This document discusses constipation in children. It defines constipation and provides Rome criteria for diagnosing it in infants/toddlers and older children. Constipation is common and usually functional without an organic cause. Treatment involves education, disimpaction with laxatives, prevention through diet/behavior changes and sometimes medications, and follow up. Functional non-retentive fecal incontinence is also discussed.

1. CONSTIPATION
DR ARAVIND A
DNB POSTGRADUATE

2. OVERVIEW
• DEFINITION
• PATHOGENESIS
• CAUSES AND RISK FACTORS
• CLINICAL EVALUATION AND DIAGNOSIS
• LABORATORY AND RADIOLOGIC
INVESTIGATIONS
• TREATMENT
• FOLLOW UP AND PROGNOSIS

3. Introduction
• Constipation and fecal incontinence represent
common problems in children.
• The stool frequency gradually declines from
more than 4/day during the 1st week of life to
one or two per day by the age of 4 years.
• From 5 yrs of age, majority of children pass
stools daily or every other day without
straining or withholding

4. Definition
• Constipation is defined by ROME criteria.
• Different diagnostic criteria for constipation in
infants and toddlers upto 4 years and for
childhood constipation in older children and
adolescents.
• FECAL INCONTINENCE: involuntary loss of
stool into the underwear in a child older than
age of 4 years.

5. Fecal incontinence
• Can be classified as constipation associated
fecal incontinece –overflow incontience and
functional nonretentive fecal
incontinence(FNRFI).
• Constipation related is more common.
• Can also be classified as primary or secondary
• FRFI and FNRFI both differ in etiology and
management.

6. Rome criteria for Pediatric Functional
Constipation
 Two or more criteria for at least 1 month in infants upto 4
years.
 Two or more symptoms for atleast once per week for
atleast 2 months in children >4 years
• Two or more defecations per week
• Atleast one episode of fecal incontinence per week
• History of retentive posturing or excessive stool retention
• History of painful or hard bowel movements
• Presence of large fecal mass in the rectum
• History of large diameter stool that may obstruct the toilet
• Additional criteria: without fulfilling irritable bowel
syndrome criteria.

7. Rome criteria for pediatric FNRFI
Diagnostic criteria must include all of the
following in children at least 4 years of age for
atleast 2 months prior to diagnosis
• Defecation into places inappropriate to the
social context at least once per month.
• No evidence of an inflammatory, anatomic,
metabolic or neoplastic process that explains
the symptoms
• No evidence of fetal retention

8. EPIDEMIOLOGY
• 3% of visits to pediatricians
• 25% of visits to pediatric gastroenterologist
• Functional/non organic is the most common
• Organic is rare(except in infancy)
• Worldwide prevalence of fecal incontinence
varies from 0.8% to 7.8%

9. Pathogenesis
• Multifactorial
• More than 90% of children – no obvious
organic cause is found – functional
• Can occur at any age , but children vulnerable
are infancy(during the introduction of cereals
and other solids), toddlers(during toilet
training), older children.
• Constipation in newborn and early infancy –
organic cause or congenital disorder.

10. Organic causes of constipation
• Intestinal causes – hirschsprung disease, anorectal
malformation, neuronal intestinal dysplasia
• Neuropathic conditions – spinal cord
abnormalities, spinal cord trauma,
neurofibromatosis, tethered cord syndrome
• Metabolic, endocrine causes – hypothyroidism,
DM,hypercalcemia, hypokalemia, vitamin D
intoxication
• Drug induced – opioids, anticholinergics,
antidepressants
• Other causes – anorexia nervosa, sexual abuse,
cystic fibrosis, dietary protein allergy, scleroderma

11. Passage of hard, painful or frightening bowel movement
Purposeful subconscious stool withholding – fear of defecation (retentive posturing)
Rectal mucosa absorbs the water from the fecal mass
Retained stools become progressively more difficult to evacuate
Vicious cycle of stool retention for a long period
Untreated for a long period, rectal wall becomes stretched
Development of megarectum
Overflow incontinence, loss of rectal sensation and loss of normal urge to
defecate

12. Fecal incontinence - pathogenesis
Stool withholding - constipation
Progressive accumulation of feces
Hardening of fecal mass
Feces seep between the fecal mass and rectal wall and escape thro the anal
canal when sphincters are relaxed
Stains the underwear – fecal incontinence
Nocturnal incontinence – indicator of severe accumulation of feces in the
rectum

13. FNRFI
• Pass stools in inappropriate places.
• Majority have complete evacuation of bowel,
not just staining of underwear.
• Colonic transit time studies, rectal compliance
and sensitivity thresholds are normal.

14. Organic causes of FI
• Repaired anorectal malformation
• Post surgical HD
• Spinal dysraphism
• Spinal cord trauma
• Spinal cord tumor
• Cerebral palsy
• Myopathies of pelvic floor and external anal
sphincter

15. AMSTERDAM STOOL SCALE

17. Clinical Evaluation
• History
Time of meconium passage after birth(within 48
hours) – delayed in preterm.
Age of onset of constipation
Stool frequency and consistency
Size of the stools
Pain during defecation or retentive posturing.
Blood in stools or toilet paper.
Presence of abdominal pain or distension

18. Loss of appetite
Fever
Nausea
Vomiting
Weight loss or weight gain
Problems with neuromuscular development
Behavioural or psychological problems
Presence of urinary incontinence or urinary tract
infections
Dietary history
Previous treatment history
School problems or sexual abuse

19. • Examination
Measurement of weight and height – obesity –
predisposting factor for constipation
Short stature – metabolic disorders
Abdominal examination – accumulation of gas or
feces, left iliac fossa tenderness
Perianal region – position of anus, fecal
incontinence, anal fissures, hemorrhoids, eczema,
signs of sexual abuse
Anorectal digital examination – sphincter tone,
perianal sensation, palpable fecal mass, size of
rectum
Lumbosacral area inspection – spina bifida

20. Laboratory investigations
• ESPGHAN and NASPGHAN recommended that
routine laboratory tests to screen for organic
cause in constipation is not required in the
absence of alarm symptoms.
• Because of the fact that only minority of
children with constipation are diagnosed with
a new organic disease in routine
investigations.

21. Radiologic investigations
• Abdominal radiography
• Colonic transit time studies
• Abdominal USG
• Contrast enema
• Anorectal manometry
• Colonic manometry
• MRI of spine

22. Treatment
ESPGHAN/NASPGHAN guidelines includes four
phases in treatment
1. Education
2. Disimpaction
3. Prevention of reaccumulation of feces
4. Follow-up.

23. Education
• Explanation to parents and children.
• Explanation about the vicious circle of
constipation – fecal retention – fecal
incontinence
• Clarification regarding fecal incontinence.
• No quick solution
• Recovery is slow but possible
• Can relapse in future

24. Disimpaction
• Disimpaction or removal of fecal impaction is
recommened prior to maintenance therapy
• Oral laxatives – less invasive & cost effective
• PEG most commonly used – dose is 1.0-1.5
gm/kg/day
• Fecal incontinece episodes increase initially after
treatment, decreased significantly later after
succesful disimpaction.
• Rectal enemas – used for many years in past for
fecal impaction – fast onset of action, more
invasive
• Manual disimpaction – rarely done – only under
anaesthesia

25. Prevention
• Can be achieved through combination of
dietary changes, behavioural interventions
and medications

26. • Dietary changes – common recommendation
is to increase the amount of their child’s daily
fluid intake. Limited evidence that additional
fiber intake improves constipation. Well
balanced diet is the most reasonable
suggestion to parents and children.
• Probiotics supplementation has not shown to
improve constipation symptoms.

27. • Behavioural interventions – toilet training (sit
on the toilet for upto 5 mins, three times a
day, following meals to take advantage of
gastrocolic reflex)
• Daily diary to record bowel movements helps
in monitoring progress and compliance.
• Coexistence behavioural problems often is
associated with poor treatment outcome

28. Maintainence- Medication
• Oral daily laxative therapy should be started
immediately after disimpaction.
• Osmotic laxatives – soften the stools by retaining water
within colon through osmosis.PEG based laxatives
commonly used worldwide.
• Serotonin agonists – cisapride, tegaserod – withdrawn.
Prucalopride (selective, high affinity 5HT4 receptor
agonist) has shown to improve the symptoms in
children in one study.
• Lubiprostone – chloride channel activator, improves
bowel habits in adults. No studies in children.

30. • Enemas – retrograde/antegrade
• Surgery – before surgery, organic cause must be ruled
out.
• Rectosigmoid resection – severe constipation –
development of megarectum, megasigmoid or both –
resection improves stool pattern and quality of life.
• Anal dilation – no benefit in children in long term follow
up studies.
• Intrasphincteric injection of botulinum toxin –
diagnostic and treatment.
• Sacral nerve modulation – new treatment for patients
with intractable functional constipation. Clinical studies
limited to adults. Lack of evidence in pediatric group.

32. Treatment of FI
• Responds poorly to laxatives.
• Behavioural therapy of toilet training + reward
system is the most important step in the
management of FNRFI.
• Surgical intervention has no use in
management.

34. QUESTIONS
• The diagnosis of constipation is based on
a) Thorough medical history taking and physical
examination
b) A+abdominal Xray
c) A+ laboratory testing
d) A+B+ laboratory testing

35. • Treatment of constipation consists of
a) Education
b) Disimpaction
c) Maintenance therapy
d) Follow up
e) All of the above