disorder. Treatment usually includes increased intake of fluids (especially those containing sorbitol, such as prune, pear and apple juices). There are also some very safe osmotic laxatives that have been shown to work. Enemas are discouraged and should be used with caution. Some types of enemas are not indicated in children younger than 2.
It depends. Sometimes functional constipation is simply a transient part of the toilet training process; these children tend to respond well to behavioral interventions. In other cases, there may not be an underlying disease, but the child may still have long-term problems with constipation for physiological reasons. It has been reported that about 30 percent of the patients will stay on laxatives for more than 10 years and that 10 to 20 percent of children with constipation may continue to have problems into adulthood.
Most kids with constipation don't need to be referred. There's a lot of behavioral modification and prevention that can be done by the primary care provider. That said, a patient should be referred to the GI department in cases of severe constipation unresponsive to therapy, associated fever, abdominal extension, anorexia, nausea, vomiting, poor weight gain, or dependence on laxatives. Severe, intractable patients may need to have more specialized testing that may include anorectal and motility studies to try to better understand the physiology of the colon, other testing to exlude other underlying pathology and more aggressive medical, behavioral and surgical treatments. These State of the Art testing and treatments are available through the Center for Motility and Functional Gastrointestinal Disorders.
More information: childrenshospital.org/motility
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