child with constipation-define,evaluation,manage

1. CHILD WITH
CONSTIPATION

2. PRESENTER
Dr.Md.Shakhawat Islam
Resident
Phase-A,year-1
Paediatric Surgery
BSMMU
SUPERVISOR
Dr.Md.Rezaul karimMojumder
Resident
Phase-B,year-1
Paediatric Surgery
BSMMU

3. CONTENTS
 Introduction
 Physiology of defecation
 Normal bowel habit
 Definition and causes of constipation
 Diagnosis
 Red flags
 Management
 Take home messages

4. INTRODUCTION
Very common problem in children
Affects up to 5-30% of children
Only one third will develop chronic symptoms requiring referral
Parent/guardian’s anxiety often outweighs the symptoms.
Male predominance

5. PHYSIOLOGY OF DEFECATION:

6. NORMAL FREQUENCY OF BOWEL
MOVEMENT
Age Bowel
movements per
week
Bowel
movements per
day
0-3 months
Breast feed
Formula feed
5-40
5-28
2.9
2.0
6-12 months 5-28 1.8
1-3year 4-21 1.4
>3 year 3-14 1.0

7. CONSTIPATION
Definition of constipation is relative & depends on:
Stool consistency
Stool frequency
Difficulty in passing the stool

8. Constipation is considered in children when hard stool is
passed with difficulty every three days that persist for two
weeks.
Soiling is a intermittent passage of small amount of faeces
which stain the undergarments of the child.
Encopresis is a soiling due to psychological factor and not
because of any organic lesion.
CONSTIPATION…cont

9. NEWBORN
First meconium passes usually within the first 36 hours of
birth- 90% pass stool within 24hours.
This may happen later in preterm infants without underlying
structural defects.
First week of life normal newborns has 4 stools per day, with
some variability:
Breastfed infants can pass stool with each feeding.
Formula fed infants tends to pass stool less regularly.
Soya formulas cause harder stool.

10. CONSTIPATION IN INFANTS &
TODDLERS
At least two of the following present for at least one month:
Less than two defecations per week.
At least one episodes of incontinence after the acquisition of
toileting skills.
History of painful or hard bowel movements.
Presence of large fecal mass in rectum.

11. CONSTIPATION IN CHILDREN (4-18
YEARS)
If two of the following present for at least two months:
Less than two defecations per week.
At least one episode of fecal incontinence per week.
History of painful or hard bowel movements.
Presence of large fecal mass in rectum.
History of retentive posturing.

12. TYPES OF CONSTIPATION
Primary or functional
Secondary or organic

13. CAUSES OF CONSTIPATION
Functional-
Low fiber diet
Lack of physical activity
Inadequate fluid intake
Failure to develop regular bowel habits
(neglect, stubborn child)
Emotional issue
Change in environment or routine
(Holidays… school entry)
Busy child

14. ORGANIC CAUSES
1.Disorders of intestinal motility:
A .Neural:
-Spina bifida
-Spinal cord injury
-Hirschsprung’s disease
-Neuronal intestinal dysplasia
B. Endocrine and Metabolic:
-Hypothyroidism
-Hypervitaminosis D
-Cystic fibrosis

15. ORGANIC CAUSES…cont
C.Drugs:
-Supplemental iron
-Anticonvulsant
-Calcium
II . ANATOMIC OBSTRUCTIONS:
-Anal stenosis
-Anterior ectopic anus
-Anorectal achalasia

16. ORGANIC CAUSES…cont
III . DISORDER OF DEFICATION MECHANISM
A.Suppression of defecation urge:
I.Pain:e.g.anal fissure leading to proctoanal pain.
II.Psychogenic:
-Forceful toiloting
-Anxity due to school or mother going to work
-Excessive parental concern
B.Inadequate defecation urge:
-Mentally challenged
-Cerebral palsy

17. EVALUATION
1.History:
Timing of first meconium stool.
Family’s definition of constipation .
Duration of condition and age of onset.
Toilet training experience.
Frequency/consistency/size of stools.
Pain or bleeding with defecation.

18. EVALUATION (cont…)
History….
Presence of abdominal pain
Stool withholding behavior
Change in appetite
Abdominal distension
Anorexia, nausea, vomiting, weight loss or poor weight gain
Allergies , dietary history, medications

19. EVALUATION (cont.)
History….
Developmental history
Psychosocial
Peer interactions , possibility of abuse,
Toilet habits at school
Family history (constipation, thyroid disorders,cystic fibrosis)

20. EVALUATION(CONT.)
2.Physical examination:
Height and weight – Failure to thrive
Abdomen – Abdominal distention,visible peristalsis, palpable
faecoloma ,Anal opening
Spine – Deep sacral cleft or tuft of hair
Neurology - Assessment of mental status,lower limbs
Anal area – Visually examine for fissures

21. EVALUATION(CONT.)
Digital rectal examination:
 Perianal sensation
 Anal tone
 Anal grip
 Presence of anal wink
 Rectum is loaded with faecal matter or empty
 Gush of stool after rectal examination

22. ORGANIC VS FUNCTIONAL
Organic Functional
Age Starts early either
since birth or later
Starts after one year
of age
Soiling Unusual Common
Straining at
defecation
No straining Present
Ability to pass large
bulky stool
Unusual Common
Pain and bleeding
on defecation
Unusual Present
Rectal exam Rectum empty Rectum full of hard
stool

23. A SUMMARY OF NICE GUIDANCE
ON CONSTIPATION
Red Flags:
Present at birth /first few weeks of life
Failure to pass meconium with 48hrs of birth
Ribbon stools
Previously unknown/undiagnosed leg weakness or motor
delay
Abdominal distension and vomiting
Amber Flags:
Faltering growth
Disclosure /evidence raising concerns over maltreatment.

24. INVESTIGATION
Red flags : Refer urgently – do not treat.
Faltering growth: Treat and test
Treat constipation
Test for coeliac disease and hypothyrodism.
Possible maltreatment: risk assess and child protection
Consider referral if inadequate response to optimum treatment
with 4 week.

25. INVESTIGATION
Plain x-ray abdomen
Barium emema
Ultrasonography of abdomen
MRI
Thyroid function test:FT3,FT4,TSH
Serum Ca++,Vit-D
Full thickness Rectal biopsy
Anorectal manometry

26. BARIUM ENEMA
Shows dilatation of the
rectosigmoid that
extends to the
anal canal.
(This rules out classic
Hirschsprung disease)

27. .
Plain abdominal x-ray:
May reveal spinal vertebral
anomalies in patients with
neurologic disorder.
MRI-study:
Rule out intraspinal pathology such
as tethering & intraspinal lipomas

28. RECTAL BIOPSY
Rectal Biopsy:
Gold standard technique
Usually taken 2-3 cm above
the dentate line in posterior wall
Techniques( full thickness and suction)
Anorectal manometry:
to rule out Hirschsprung disease also.

30. TREATMENT OF CONSTIPATION
Aim of treatment-
Child should have no pain during defecation.
Stool should be soft.
Bowel & sphincter should recover motor & sensory function.

31. TREATMENT OF CONSTIPATION
General approach-
Provide parental counseling & education.
Determine whether a fecal impaction is present.
Disimpact the fecaloma if present.
Initial oral medication.

32. COUNSELING & EDUCATION
First step of management.
Pathogenesis of constipation to be clearly defined.
Encourage the parents to maintain constant support.
Educate the child & parents.
Emotional support.
Commitment to continue to see the family.

33. DISIMPACTION
Fecal mass identified by physical examination, rectal
examination or radiographic methods.
Typical symptom is overflow incontinence.
Disimpaction traditionally by bowel washout.(1to 3 times).
In recalcitrant cases manual evacuation under G/A.

34. DISIMPACTION CONTINUE-
Oral disimpaction by :
Osmotic laxatives: Lactulose
Stimulant laxative: Sodium picosulfate, Bisacodyl, Senna,
Docusate sodium.
Macrogol 3350 (polyethylene glycol 3350)a 6.563 g; sodium
bicarbonate 89.3 mg; sodium chloride 175.4 mg; potassium
chloride 25.1 mg/sache

35. MAINTENANCE THERAPY
Goal- one to two soft stools per day.
Dietary intervention-
increase intake of fluid & fibres.
discourage intake of too much cow milk.
Laxatives –
For short period: Na picosulfate.
For long period: lactulose, PEG.
Dose of medication tapered gradually.

36. BEHAVIORAL THERAPY
Schedule toileting, such as after meal or before bed.
Use of bowel diary to track frequency and consistency of stool.
Use of encouragement and reward system.
In infant & toddlers – has no role.
Too early & aggressive toilet training is discouraged.

37. SURGICAL OPTION
This will be determined according to cause…

38. TAKE HOME MESSAGES
 It is common
 Recognise and treat early
 Diarrhoea may be overflow due to severe constipation
 Always remember the red flags and manage accordingly
 Optimise treatment
 Need to work and engage parent and child
 Reassure and keep consistent message

39. THANK YOU