Approach Considerations
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 regimen is likely to be effective as long as it is sufficiently aggressive and persistent. [17] 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. [18]
A group of patients with severe constipation that does not respond to conservative medical therapy may require more aggressive treatments, including surgery. A discussion of these interventions is beyond the scope of this article. See Surgery for Pediatric Constipation and Bowel Management.
Also see Constipation.
Colon Evacuation
When there is evidence of a fecal impaction, initial therapy should be directed at evacuating the colon. A fecal impaction can be identified by palpating a hard mass of stool on physical examination, finding a large amount of stool in a dilated rectum during rectal examination, or finding excessive stool in the colon on an abdominal radiograph.
Aggressive use of oral cathartics such as polyethylene glycol, sodium phosphate, magnesium citrate, or a balanced electrolyte solution with polyethylene glycol or a series of enemas can accomplish disimpaction. [19] In trials, disimpaction by the oral route or the rectal route were reported to be equally effective. [20, 21]
Convincing a young child to ingest sufficient amounts of oral cathartics to evacuate their colon may be difficult; therefore, enemas or suppositories may be necessary. See the images below.
Incorrect enema administration. The enema is administered against stool impaction and cannot be successful.
Removal of Pain-Associated Defecation
Once the colon has been evacuated, chronic laxative therapy is generally required. [22] 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, it is very important to reassure caregivers that long-term laxative usage is safe. Address the common misconceptions regarding laxative dependency, laxative abuse, and the risk of colon cancer due to long-term laxative usage.
If the child has anal fissures, using Xylocaine ointment or hydrocortisone suppositories for a short time period to provide symptomatic relief may be helpful.
Establishing Regular Bowel Habits
In many cases, long-term success in the management of constipation depends on the child establishing regular and routine toilet times. It is generally recommended that the child be encouraged to attend the toilet twice daily for 5-10 minutes, preferably after breakfast and after supper to take advantage of the gastrocolic reflex. For school age children, it is preferable not to expect the child to attend the toilet while at school.
When the affected child has passed bowel movements regularly for weeks or months without apparent pain, fear, or excessive straining, it is reasonable to attempt to discontinue laxative therapy. 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.
Dietary Modification
Dietary changes, such as increasing the child's intake of fluids and carbohydrates, are commonly recommended as part of the treatment of constipation. [23]
Balanced diet
Complex carbohydrates and unabsorbable sugars (eg, sorbitol) are found in many fruit juices (eg, prune, pear, apple). These carbohydrates increase stool frequency by increasing fecal water content. Although randomized controlled trials have not been conducted to examine the effects of increasing the intake of fluids, nonabsorbable carbohydrates, or fiber on childhood constipation, recommending a balanced diet that includes whole grains, fruits, vegetables, and an abundance of fluids seems appropriate. Because data are limited, forceful implementation of a particular diet does not seem warranted.
Cow milk avoidance
In infants and young children, it is appropriate to consider removing cow-milk protein from the diet for a period is appropriate, because chronic constipation may be precipitated by ingestion of cow-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 milk; in most cases, the constipation recurred when cow milk was reintroduced. [24]
Unnecessary or ineffective dietary changes
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. [25]
Although some evidence suggests that gastrointestinal flora is important in gut motility, no evidence suggests that gut florae are different in children with constipation than gut florae in healthy controls. While both Lactobacillus and Bifidobacterium have been shown to increase stool frequency and decrease stool consistency in healthy adults, there is little evidence that probiotics are effective in treating constipation in either adults or children. [26, 27] However, a study that investigated whether oral supplementation with Lactobacillus reuteri DSM 17938 during the first 3 months of life can reduce the onset of colic, gastroesophageal reflux, and constipation in term newborns reported that prophylactic use of L reuteri DSM 17938 during the first 3 months of life reduced the onset of functional gastrointestinal disorders and reduced private and public costs for the management of this condition. [28]
A meta-analysis by Wegh et al that included 52 randomized controlled trials evaluating nonpharmacologic treatments for constipation showed no benefit for the use of probiotics or synbiotics. [29] Similarly, a Cochrane review found insufficient evidence to determine whether probiotics are effective in treating chronic functional constipation in children. [30]
Consultations
Consultation with a pediatric gastroenterologist or pediatric surgeon is appropriate if the child's history or examination findings suggest an underlying organic cause (eg, Hirschsprung disease). Also seek consultation when the child fails routine therapy or when management is otherwise complex.
See Surgery for Pediatric Constipation and Bowel Management.
Long-Term Monitoring
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.
Other Treatment
A study by Sharifi-Rad et al that included 90 children reported treatment success with interferential electrical stimulation as an adjuvant therapy for functional constipation. [31]
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Plain abdominal radiograph that demonstrates stool throughout the colon.
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This table differentiates functional constipation from Hirschsprung disease.
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This unprepared single-contrast barium enema demonstrates a transition zone consistent with Hirschsprung disease.
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The images illustrate normal anorectal manometry with relaxation of the internal anal sphincter in response to rectal distention.
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This image delineates common withholding behaviors in young children.
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Contrast enema of a patient with megasigmoid and impacted stool.
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Contrast enema in a patient in whom the rectosigmoid was resected.
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Position for enema administration in an infant.
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Another position for enema administration.
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Administration of an enema.
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Incorrect enema administration. The enema is administered against stool impaction and cannot be successful.
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Enema administration with a tube.
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Enema with inflated Foley balloon catheter.
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Administration of an enema against impacted stool.
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Administration of an enema against fecal impaction.
