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SYMPOSIUM: GASTROENTEROLOGY

Management of chronic
constipation in children

Diagnosis of functional constipation is as per the ROME


III criteria
Infants up to 4 years should have at least two symptoms for 1
month prior to diagnosis and those over 4 years at least two of the
following symptoms present for the previous 2 monthsa,b:
C
Two or fewer defaecations per week
C
At least 1 episode of faecal incontinence per week
C
Retentive posturing or stool retention.
C
Painful or hard bowel movements
C
Presence of a large faecal mass in the rectum
C
Large diameter stools that may obstruct the toilet

Lucy J Howarth
Peter B Sullivan

Abstract
Children are commonly affected by constipation. Management of chronic
constipation requires a good understanding of the underlying pathophysiology. The presentation and management of constipation varies by age.
This review aims to give the reader a clear guide to diagnosis, investigation, pharmacological and non-pharmacological management of chronic
constipation in children. The way in which pathology can interrupt normal
physiology and features of the clinical history are described. It will outline
the age dependent presentation and management of chronic, functional
constipation based on the best available evidence and examine the
NICE guideline for laxative use in children.

a
b

Table 1

also low maternal education level or social circumstance play


a part. The association with behaviours is complex because
constipation can be both caused by and cause changes in
behaviour. Significantly higher rates of constipation have been
reported amongst mothers of constipated children as opposed to
fathers or siblings of a constipated child. A genetic component is
likely to be part of the pathogenesis of functional constipation
but no mutations in specific genes have been linked.
Like many other functional gastrointestinal disorders the
pathophysiology and prognosis are variably understood by
medical practitioners. This results in a large variety of strongly
held beliefs and management strategies. To understand constipation in childhood it is necessary to have a good knowledge
of normal physiology, the wide range of normality and the role of
diet and behaviour.

Keywords chronic constipation; clinical diagnosis; age dependent


presentation; red flag symptoms and signs; investigations; laxative
treatment; non-pharmacological treatment

Introduction
Constipation, derived from the Latin constipare, meaning to
cram together, is the commonest gastrointestinal disorder
comprising up to 25% of referrals to tertiary paediatric gastroenterology clinics. In primary, secondary and tertiary care, there
are more consultations for constipation management than for
other periodic, chronic conditions such as asthma or migraine.
Chronic constipation is a heterogeneous group of disorders, and
is often late-presenting. It is defined by infrequent and or difficult
passage of stools, and is a clinical diagnosis that should be based
on symptoms that fulfil the ROME III criteria (Table 1).

Physiology of defaecation
Enteric content enters the colon via the ileocaecal valve. Stools
are formed by the progressive absorption of water, and are
propelled along the colon to the rectum. Stool is stored until
a socially acceptable time to defecate. The rectum stores and
eliminates stool through a complex mechanism involving pelvic
floor muscles, the autonomic and somatic nervous systems. The
anorectal angle, formed by the anal sphincter complex and
puborectalis muscle is crucial to successful storage and defaecation. This angle is 85e105 at rest. The rectum is usually
empty but distension of the rectal wall with stool descending
from the sigmoid colon causes a temporary reflex relaxation of
the internal anal sphincter allowing stool to come into contact
with sensitive receptors in the anal canal. The rectoanal inhibitory reflex results in a contraction of the internal sphincter,
inhibiting defecation. The process, however, alerts the individual to the presence of stool, liquid or flatus in the rectum. An
indication of the exquisite sensory innervation of the anorectum
is the ability to distinguish between distension caused by solid,
liquid or gas. An inability to do this would have disastrous
social consequences.
Once a child has an opinion about the appropriate time to
respond to this signal, a voluntary process of defaecation is either
begun or overruled. If the sensation on passing stool is pain (for

Definitions
The prevalence of constipation varies from 0.8 to 28% and the
condition has a wide geographic variability, with the highest
reported prevalence in the USA and the lowest in Finland.
Pathogenesis is multifactorial with research focussing on environmental factors, behavioural problems and genetic predisposition. Environmental factors such as activity level and diet but

Lucy J Howarth BM MRCPCH is a Specialist Registrar in Paediatric


Gastroenterology in the University Department of Paediatrics,
Childrens Hospital, John Radcliffe Hospital, Headington, Oxford, UK.
Conflict of interest: none.
Peter B Sullivan MA MD FRCP FRCPCH is Reader in Paediatric Gastroenterology, Honorary Consultant Paediatrician, University Department of
Paediatrics, Childrens Hospital, John Radcliffe Hospital, Headington,
Oxford, UK. Conflict of interest: none.

PAEDIATRICS AND CHILD HEALTH 22:10

Without objective evidence of a pathological condition.


Without fulfilling irritable bowel syndrome criteria.

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SYMPOSIUM: GASTROENTEROLOGY

example when the stool is both large and hard) then even very
young children can resist the urge to push. Such stool withholding e often misinterpreted as straining to evacuate stool e is
frequent in toddlers. If the individual decides the time is right
then increased intrarectal pressure comes from straining of intraabdominal muscles and pelvic floor muscles to push faeces
towards the anal canal. The puborectalis muscle relaxes to allow
the descent of the pelvic floor, straightening the anorectal angle
and inhibiting the internal and external anal sphincters, allowing
faeces to be expelled. In newborn babies and very young infants
the voluntary element of control is not yet developed so defaecation occurs following initial distension of the rectal wall
(Table 1).

parents or other carers, and may be subject to over- or underreporting bias.


Functional constipation may often present late, or with
abdominal pain or spurious diarrhoea. A large faecal mass in the
rectum gives the sensation of incomplete evacuation and children may try to open their bowels several times a day. If only
small amounts of soft/liquid stools are passed around the sides of
the obstructive faecal mass, this is termed overflow, or overflow
diarrhoea. Anal canal trauma from passage of hard or large stool
can present with bright red rectal bleeding or severe anal pain.
Pain may exacerbate the problem, as it will inhibit defecation.
Key features in history taking
 Delay in passage of meconium
 Age at onset
 Relation to toilet training
 Toileting history-stool frequency, consistency, pain, soiling, presence of blood
 Stool withholding behaviour
 Urinary symptoms (13% of those with constipation have
urinary symptoms)
 Abdominal pain
 Diet-history of exacerbation with particular foods such as
cows milk or evidence of a poor diet low in fruit and fibre.
 General health and developmental milestones
 Family history
 Social history

Pathophysiology of constipation
Whilst the majority of children with chronic constipation will be
considered to have functional, idiopathic constipation, exclusion
of organic causes is important (Figure 2).
Coeliac disease is commonly thought of as causing diarrhoea,
but constipation is seen, possibly due to anorexia or changes in
ileal function or gut motility. Constipation is prevalent in Cystic
Fibrosis, and is under-reported. There is an association with low
total fat absorption and a history of meconium ileus.
Neuromuscular conditions can affect the gut. Smooth
muscle cells and intestinal cells of Cajal play a major role in
normal gut motility. These cells ensure regular contractions of
the colonic wall and propulsion of content. Constipation is
often seen in patients with Cerebral Palsy and Duchenne
Muscular Dystrophy. In patients with spinal muscular atrophy
(SMA) proximal muscle weakness is a cardinal feature. In most
of these patients constipation is a problem because of reduced
abdominal muscle tone as well as disturbed innovation of the
myenteric plexus.
Children with significant developmental delay are more prone
to constipation for a wide variety of reasons depending on their
underlying disorder. For example, children with cerebral palsy
often have dysmotility problems. Disorders that affect the enteric
nervous system such as hereditary sensory and autonomic
neuropathy (previously known as Riley-Day syndrome) are
associated with constipation. Normal gastrointestinal motility is
disturbed by abnormal autonomic function.
Constipation can be a feature of disorders that affect water/
electrolyte balance such as diabetes insipidus. This can lead to
reduced water content i.e. harder stools or as a result of muscle
weakness caused by electrolyte imbalance. Other endocrine diseases
such as MEN3 and hypothyroidism can present with constipation.
It is important that there is a general awareness of the wide
range of rare pathologies that may present with constipation as
effective management depends on an understanding of the
underlying pathophysiology. Constipation should be regarded as
a symptom and not a disease. Anorectal malformations and
Hirschsprungs disease are amongst the commoner pathologies
underlying very early onset childhood constipation.

Age dependent presentation


Newborn e 4 months: ninety nine percent of term infants pass
meconium within the first 24 h following delivery. Very low birth
weight or premature infants can have non-pathological delay in
opening their bowels. 94% of children with Hirschsprungs
Disease and 25% of those with Cystic Fibrosis have initial delay
in the passage of meconium. Newborn babies generally have
a higher stool frequency of around 4/day but there is particularly
high variability amongst breast-fed babies who can sometimes
not open their bowels for days without being constipated. It is
unusual for babies to become constipated in the first 4 months
unless they have a congenital/anatomical abnormality, systemic
upset or possibly cows milk protein allergy. A change from
breast to formula feeding can result in constipation or the use of
hungrier baby milk with higher sodium content.
 It is unusual for young babies to develop chronic
constipation.
 Beware of red flags in the history and examination
 Late passage of meconium
 Systemically unwell
 Anatomical anomalies
 Developmental delay
5 months to potty training: during this period infants start to
wean from milk onto a variety of foods. The commonest cause of
constipation in this age group is change in diet and consistency
of stools. As baby rice and high fibre foods are added to an
infants diet, stools become more bulky. It is common for
parents to describe long periods of straining and sometimes pain
associated with large diameter stools. Often early constipation

History
Pitfalls
Although the ROME III criteria (Table 1) appear self-explanatory,
history-taking can be difficult. Often it depends upon reports by

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can be treated effectively with change in weaning foods, such as


an increase in fruits such as pear and less baby rice until the
infants digestive system has adapted. In babies with reflux, no
response to laxatives or a family history of atopy, a trial of
a dairy-free diet (cows milk and soya) may be helpful. A clear
association with cows milk protein allergy and constipation has
been demonstrated.1 Many children start to take gluten in their
diet at 9e12 months and if gastrointestinal symptoms including
constipation start at this time then coeliac disease should be
considered.
Toddlers who have had the sensation of pain following the
passage of a hard stool are at high risk of stool withholding and
rapidly worsening constipation. It is important to ask questions
about posturing during a bowel movement as withholding
behaviours can easily be misinterpreted as straining. In toddlers
nearing 3 or at the time of potty training it is very important that
a period of time has passed with soft stools to allow them to gain
confidence and lose their fear of opening their bowels prior to
any attempts to encourage them to use a potty or toilet. Often
subtle manipulations in diet and fluid intake can be helpful.
Some children are prone to constipation and some may drink
insufficient fluid particularly in hot weather. A consultation
with a paediatric dietician is invaluable, but may not be readily
available.
 Constipation is often related to dietary changes
 Do not forget the association with cows milk protein
allergy and coeliac disease
 Stool withholding may result from painful defaecation and
can be easily mistaken for straining

constipation is common. One approach that can be helpful is to


try and emphasise the importance of adequate time before school
for breakfast and going to the toilet. Sometimes there are
improvements that can be made to privacy at school or the
decorative state of the toilets to make them more appealing.
There are often significant changes in diet at this time with
children eating school dinners and having to make independent
choices about what they do and dont eat. Dietetic assessment at
this age is very helpful and it is important to involve the child in
education about healthy eating and a diet that has adequate fruit,
fibre and fluid. Children are usually only allowed to drink water
at school and many prefer juice prior to this and so drink much
less than usual while running around more. This dehydration can
exacerbate constipation.
 Practical tips to improve toileting behaviour such as
ensuring enough time for breakfast can be helpful
 Involve children in advice about lifestyle changes
Older children and early teens: children can become acutely
constipated at any stage following an infection, change in diet,
routine (e.g. moving house or school) or emotional upset. When
reviewing older children early history remains important as
symptoms are often long standing. Eating disorders need to be
considered. Constipation can present with abdominal pain,
nausea, anorexia or soiling. Rarely soiling may occur because of
an involuntary leakage of soft stool around faeces impacted in
the rectum. This will cause significant psychological morbidity.
Older children who have been constipated for some time and
who are soiling regularly are often bullied and become withdrawn and disengaged with education. Families find the
symptom of soiling understandably difficult to manage and often
feel anger and resentment towards the child who they often
blame for the problem. Treatment must address underlying
issues and offer support to the child and the family.
 Constipation can present with a variety of symptoms and
often families need a lot of reassurance that there is no
serious underlying pathology
 Symptoms have often been longstanding

Age of toilet training: this is a common time for children to


become constipated. The age at which children start toilet
training varies between and within families. There is evidence
that early toilet training is associated with a higher incidence of
constipation. The optimum time is when a child is able to
communicate their desire to do a poo, has enough motor
control to be able to overrule an urge if no toilet is available and
can sit and actively strain on a toilet when the time is right. Many
children and families find this stage of development a stressful,
frustrating and unpleasant time. The transition can be very
frightening to young children. The inconvenience of cleaning up
accidents and the patience necessary to encourage young children to successfully toilet train should not be underestimated.
Many families need help with this stage of normal development
and may benefit from support groups or parenting classes. Long
standing constipation often starts with difficulties with early
toilet training and adverse toileting behaviour.
 It is always important to ask about the ease of potty
training as this is a common time for constipation to begin

Key features in examination


 General health, plot on growth chart
 Look for evidence of systemic illness, faltering growth,
anaemia
 Abdominal palpation
 Evidence of faecal loading/ a faecal mass-can be
difficult in the child is obese
 Perianal region and digital rectal examination
 It is important that the perianal region is examined for
signs of fissures, soiling, infection (such as group A
streptococcus) or anatomical anomalies. A rectal examination should only be performed if it gives additional
information: a sudden gush of stool may be found in
a child with Hirschsprungs disease post examination.
Hard, impacted stool may be found confirming the need
for a faecal disimpaction
 Neurological exam, including inspection of the lumbarsacral spine and examination of the lower limbs
 Spinal abnormalities or spinal cord tumours can present
with constipation (Table 2)

School age children: children generally learn to use their own


toilet at home but need their parents ongoing support, praise and
bottom wiping for some years afterwards. When children start
full time school they need to be independent. Schools have
variable amounts of support available for toileting needs of
young reception age children. Toilets may be inaccessible from
the playground or lunch hall and young children are often scared
to go alone, unable to do up buttons or wipe their own bottom.
This is a time where stool withholding and inevitable

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Organic causes of childhood constipation


Structural colorectal

Spinal cord

Systemic

Neuropathic lesions
of intestine

Drugs

Other important causes

Anal stenosis
Post NEC/IBD stricture

Spinabifida
Sacral agenesis

Diabetes
Hypothyroid

Hirschsprung disease
Intestinal neuronal
dysplasia

Opioid analgesia
Antacids

Coeliac disease
Cystic fibrosis

Chronic intestinal
pseudoe obstruction

Spinal cord tumours

Hypo/hypercalcaemia

Iron

Cows milk protein allergy

Neurofibromatosis
Cerebral palsy

Cholestyramine

Table 2

Investigation of children with chronic constipation


Investigation

Indication

Change to management

Plain abdominal radiograph

Not usually indicated

Bowel transit studies


Radio eopaque shapes swallowed
daily for 5 days and then an
abdominal radiograph performed
to assess the transit time of the shapes

Not routinely indicated e interpret with


caution as shapes can adhere to the
colonic mucosa.
Useful in children with chronic diarrhoea
or soiling for whom there is uncertainty
about constipation as the underlying cause
Not indicated in young children.
Demonstrates whether there is normal
relaxation of the internal anal sphincter
in response to rectal dilation.
May be indicated if there is possibility
of cows milk protein enteropathy
To exclude Hirschsprungs disease if delay
in early passage of meconium or only able
to pass paste like stools with long
standing constipation or abdominal distension.
All children with long standing constipation
not responding to initial management.

May be useful to exclude sacral agenesis


or other spinal abnormalities.
Occasionally used to provide families with
visual evidence of constipation
If delayed transit shown it is more
acceptable to families to comply with
the advice for a child to undergo
disimpaction of faeces.

Anorectal manometry

Endoscopy
Full thickness rectal biopsy

Coeliac screen tissue


transglutaminase or endomysial
antibodies immunoglobulin A levels

Electrolytes and glucose

Thyroid function

Fbc and iron studies

Concerning features of history or examination


or not responding to treatment. Exclude
hypo/hypercalcaemia.
Urine dip-exclude diabetes.
Infants with early constipation and
developmental delay. Family history of
thyroid disease. Clinical suspicion
Iron deficiency anaemia common because
of poor diet. Iron therapy can cause constipation.

Can demonstrate anatomical reasons


underlying constipation. May need
referral to a colorectal surgeon.
May demonstrate eosinophilic enteropathy
Surgical excision of aganglionic bowel
with temporary colostomy followed by
a later pull through anastamoses
If serology positive will need
endoscopic duodenal biopsies and
histological confirmation of the
diagnosis while on full gluten
containing diet.
Gluten free diet should lead to
a resolution of symptoms
Treat electrolyte abnormality

Thyroxine replacement.

Treat iron deficiency anaemia

Table 3

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Investigations

breakfast as a meal and starting the family day earlier to make


time for breakfast, activity and then a relaxed attempt at opening
bowels using the gastrocolic reflex and achieving a clear out prior
to nursery/school is useful advice. Although there is a lack of
trial evidence to support the effectiveness of increased physical
activity in constipation management, it is a common observation
that obesity and lack of physical activity are associated with
constipation.
 A diet sufficient in fruit, fibre and adequate fluid will be
essential to an effective cure.
 Increased activity levels are helpful

At all ages, if the history and examination are suggestive of


functional constipation and there are no abnormal findings on
examination, further investigations are not indicated. If a child
has long standing constipation that has been resistant to treatment or there are worrying features then the following investigations may be considered (Table 3).

Management
The overall aim of management of childhood constipation should
be rapid diagnosis and restoration of regular, pain free bowel
movements at the appropriate time in the appropriate place with
the minimum amount of laxatives possible. Effective management relies on a good relationship with the family and interventions to treat the underlying cause and not just the symptom
(Figure 1).

Toileting behaviour
Difficulties with the transition from nappies to potty/toilet are
common and it is always useful to help familys access advice
about toilet training. The basic principal of ignoring failure and
praising success is important to convey. Improving the environment in the toileting area can be effective. Some children like
to listen to music or read books while sitting and straining on the
toilet. Breathing techniques can be useful to overcome fear. Some
children find blowing bubbles or blowing up balloons help with
their efforts to push a stool out. It can be helpful for children to
have a foot-stool to rest their feet on while opening their bowels
or a cushioned seat that can be smaller than the full adult sized
seat.
 A non-punitive approach is necessary to improve toileting
behaviour
 Aim to improve the whole toileting experience

Non-pharmacological treatment of constipation


Diet and lifestyle: Education about normal physiology and
healthy eating habits is a cornerstone of management. There is
wide variability in the adequacy of childrens diets and multiple
factors including socioeconomic status, health beliefs of families
and eating habits of individual children. There is a clear correlation between inadequate fibre and fluid intake and also
evidence that it is very difficult to change eating habits of families. There is insufficient evidence to suggest a high fibre or high
fluid intake is beneficial and is difficult to comply with.2 A dietetic assessment is extremely useful to accurately assess an
individual childs diet and make recommendations that are likely
to be acceptable/manageable for their family. The recommended
fibre intake in children over 2 is their age in years plus 5 g per
day. Two weetabix provide 3.8 g fibre. The importance of

Psychological assessment
Many children and families who have been struggling with
chronic constipation benefit enormously from psychological
input. There are many issues which commonly arise such as
toilet phobia, depression, distress from bullying, or abuse and
clinical psychologist have many effective strategies that help
children.
Behaviour modification through reward
Reward schemes are often successful; depend on a consistent
approach and the child being old enough to respond. Star charts
can be used, which can be as simple as a blank sheet of paper
with stars for eating breakfast, sitting on the toilet, taking
medication, doing a poo on the toilet or dealing with relevant
issues. It is important that the rewards are awarded frequently
enough to be seen as valuable by the child.
 Star charts should be used at appropriate ages

Pharmacological treatment
Success of pharmacological treatment relies on addressing the
underlying causes of constipation and the non-pharmacological
advice should be reviewed and reinforced each time a child
comes to clinic.
Constipation management is complicated and requires regular
review and assessment particularly at the beginning of laxative
treatment. In children with acute onset constipation or mild
symptoms lifestyle manipulations may be enough. For the
majority seeking medical help it will be necessary to start a laxative. If the underlying problem is infrequent passage of large, hard
stools then it is logical that a faecal softener should be the first line

Figure 1 Non-pharmacological treatment of constipation.

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Disimpaction
Disimpaction can be achieved at home but families will need
support. Children are asked to drink large volumes of PEG
3350 which can be difficult to tolerate. A stimulant laxative is
added if disimpaction has not been achieved by 2 weeks. In
practice, in severe cases may require enemas. A recent RCT
compared daily enemas with 1.5 g/day PEG 3350 and found no
significant difference in efficacy or in behaviour scores,
measuring fear/distress, caused by the treatment. The NICE
guideline recommends trying oral stool softeners and stimulants or sole agent stimulant laxative such as senna or sodium
picosulpahte (elixir) or picolax (sachet) prior to rectal medication (Figure 2).

treatment. For many children with overflow diarrhoea, soiling or


long standing symptoms disimpaction of large volume, hard stool
in the rectum is essential before any management strategies or
lifestyle changes will have any effect. There is little trial data to
guide stimulant laxative use but there is widespread consensus
amongst specialists that they are often required either to ensure
adequate disimpaction or as a maintenance agent.
A systematic review of the literature showed only 50% of all
children started on laxative treatment followed for 6e12
months are shown to recover and be asymptomatic whilst no
longer on laxatives.3 It is important that expectations are
managed and the length of treatment with laxatives is not
underestimated.

Figure 2

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Osmotic laxatives
Age

Dose

Mechanism of action

Side effects

Lactulose

Infants under 2

1e3 ml/kg

Non-absorbable disaccharide
of sugars D-galactose and D-fructose.
Fermented by colonic bacteria
producing hyperosmolar by-products

PEG 3350
(with electrolytes)
Movicol

Only licensed for over


2 years but recommended
by NICE as 1st line for all

0.3e0.8 g/kg/day
maintenance
1e1.5 g/kg/day
disimpaction

Large molecular size. Not absorbed.


Produces a direct osmotic effect.
No impact on electrolyte balance.

Relating to fermentation
by-products with excess
gas production leading
to flatulence, bloating
and abdominal cramps.
Diarrhoea, abdominal
distension, nausea

Table 4

Maintenance treatment
It is good practice to follow-up the initial visit with a phone call
and to review children regularly to ensure adequate disimpaction. Constipation is often most effectively managed in
the community by a specialist nurse who forms a relationship
with the family and provides regular support over the phone
and in clinic.4,5 The addition of a stimulant laxative such as
senna once stools are soft is often necessary to overcome stool
witholding. There are a wide number of osmotic and stimulant

laxatives available. Trial evidence commonly suffers from


small sample sizes and short duration of follow-up. There have
been recent randomized trials and a meta analysis of efficacy
for PEG 3550. Two systematic reviews compared PEG 3350
with placebo in the treatment of chronic constipation in children. PEG 3350 significantly improved pain during defaecation
and increased the number of stools per week but did not
significantly reduce the number of incontinent episodes
(Table 4).6

Stimulant laxatives. As recommended by NICE


Age

Dose

Mechanism of action

Sodium
Elixir 5 mg/5 ml
picosulphate Child 1 month
to 4 years
Child 4e18 years

2.5e10 ml od
2.5e20 ml od

Bisacodyl

5e20 mg od
5e10 mg od

Stimulating the mucosa of both the colon,


causing peristalsis, and the rectum, causing
increased motility and a feeling of rectal fullness.
By bacterial cleavage the active form is formed
in the colon.
Action after 6e12 h
Diphenylmethane laxative, which, when activated,
stimulates intestinal fluid
secretion and colonic contraction

Senna

Docusate
sodium

Orally
Child 4e18 years
Rectally
Child 2e18 years

Side effects

Withdrawn in the United States after


rodent studies suggested carcinogenic
links. Subsequent studies have not
demonstrated an increased risk of
cancer in humans taking
phenolphthalein laxatives
Elixir 7.5 mg/5 ml 2.5e10 ml od
Anthraquinone laxative increase fluid and electrolyte Changes in the colon produced by
Child 1 month
2.5e20 ml od
accumulation in the distal ileum and colon after
chronic anthraquinone use include
to 4 years
metabolism. This occurs only when the prodrug
melanosis coli, a benign and
Child 4e18 years
comesinto contact with intestinal micro-organisms. reversible condition. No evidence
For this reason, sennosides can be given orally
exists that anthraquinone laxatives
but not by suppository
given in clinically appropriate doses
cause enteric damage
6 monthse2 years 12.5 mg tds
An anionic surfactant that reduces surface tension
2e12 years
12.5e25 mg tds of water, allowing water to penetrate the intestine,
12e18 years
500 mg/day in softening the stool. Docusate also has a stimulatory
divided doses
affect by increasing cAMP concentrations in colonic
mucosal cells which increases contractility.

Table 5

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Stimulant laxatives
Work by increasing intestinal motility. Intermittently stimulant
laxatives receive adverse press and as the side effects can be more
prominent. As the safety and long term efficacy in children is not
proven, the use of stimulants should be regularly reviewed (Table 5).

3 Pijpers MA, Bongers ME, Benninga MA, Berger MY. Functional constipation in children: a systematic review on prognosis and predictive
factors. J Pediatr Gastroenterol Nutr 2010; 50: 256e68.
4 Burnett CA, Juszczak E, Sullivan PB. Nurse management of intractable
functional constipation: a randomised controlled trial. Arch Dis Child
2004; 89: 717e22.
5 Sullivan PB, Juszscak E, Burnett C. Parent Satisfaction in a nurse-Led
clinic compared with a paediatric gastroenterology clinic for the
management of intractable, functional constipation. Arch Dis Child
2006; 91: 499e501.
6 Tabbers MM, Boluyt N, Berger M, Benninga MA. Diagnosis and treatment of functional constipation. Eur J Pediatr 2011; 170: 955e63.

Discussion
Constipation is a distressing symptom for children and their
families and is time consuming and difficult medical problem to
manage. Management of constipation can be dispiriting as often
symptoms persist and families often become very frustrated. It is
important to provide targeted and appropriate lifestyle advice.
Laxatives alone will rarely be sufficient to cure any patient of
chronic constipation. While most children are unable to entirely
change their lifestyle the importance of the non-pharmacological
treatment of constipation is crucial to its successful management.
With the development of chronic constipation, possibly exacerbated by stool withholding, the rectum changes from being
highly sensitive to distension by stool to a large, distended sac
unresponsive to distension. Moreover, the longer the condition
persists the more likely it is that there will be histological changes in
the lining (mucosa) of the rectum. Atrophy of the rectal musculature with degeneration (focal muscle fibre vacuolation) of muscle
or even muscle fibre disappearance has been found in all chronically constipated children where this has been looked for. These
changes are long-lasting and manometric (pressure) studies show
that abnormal anorectal function is still present many years after
the cessation of treatment and recovery from chronic constipation.
Constipation is a distressing symptom for children and their
families and is time consuming and difficult medical problem to
manage. Management of constipation can be dispiriting as
often symptoms persist and families often become very frustrated. It is important to provide targeted and appropriate life
style advice. Laxatives alone will rarely be sufficient to cure any
patient of chronic constipation. While most children are unable
to entirely change their lifestyle the importance of the nonpharmacological treatment of constipation is crucial to its
successful management.
A

FURTHER READING
Choung Rok Seon, Nilay D Shah, Denesh Chitkara, et al. Direct medical
costs of constipation from childhood to early adulthood: a populationbased birth cohort study. JPGN 2011; 52: 47e54.
Constipation in children and young people. Diagnosis and management
of idiopathic childhood constipation in primary and seconday care.
National Institute of Clinical Excellence Guideline, www.nice.org.uk/
guideline/CG99; May 2010.
Kiefte-de Jong JC, Escher JC, Arends LR, et al. Infant nutritional factors and
functional constipation in childhood: the generation r study. Am J
Gastroenterol 2010; 105(4): 940e5.
Peeters B, Benninga MA, Hennekam RC. childhood constipation; an
overview of genetic studies and associated syndromes. Best Practice
Res Clin Gastroenterology 2011; 25: 73e88.
Rajindrajith Shaman, Devanarayana Niranga Manjuri. constipation in
children: novel insight into epidemiology, pathophysiology and
management. J Neurogastroenterol Motil 2011; 17.

Practice points
C

REFERENCES
1 Borrelli O, Barbara G, Di Nardo G, et al. Am J Gastroenterol 2009; 104:
454e63;
Cafferelli C, Coscia A, Baldi F, et al. Characterization of irritable bowel
syndrome and constipation in children with allergic diseases. Eur J
Pediatr 2007; 166: 1245e52.
2 Sullivan PB, Alder N, Shrestha B, Turton L, Lambert B. Effectiveness of
using a behavioural intervention to improve dietary fibre intakes in
children with constipation. J Hum Nutr Diet 2012; 25(1): 33e42.

PAEDIATRICS AND CHILD HEALTH 22:10

408

The diagnosis of functional constipation in childhood should


be clinical and be based on fulfilling the ROME criteria
It is important to exclude underling pathology that either
directly or indirectly causes constipation as a symptom
Investigations should be tailored to children who have concerning
signs or symptoms and be based on the clinical history
It is important to be aware of the differences in presentation at
different ages, and underlying causes of constipation
Treatment should be targeted on the underlying cause and be
based on lifestyle modification and effective use of appropriate laxatives
Management of constipation benefits from a multidisciplinary
team approach and families need ongoing support to improve
the success of treatment

2012 Elsevier Ltd. All rights reserved.

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