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Management of chronic
constipation in children
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
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
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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).
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.
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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Spinal cord
Systemic
Neuropathic lesions
of intestine
Drugs
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
Hypo/hypercalcaemia
Iron
Neurofibromatosis
Cerebral palsy
Cholestyramine
Table 2
Indication
Change to management
Anorectal manometry
Endoscopy
Full thickness rectal biopsy
Thyroid function
Thyroxine replacement.
Table 3
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Investigations
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
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
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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).
Figure 2
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SYMPOSIUM: GASTROENTEROLOGY
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
0.3e0.8 g/kg/day
maintenance
1e1.5 g/kg/day
disimpaction
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
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
Senna
Docusate
sodium
Orally
Child 4e18 years
Rectally
Child 2e18 years
Side effects
Table 5
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SYMPOSIUM: GASTROENTEROLOGY
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.
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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
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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.
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