eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Constipation

Stephen Borowitz, MD, Professor of Pediatrics and Public Health Sciences, Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Virginia

Updated: Oct 30, 2009

Introduction

Background

Concern about bowel function has been prevalent throughout history across many cultures. A normal bowel pattern is thought to be a sign of good health. Unfortunately, no uniform definition of childhood constipation is recognized. Moreover, health care providers have definitions of constipation that are very different than most parents' definitions.

The North American Society of Gastroenterology and Nutrition defines constipation as "a delay or difficulty in defecation, present for 2 weeks or more, and sufficient to cause significant distress to the patient."¹ The Paris Consensus on Childhood Constipation Terminology defines constipation as "a period of 8 weeks with at least 2 of the following symptoms: defecation frequency less than 3 times per week, fecal incontinence frequency greater than once per week, passage of large stools that clog the toilet, palpable abdominal or rectal fecal mass, stool withholding behavior, or painful defecation."² For practical clinical purposes, constipation is generally defined as infrequent defecation, painful defecation, or both. In most cases, parents are worried that their child's stools are too large, too hard, not frequent enough, and/or painful to pass.

Constipation in children is an extremely common problem with reported prevalence rates between 1-30%.³ Constipation is the principal complaint in 3-5% of all visits to pediatric outpatient clinics and as many as 35% of all visits to pediatric gastroenterologists.⁴

Pathophysiology

Most children with constipation have no underlying medical condition. They are often labeled as having functional constipation or acquired megacolon. In most cases, childhood constipation develops when the child begins to associate pain with defecation. Once pain is associated with the passage of bowel movements, the child begins to withhold stools in an attempt to avoid discomfort. As stool withholding continues, the rectum gradually accommodates, and the normal urge to defecate gradually disappears. The infrequent passage of very large and hard stools reinforces the child's association of pain with defecation, resulting in worsening stool retention and progressively more abnormal defecation dynamics with anal sphincter spasm. Chronic rectal distension ultimately results in both loss of rectal sensitivity, and loss of the urge to defecate, which can lead to fecal incontinence (ie, encopresis).

The differential diagnosis of childhood constipation can be extensive and may include Hirschsprung disease (ie, congenital megacolon), spinal or neuromuscular abnormalities, hypothyroidism, anal stenosis, imperforate anus with fistula, anterior displacement of the anus (this is a controversial diagnosis), allergy or sensitivity to cow's milk, and celiac disease. Fortunately, in most cases in which an underlying condition causes constipation, other stigmata of the disorder point to diagnosis. For example, constipation is rarely the only symptom of hypothyroidism.

For practical purposes, in an otherwise healthy child, the differential diagnosis of chronic constipation is Hirschsprung disease and functional constipation (not Hirschsprung disease). Although this differentiation sometimes may be difficult, a number of clues in the history and physical examination are helpful (see Media file 1).

Differentiating functional constipation and Hirschsprung disease.

Frequency

United States

Constipation is extremely common among infants and young children. Issenman et al found that 16% of parents reported that their 2-year-old children had constipation.⁵  Loening-Baucke reported that the prevalence of constipation was 22.6% among 482 children aged 4-17 years.⁶ In a longitudinal study of children aged 9-11 years, Saps et al reported an 18% overall prevalence of constipation.⁷

International

Yong and Beattie found that 34% of parents in the United Kingdom reported their children aged 4-7 years had at least intermittent difficulties with constipation.⁸ de Araujo Sant'Anna and Calcado found that 28% of Brazilian children aged 8-10 years were constipated.⁹

Sex

Before puberty, constipation appears to be equally common among girls and boys. After puberty and into young adulthood, females are more likely to develop constipation.

Age

Constipation occurs in all pediatric age groups from infancy to young adulthood. Typically, childhood constipation develops during 3 stages of childhood: in infants during weaning, in toddlers during toilet training, and in school-aged children. In several published reports, approximately half of childhood constipation occurs during the first year of life.

Clinical

History

• History is often helpful in discriminating functional constipation from Hirschsprung disease. Asking parents when their child passed his or her first bowel movement after birth is particularly important. Most children with Hirschsprung disease have difficulties with constipation dating to birth or shortly after birth. In most published series, more than one half of infants with Hirschsprung disease do not pass meconium during the first 36 hours of life and are diagnosed with constipation within the first 4-6 months of life.
• Asking the family about specific symptoms of their child's constipation is also important. Inquiring about the onset and duration of symptoms, whether the passage of bowel movements appears to be painful, and whether any bleeding has been associated with defecation is important. Obtaining history of fecal incontinence or soiling is also crucial because many parents confuse fecal soiling (ie, encopresis) with chronic or recurrent diarrhea.
• Most cases of chronic childhood constipation are precipitated by painful bowel movements with resultant voluntary withholding of stool.¹⁰ In young children, parents often confuse withholding of stool with pain or excessive straining (see Media file 5). In many cases of functional constipation, parents can identify a precipitating event.
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  Common withholding behaviors in young children.

  
  
• In young infants, functional constipation often develops at the time of a dietary transition (eg, from breast milk to formula, the addition of solid foods into the diet, from formula to whole milk).
• In toddlers, functional constipation often develops near the time of toilet training.
• In toddlers and young children, constipation may develop following an illness associated with either a severe diaper dermatitis or dehydration.
• In older children, functional constipation often develops at the time of school entry because they refuse to defecate while they are at school.

Physical

• The most important part of the physical examination is the rectal examination. Perform a rectal examination in any child with chronic constipation, regardless of age. In young infants, the anus should be sufficiently large to permit the introduction of a pinkie finger.
• Carefully examine the perineum for any sacral dimples or pits that might indicate an abnormality of the distal spinal cord. Also note the location of the anus on the perineum.
  • In most children, the anus is approximately halfway between the posterior fourchette (base of the scrotum) and the tip of the coccyx.
  • Whether children with anterior displacement of the anus are at increased risk for constipation is not entirely clear. To date, no large prospective studies have been performed. In some cases, if the anus is sufficiently anterior, a posterior rectal shelf may develop, resulting in abnormal defecation dynamics. Some pediatric surgeons and pediatric gastroenterologists believe that this entity is at one end of the continuum of imperforate anus with a perineal fistula.
• Examine the anus for the presence of any fissures, fistulae, or hemorrhoids. Also, confirm the presence of an anal wink. To elicit an anal wink, stroke the perianal skin with a pin or probe. In response to the stroking, the subcutaneous portion of the external anal sphincter should contract and visibly pucker at the anal margin. Failure to elicit this reflex can indicate an abnormality with either peripheral sensory or motor nerves or central connections mediating the reflex.
• Upon digital examination, note the size of the anal canal, the size of the rectum, and whether any intrarectal masses are present. Also, note if the rectum is empty or filled with stool and note the consistency of the stool.
• Among children with Hirschsprung disease, the rectum is typically quite small and empty of stool. Following the digital examination, the infant may have a gush of liquid stool because the functional obstruction has transiently been relieved.
• Among children with functional constipation, the rectum is generally enlarged, and stool is present just beyond the anal verge.

Differential Diagnoses

Hirschsprung Disease
Hypercalcemia
Hypokalemia
Hypothyroidism
Imperforate Anus
Neurofibromatosis

Other Problems to Be Considered

Anal stenosis
Anterior displacement of the anus
Celiac disease
Cerebral palsy (static encephalopathy)
Currarino's triad (rectal stenosis, hemi sacrum, presacral mass)
Cow's milk intolerance
Mitochondrial disorders
Neuronal intestinal dysplasia
Prune-belly syndrome
Spinal muscular atrophy
Tethered cord

Workup

Imaging Studies

• Radiography
  • In most cases, the diagnosis is based on the history and physical examination; however, among children who are obese or who refuse a rectal examination, plain abdominal radiography can assess whether significant fecal retention is present (see Media file 3).
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    Plain abdominal radiograph that demonstrates stool throughout the colon.

    
    
  • Plain abdominal radiography can also be useful in assessing efficacy of medical therapy when the history is unclear.
• Contrast enema
  • Radiography can be useful in excluding or diagnosing Hirschsprung disease. Although the diagnosis of Hirschsprung disease ultimately relies on a histologic demonstration of an absence of ganglion cells in the affected colon, the diagnosis is often suggested by single-contrast barium enema.
  • Do not use an air-contrast enema because radiographic evaluation for Hirschsprung disease depends on finding a change in colonic caliber between the normal and abnormal aganglionic segment. With an air-contrast study, the colon is evacuated to identify mucosal abnormalities. By evacuating the colon prior to study, any caliber change may be masked.
  • Moreover, do not perform any form of rectal manipulation on the child (eg, rectal examination, therapeutic enema, suppository) for 48 hours prior to the procedure. The radiologist is looking for a change in colonic diameter from the narrow aganglionic segment to more dilated ganglionic segment (see Media file 2).
  • 
    

    

    Unprepared single contrast barium enema demonstrating a transition zone consistent with Hirschsprung disease.

    
    
  • This transition zone is characteristic of Hirschsprung disease. Rectal manipulation with suppositories or therapeutic enemas may transiently dilate the narrowed distal segment, causing a false negative result.
  • Although an unprepared barium enema has reasonably good diagnostic sensitivity and specificity in older children, this procedure is substantially less reliable during the first several months of life. The proximal colon may require several months after birth to dilate sufficiently for a transition zone to be apparent.

Other Tests

• Anorectal manometry can be useful in discriminating between functional constipation and Hirschsprung disease. With anorectal manometry, a balloon catheter is inserted into the rectum. Normally, when the rectal balloon is inflated, the internal anal sphincter relaxes reflexively (see Media file 4).
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  Normal anorectal manometry that demonstrates relaxation of the internal anal sphincter in response to rectal distension.

  
  
• Among patients with Hirschsprung disease, the internal anal sphincter fails to relax in response to rectal distension. As many as 20% of healthy children may have a falsely absent reflex, especially if they were born prematurely or at low birth weight; however, a positive response is strong evidence against Hirschsprung disease.

Procedures

• Rectal biopsy is the definitive means of establishing or excluding Hirschsprung disease.¹¹ The tissue is examined histologically for the presence or absence of ganglion cells in the submucosal plexus.

Treatment

Medical Care

Although constipation is an extremely common problem among children, few studies have systematically evaluated different management strategies. Childhood constipation is treated in many ways, and virtually any therapeutic regime is likely to be effective as long as it is sufficiently aggressive and persistent.¹² Because of the medical profession's understanding of the pathophysiology of the problem, the basic tenets of therapy include evacuation of the colon, elimination of pain with defecation, and establishing regular bowel habits.

• Evacuate the colon.
  • With evidence of a fecal impaction, aim initial therapy at complete evacuation of the colon. Palpating a hard mass of stool upon physical examination, finding a large amount of stool in a dilated rectum during rectal examination, or finding excessive stool in the colon using abdominal radiography can identify a fecal impaction.
  • A series of enemas or the aggressive use of oral cathartics such as polyethylene glycol, sodium phosphate, magnesium citrate, or a balanced electrolyte solution with polyethylene glycol can accomplish disimpaction.¹³ In uncontrolled trials, disimpaction by the oral route, the rectal route, or a combination of both have proven effective.
  • Convincing young children to ingest sufficient amounts of oral cathartics to evacuate their colons is difficult; therefore, enemas or suppositories may be necessary.
• Eliminate any pain associated with defecation.
  • Once the colon has been evacuated, chronic laxative therapy is generally required. Virtually any laxative can be used as long as it is used in sufficient quantity to produce 1-2 soft stools daily. In young children, eliminating any pain associated with the passage of bowel movements is extremely important. Using very large doses of laxatives to produce very soft stools may be necessary.
  • Continuing laxative therapy for a number of months is often necessary. As a result, reassuring caregivers of the safety of long-term laxative usage is very important. Address specific concerns regarding laxative dependency and the risk of colon cancer due to chronic laxative usage. Many popular misconceptions about laxative use and abuse exist.
  • If the child has anal fissures, using Xylocaine ointment or hydrocortisone suppositories for a short period of time to provide symptomatic relief may be appropriate.
• Establish regular bowel habits.
  • In many cases, long-term success depends on the child establishing regular and routine toilet times. Encouraging the child to attend the toilet once or twice daily for 5-10 minutes, preferably after breakfast and supper to take advantage of the gastrocolic reflex, is generally recommended. Not expecting the child to attend the toilet while at school is also preferable.
  • When the affected child has passed bowel movements regularly for weeks or months without apparent pain, fear, or excessive straining, attempting to discontinue laxative therapy is reasonable. Inform the family that relapses are common, particularly with changes in the child's daily routine (eg, vacations) and during times of stress. Also inform the family that requiring intermittent therapy with laxatives into adulthood is not unusual.

Consultations

• Consultation with a pediatric gastroenterologist or pediatric surgeon is appropriate if the history or examination findings suggests an underlying organic cause (eg, Hirschsprung disease). Seek consultation when the child fails routine therapy or when management is otherwise complex.

Diet

• Dietary changes, such as increasing the child's intake of fluids and carbohydrates, are commonly recommended as part of the treatment.¹⁴ Complex carbohydrates and unabsorbable sugars (eg, sorbitol) are found in many fruit juices (eg, prune, pear, apple). These carbohydrates increase stool frequency as a result of increased fecal water content. Although randomized controlled trials have not been conducted to examine the effects of increased fluids, nonabsorbable carbohydrates, or dietary fiber on childhood constipation, recommending a balanced diet that includes whole grains, fruits, vegetables, and lots of fluid seems appropriate. Because data are limited, forceful implementation of a particular diet does not seem warranted.
• In infants and young children, considering the removal of cow's milk protein from the diet for a period of time is appropriate because chronic constipation may be precipitated by ingestion of cow's milk proteins. Iacono and colleagues found that among 27 Italian children aged 5-36 months who had chronic constipation, the constipation resolved in 78% of the children when soy milk was substituted for cow's milk; in most cases, the constipation recurred when cow's milk was reintroduced.¹⁵
• Switching the patient to a low-iron formula is not necessary. Several studies have shown that ingestion of iron-supplemented formulas is not associated with an increased incidence of constipation.¹⁶
• Although some evidence suggests that GI flora is important in gut motility, no evidence suggests that gut flora is different in children suffering from constipation than gut flora in healthy controls. Both Lactobacillus and Bifidobacterium have been shown to increase stool frequency and decrease stool consistency in healthy adults; little evidence suggests that probiotics are effective in treating constipation in either adults or children.¹⁷

Medication

In several randomized trials, laxatives have been shown to be beneficial in the treatment of chronic childhood constipation.^18,19 Studies have shown that polyethylene glycol,²⁰ mineral oil, magnesium hydroxide, and lactulose are effective and can be used for prolonged periods of time without risk. The key to therapy is to use a sufficient amount of laxative to produce the desired effect. The use of stimulant laxatives may be necessary intermittently in some children; however, routine usage of these agents in young children is not generally recommended. Continuous laxative therapy may be required for several months until the child extinguishes the association between pain and the passage of bowel movements.

Osmotic laxatives

These agents produce osmotic effect in colon that results in distention and promotes peristalsis.

Polyethylene glycol (MiraLax, GlycoLax)

Polyethylene glycol (PEG) is a long chain of ethylene glycol molecules. The resulting molecule is extremely large, is very poorly absorbed, and functions as an osmotic laxative. These powders are tasteless and odorless and dissolve completely in nearly all liquids including water. These agents often can also be used as purgatives in preparation for colonoscopy. At very large dosages, PEG is occasionally difficult to take and its usage may be associated with nausea, bloating, abdominal cramps, and vomiting.

Dosing

Adult

Occasional constipation: 17 g mixed in 180 - 240 mL of fluid PO qd prn

Pediatric

Mix 1 packet (17 g) in 240 mL to yield approximately 1 g per 14 mL; may store refrigerated for 48 h
Disimpaction: 1-3 g (14-42 mL)/kg/d PO divided 2-4 doses
Maintenance therapy in children 6 months to 15 years: ~0.5 g (7 mL)/kg/d PO qd or divided bid

Interactions

Do not administer PO medications within 1 h of initiation of therapy due to potential risk of reduced absorption

Contraindications

Documented hypersensitivity; colitis, ileus, megacolon, bowel perforation, gastric retention, GI obstruction

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Mixing the product in juice or other flavored fluids may make it more palatable; chilled product is more palatable; caution in ulcerative colitis and hot loop polypectomy

Magnesium hydroxide (Philips' Milk of Magnesia, Haley's MO)

Magnesium is a divalent cation maximally absorbed in the distal small intestine. At low concentrations, magnesium appears to absorb by a saturable carrier-mediated process influenced by vitamin D. At higher concentrations, magnesium absorption appears to occur largely by diffusion and is quite inefficient. Increased serum magnesium levels may release cholecystokinin, which stimulates GI motility and secretion; this may explain why some children experience abdominal cramping. Mostly flavorless but has a thick, chalky texture. More palatable when mixed with a fluid (eg, milk, chocolate milk).

Dosing

Adult

30-60 mL/d (as 400 mg/5 mL PO susp) PO qd or divided bid

Pediatric

1-3 mL/kg/d (as 400 mg/5 mL susp) PO qd or divided bid

Interactions

Decreases absorption of tetracyclines, digoxin, indomethacin, and iron salts

Contraindications

Documented hypersensitivity; colostomy, ileostomy, fecal impaction, intestinal obstruction

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Infants may be more susceptible to magnesium poisoning than older children and adults; overdosage can lead to hypermagnesemia, hypophosphatemia, and secondary hypocalcemia; administer magnesium-containing laxatives cautiously among patients with renal insufficiency because most of a magnesium load is excreted in the urine

Lactulose (Chronulac, Duphalac, Kristalose)

Synthetic, nonabsorbable disaccharide available as a 70% solution. Generally very well tolerated and tastes sweet. Contains 10 g lactulose/15 mL of PO solution.

Dosing

Adult

10-30 mL PO qd

Pediatric

1-3 mL/kg/d PO qd or divided bid

Interactions

Neomycin may eliminate certain colonic bacteria and interfere with the desired degradation of lactulose, thus preventing colonic content acidification

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Exercise caution in patients with diabetes mellitus; at commonly used doses, often produces flatulence and occasional abdominal cramping

Sorbitol

This alcohol of glucose is largely nonabsorbable. Available as a 70% solution. As with lactulose, generally well tolerated and tastes quite sweet.

Dosing

Adult

30-150 mL PO qd prn

Pediatric

1-3 mL/kg/d PO qd or divided bid

Interactions

None reported

Contraindications

Documented hypersensitivity; anuria

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

At commonly used doses, often produces flatulence and occasional abdominal cramping

Magnesium citrate

Magnesium is a divalent cation maximally absorbed in the distal small intestine. At low concentrations, magnesium appears to absorb by a saturable carrier-mediated process influenced by vitamin D. At higher concentrations, magnesium absorption appears to occur largely by diffusion and is quite inefficient. Increased serum magnesium levels may release cholecystokinin, which stimulates GI motility and secretion; this may explain why some children experience abdominal cramping.

Dosing

Adult

150-300 mL/d PO qd

Pediatric

<6 years: 1-3 mL/kg/d PO qd
6-12 years: 100-150 mL/d PO qd
>12 years: Administer as in adults

Interactions

Decreases absorption and effects of tetracyclines, digoxin, indomethacin, and iron salts

Contraindications

Documented hypersensitivity; colostomy, ileostomy, fecal impaction, intestinal obstruction, diabetes mellitus, renal failure

Precautions

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Infants may be more susceptible to magnesium poisoning than older children and adults; overdosage can lead to hypermagnesemia, hypophosphatemia, and secondary hypocalcemia; administer magnesium-containing laxatives cautiously among patients with renal insufficiency, as most of a magnesium load is excreted in the urine; exercise caution in patients who are taking digoxin and lithium; product may be chilled to improve palatability

Sodium phosphate oral solution (Fleet Phospho-Soda)

Phosphate is a divalent anion largely absorbed in the proximal small intestine. When administered as an enema, only small amounts are absorbed so the phosphate functions as an osmotic agent. Each 15 mL contains 7.2 g monobasic sodium phosphate monohydrate and 2.7 g dibasic sodium phosphate heptahydrate.

Dosing

Adult

1 tablespoonful mixed with 8 oz water PO qd prn; may increase dose not to exceed 3 tablespoonfuls per day; drink at least 8 oz of extra fluid with each dose

Pediatric

<5 years: Not recommended
5-9 years: Up to 1/2 tablespoon PO qd taken with eight ounces of fluid
10-11 years: Up to 1 tablespoon PO qd taken with eight ounces of fluid
>12 years: Administer as in adults

Interactions

Sucralfate or antacids that contain aluminum, calcium, or magnesium may bind phosphate in gut and decrease absorption (separate administration by at least 1 h); phosphate may also bind magnesium and reduce its absorption (separate administration by at least 1 h); anion exchange resins (eg, colestipol) may alter phosphate absorption; caution with other drugs that may lower seizure threshold (eg, antipsychotics); caution when coadministered with other drugs that prolong QT interval (eg, antipsychotics, macrolide antibiotics, class IA or class III antiarrhythmic agents); risk of acute phosphate nephropathy may increase with drugs that alter renal perfusion (eg, diuretics, ACE inhibitors, angiotensin II antagonists, NSAIDs)

Contraindications

Do not administer sodium phosphate to patients with renal insufficiency because severe and lethal episodes of hyperphosphatemia may develop with resultant hypocalcemia and tetany; fecal impaction

Precautions

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Caution in congestive heart failure, and cirrhosis; electrolyte disturbances (eg, hypernatremia, hypokalemia, hyperphosphatemia, hypocalcemia) dehydration, metabolic acidosis, renal failure, tetany, and death have been attributed to prescribing >45 mL as bowel preparation for colonoscopy, surgery, or barium enema and/or prescribing it for people at medical risk

Lubricants

These agents soften stools and decrease water absorption from the GI tract. They may also promote salt and water secretion by the colon.

Mineral oil

Nonabsorbable fat that softens stool and decreases water absorption, partly by its metabolism in the colon to hydroxy fatty acids. Largely tasteless. Has an oily consistency. More palatable if cold or mixed into a fluid (eg, orange juice). When taken in high doses, many children experience seepage of orange oil into their underwear, which can produce perianal pruritus.

Dosing

Adult

15-45 mL PO qd prn

Pediatric

<1 year: Not recommended
>1 year: 1-3 mL/kg/d PO qd or divided bid

Interactions

Theoretically, mineral oil may interfere with absorption of fat-soluble vitamins; however, several long-term studies have not demonstrated any deleterious effects on vitamin levels; decreases effect of docusate sodium and may decrease absorption of warfarin, or PO contraceptives

Contraindications

Documented hypersensitivity; do not administer to people with increased aspiration risk because aspiration of mineral oil can result in lipoid pneumonia

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not administer with food or meals since may cause aspiration leading to lipid pneumonitis

Stimulant laxatives

These agents increase peristaltic activity in the GI tract. Most of these agents also stimulate salt and water secretion in the colon.

Senna (Ex-Lax, Senokot, Fletcher's Castoria, Aloe Vera)

Sennosides are plant alkaloids that stimulate colonic salt and water secretion and promote colonic motility. At higher doses, these agents often produce abdominal cramping. Long-term use in animals has not been associated with any evidence of cathartic colon, tachyphylaxis, or secondary hyperaldosteronism.

Dosing

Adult

10-15 mL PO qhs prn

Pediatric

<2 years: Not recommended
2-5 years: 2.5-5 mL/dose (8.8 mg of sennosides/5 mL) PO qd/bid
>5 years: 5-10 mL/dose (8.8 mg of sennosides/5 mL) PO qd/bid

Interactions

Decreases effects of anticoagulants

Contraindications

Documented hypersensitivity; bowel obstruction, fecal impaction

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Chronic use of sennosides can be associated with melanosis coli (brown pigment accumulation in the colonic mucosa); this finding does not appear to have any pathological significance and resolves within several months of discontinuing the laxative

Bisacodyl (Dulcolax)

Colorless and odorless compound that is very poorly absorbed. Can be administered PO or rectally. Bisacodyl increases colonic peristalsis and stimulates salt and water secretion.

Dosing

Adult

5-15 mg PO as single dose
10 mg PR as single dose

Pediatric

<2 years: Not recommended
>2 years: 0.5-1 of a 10-mg suppository/dose PR or one third of the 5-mg tab/dose PO

Interactions

Decreases effects of warfarin and antacids

Contraindications

Documented hypersensitivity; intestinal obstruction

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

At higher doses, these agents often produce abdominal cramping

Stool softeners

These agents allow incorporation of water and fat into stool, causing stool to soften.

Docusate sodium (Colace, DC 240 Softgels, Diocto, Surfak)

Used to avoid straining during defecation. Allows incorporation of water and fat into stool causing stool to soften.

Dosing

Adult

50-400 mg/d PO qd or divided qid

Pediatric

3-6 years: 20-60 mg/d PO qd or divided qid
6-12 years: 40-150 mg/d PO qd or divided qid
>12 years: Administer as in adults

Interactions

Decreases effects of warfarin and increases effects of phenolphthalein

Contraindications

Documented hypersensitivity; nausea, vomiting, acute abdominal pain

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged use of medication may result in electrolyte imbalance

Stool softeners in combination with stimulants

Emollient stool softeners cause stool to soften. Most of these agents also promote salt and water secretion by the colon. Stimulants increase peristaltic activity in the GI tract. Most of these agents also promote salt and water secretion by the colon.

Docusate sodium and casanthranol combination (Peri-Colace, Diocto C, Silace-C)

Docusate sodium allows incorporation of water and fat into stool causing stool to soften. Casanthranol is an anthraquinone stimulant hydrolyzed by colonic bacteria into active compound. Usually produce action 8-12 h after administration.

Dosing

Adult

1-4 cap or tab PO hs
Alternatively, 5-60 mL PO hs if syrup or emulsion administered

Pediatric

<6 years: Not recommended
>6 years: 1-2 cap or tab PO hs; alternatively, 5-15 mL PO hs if syrup or emulsion administered

Interactions

Decreases effects of warfarin and increases effects of phenolphthalein

Contraindications

Documented hypersensitivity; nausea, vomiting, GI bleeding, appendicitis, GI bleeding, congestive heart failure, fecal impaction, appendicitis, nausea, vomiting, acute abdominal pain

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Excessive use may lead to electrolyte imbalance, osteomalacia, steatorrhea, cathartic colon

Osmotic enemas

These agents produce osmotic effect in colon that results in distention and promotes peristalsis.

Sodium phosphate enema (Fleet enema)

Phosphate is a divalent anion largely absorbed in the proximal small intestine. When administered as an enema, only small amounts are absorbed so the phosphate functions as an osmotic agent drawing water into intestinal lumen increasing intraluminal and hydrostatic pressure. May also decrease water and electrolyte absorption.

Dosing

Adult

1 adult enema (4.5 fl oz) PR prn

Pediatric

<2 years: Do not use
2-5 years: 1 pediatric enema (2.25 fl.oz) PR once or twice daily prn
>5 years: 1 adult enema (4.5 fl. oz) PR once or twice daily prn

Interactions

Do not administer aluminum, magnesium antacids, or sucralfate

Contraindications

Documented hypersensitivity; hypernatremia, hyperphosphatemia, renal failure, hypocalcemia, and fecal impaction

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, and cirrhosis; electrolyte disturbances (eg, hypernatremia, hypokalemia, hyperphosphatemia, hypocalcemia) dehydration, metabolic acidosis, renal failure, tetany, and death have been attributed to prescribing >45 mL as bowel preparation for colonoscopy, surgery, or barium enema and/or prescribing it for people at medical risk

Follow-up

Further Outpatient Care

• Assessment of constipation after disimpaction assures that the prescribed therapy was effective. At that time, maintenance laxative therapy can be prescribed.
• When the patient has bowel movements regularly for weeks or months without apparent pain, fear, or excessive straining, attempting to discontinue laxative therapy is reasonable.

Patient Education

• Educating the family that using laxatives continuously for months may be necessary is important. This is particularly true among toddlers, because many months may pass before the association between fear and defecation is extinguished. Reassuring caregivers as to the safety of long-term laxative use and reinforcing the need for persistence is very important. Repeatedly address specific concerns regarding laxative dependency and the risk of colon cancer.
• Inform the family that relapses are common and are associated with changes in the child's daily routine (eg, vacations) and may occur during times of stress. Also, inform the family that the requirement of intermittent therapy with laxatives into adulthood is not unusual.
• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article, Constipation in Children.

Miscellaneous

Medicolegal Pitfalls

• Perform a digital rectal examination on every young child with chronic constipation to exclude underlying anatomic abnormalities that might account for the constipation, such as an imperforate anus with perineal fistula, intestinal obstruction (mass effect), or Hirschsprung disease.

Multimedia

Media file 1: Differentiating functional constipation and Hirschsprung disease.

Media file 2: Unprepared single contrast barium enema demonstrating a transition zone consistent with Hirschsprung disease.

Media file 3: Plain abdominal radiograph that demonstrates stool throughout the colon.

Media file 4: Normal anorectal manometry that demonstrates relaxation of the internal anal sphincter in response to rectal distension.

Media file 5: Common withholding behaviors in young children.

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Keywords

constipation, acquired megacolon, functional constipation, functional megacolon, megacolon, stool hoarding, stool retention, stool withholding, Hirschsprung disease, defecation, fecal incontinence, abdominal mass, rectal fecal mass, treatment, diagnosis

Contributor Information and Disclosures

Author

Stephen Borowitz, MD, Professor of Pediatrics and Public Health Sciences, Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Virginia
Stephen Borowitz, MD is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, American Pediatric Society, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Chris A Liacouras, MD, Director of Pediatric Endoscopy, Department of Pediatrics, Division of Gastroenterology and Nutrition, Associate Professor, Children's Hospital of Philadelphia and University of Pennsylvania
Chris A Liacouras, MD is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

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