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Symposium: Gastroenterology

The management of chronic (PACCT) group and the more recent Rome III criteria have pro-
duced more precise definitions.

constipation PACCT defined childhood constipation as the occurrence


of two or more of the following six criteria in the previous 8
weeks: frequency of movements less than three a week; more
Mairi C Gillespie than one episode of faecal incontinence a week; large stools in
the rectum or palpable on abdominal examination; passing of
Katherine J Price stools so large that they may obstruct the toilet; retentive postur-
ing and withholding behaviour; painful defecation. The group
defined the term faecal incontinence as the passage of stool in an
inappropriate place, and divided this into: organic (i.e. second-
ary to an underlying pathology) or functional, which is further
Abstract subdivided into (i) constipation-associated (previously referred
Chronic constipation is a common problem in childhood. A minority of to as ‘soiling’) and (ii) non-retentive (previously referred to
cases are due to an underlying organic cause and such cases can usually ­‘encopresis’).2
be identified through a thorough history and examination, with focused
investigations. Constipation can have a significant impact on the social
Aetiology
and emotional development of a child, as well as affecting the family
dynamics. It is important to take these factors into consideration when Although a number of conditions can cause constipation (see
assessing and treating a child and a multidisciplinary approach to care Table 1), more than 95% of children have no identifiable underly-
has been shown to be the most effective. Although there is a general ing organic cause, which is referred to as ‘functional constipation’.
consensus regarding the principles of treatment, the evidence behind Acute constipation can be triggered by any event that causes a
the choice of laxative is still lacking. Effective treatment requires the delay in bowel opening, be that weaning onto solids, an acute ill-
disimpaction of retained stool followed by re-establishment of a regular ness, a period of immobility, a lack of access to a toilet or simply
bowel habit. Whilst approximately 70% of children will become symptom being too engrossed in activities to go. Pain associated with the
free off all medication, a significant cohort continues to have symptoms passage of a hard stool may result in voluntary stool withholding
despite a prolonged period of treatment. and a vicious cycle develops whereby the child becomes fear-
ful of defecation, withholds further and stool accumulates in the
Keywords constipation; faecal incontinence; laxatives; macrogol; soiling rectum and colon. This may be exacerbated by the development
of an anal fissure.
Some children with constipation have abnormal defecation
dynamics on anal manometry, in that they will contract their
Introduction
external anal sphincter rather than relax it on defecation but it
Constipation is a common paediatric complaint, with a commonly is not clear whether this is a primary pathology or a secondary
quoted prevalence of 3% of all referrals to general paediatric outpa- learned behaviour.
tients and 25% of paediatric gastroenterology clinics. This review Rectal capacity increases (referred to as mega rectum) and
aims to discuss the assessment and management of children pre- the child’s awareness of the need to defecate appears to dimin-
senting with chronic constipation, which is often distressing for ish as faecal retention occurs. As retention increases small
both child and the family, impacting on their ­quality of life. amounts of retained stool may leak, referred to as faecal incon-
tinence or overflow soiling. This is often of liquid, foul-smelling
stool but soiling can be of any consistency. A key feature of
Definition
overflow soiling is the child’s lack of awareness of the need to
The definition of childhood constipation considers the frequency defecate.
of bowel motions, the consistency of motions and the presence
of associated discomfort. Whole gut transit time increases with
Presentation
age, with stool frequency reducing from four stools per day in
neonates to 1.7 stools a day at 1 year of age. A total of 96% of The presenting symptoms vary with age, with one study showing
1–4 year olds open their bowels between three times a day to only 31% children presenting with ‘classical constipation’ (that
once every other day.1 is, the passage of hard, infrequent stools).3
Constipation has been defined across all age groups as a delay A total of 98% of healthy term infants and 76% of preterm
or difficulty in defecation that persists for 2 weeks or more. infants pass meconium within the first 24 hours of age and by 48
The Paris Consensus on Childhood Constipation Terminology hours all healthy term infants should have done so.4 Failure to
do so should prompt evaluation for an ano-rectal abnormality or
intestinal obstruction.
Mairi C Gillespie MB ChB MRCPCH is a Specialist Registrar at the Sheffield Toddlers usually present with a history of reduced stool fre-
Children’s Hospital NHS Foundation Trust, Sheffield, UK. quency, the passage of hard stools, often associated with pain,
and rectal bleeding. Withholding is suggested by the passage of
Katherine J Price MB ChB MRCP FRCPCH is a Consultant Paediatrician at the infrequent enormous stools and these children often adopt odd
Sheffield Children’s Hospital NHS Foundation Trust, Sheffield, UK. postures such as crossing their legs, going rigid, hiding etc. when

PAEDIATRICS AND CHILD HEALTH 18:10 435 © 2008 Elsevier Ltd. All rights reserved.
Symposium: Gastroenterology

Initial assessment
Causes of chronic childhood constipation
A thorough history and examination will identify the few chil-
Non-organic causes dren who require further investigation for organic disease. It
Diet Poor diet, food fads should also highlight factors that might influence your future
Inadequate fluid intake management plan.
Excessive milk intake
History
Pychological/behavioural Toilet refusal/ignoring the urge to go
Table 2 outlines specific areas that should be addressed in the
School bullying
history.
Developmental delay
It is important to clarify any previous laxative treatment and
Drugs Oxybutynin the child’s response to this, which often also highlights the par-
Opiate analgesia ents’ attitudes to laxatives and any problems with compliance.
Loperamide Urinary tract infections and daytime wetting are more common
Other Sexual abuse in children with constipation but day wetting should alert the
clinician to the possibility of a spinal problem.
Organic causes In our experience constipation is not a common primary pre-
Anal–rectal Congenital sentation of childhood sexual abuse but it is important to consider
abnormalities Hirschsprung’s disease it and to explore other features that may suggest the possibility,
Imperforate anus such as behavioural and emotional problems.
Anal stenosis There is a need to establish the impact constipation has on the
Anterior anus child and their family. Faecal incontinence in particular can be
 Acquired very stressful, causing embarrassment to the child and affecting
Anal fissure peer relationships. Parents may not understand that the child is
Perianal infection (group A not aware of the soiling episodes and may view the soiling as a
streptococcal) deliberate act of defiance. Education may be affected, with nurs-
ery placements jeopardised if a young child is not fully continent
Food intolerance Cow’s milk intolerance and older children often reporting embarrassment, bullying and
Coeliac disease school avoidance. The quality of life in children with constipa-
Gastrointestinal Inflammatory bowel disease tion has been reported to be lower than that in children affected
Cystic fibrosis by other chronic gastrointestinal ­illnesses.6

Neurological Spina bifida Examination


Cerebral palsy Physical examination aims to establish the degree of faecal loading
Hypotonia of any cause and identify any physical clues to underlying pathology. Growth
Endocrine/metabolic Hypothyroidism parameters are a good indicator of general health and possible
Hypercalcaemia endocrine causes. Abdominal examination may reveal distension
Electrolyte imbalance – or palpable faeces but a normal examination does not exclude
hypokalaemia, hypomagnesium faecal loading. Inspection of perineum allows assessment of the
position and patency of anus, possible infection and any perianal
Table 1 changes such as anal fissures and skin tags. Although some advo-
cate digital rectal examination, this is not routinely part of our
practice as it rarely provides additional information and can be
the sensation to defecate occurs. Parents often misinterpret this distressing. Examination of spine and neurological examination of
as straining to pass stool. lower limbs, including gait, may help identify spinal lesions.
Although older children may have similar symptoms as
younger children it is often harder to obtain a clear history of
Investigations
constipation symptoms, particularly from adolescents, who can
find such discussions embarrassing, and the use of stool charts If the history or examination raises the possibility of an underly-
(see Figure 1) and diaries may be helpful. Overflow soiling ing organic cause, this should be investigated in a focused man-
becomes a more prominent symptom as children get older, and is ner (see Table 3). Poor response to treatment may also prompt
present in half of those presenting after 3.5 years.3 The family or further investigation and we have, for instance, identified cow’s
health professionals may mistake soiling for diarrhoea. Abdomi- milk protein intolerance in children who have responded poorly
nal pain is also more prominent in this age group, as well as non- to laxatives.
­gastrointestinal symptoms including anorexia, general malaise, Abdominal x-ray is the most common type of imaging used in
urinary symptoms and headache. constipation. It is essential in neonates with possible obstruction
As discussed in a previous review, children with physical dis- but may also be helpful in the older child if the history is unclear
abilities and developmental delay, including social development or examination proves difficult. Grading of faecal loading on
disorders, are more likely to suffer from constipation.5 x- ray has been shown to correlate with the severity of ­symptoms.

PAEDIATRICS AND CHILD HEALTH 18:10 436 © 2008 Elsevier Ltd. All rights reserved.
Symposium: Gastroenterology

Figure 1 The Bristol stool chart.

PAEDIATRICS AND CHILD HEALTH 18:10 437 © 2008 Elsevier Ltd. All rights reserved.
Symposium: Gastroenterology

Constipation history Investigating an underlying organic cause of chronic


constipation
• Age of onset
• Timing of first passage of meconium Underlying Suggested by Investigation
• Stool frequency and consistency condition
• Episodes of soiling and frequency
Hirschsprung’s Failure to pass Rectal biopsy
• History of straining or rectal bleeding
disease meconium in first
• History of behaviour suggestive of withholding
48 hours
• History of abdominal distension or discomfort
Onset of symptoms in
• History of toilet training – whether fully trained, in nappies/
neonatal period
pull-ups etc.
Failure to thrive
• Associated urinary symptoms – nocturnal enuresis, urge
Poor response to
incontinence, dribbling, urinary infections
treatment
• Appetite – including diet and fluid intake
• Previous treatment of constipation and response
Hypothyroid Symptoms or TSH, T4
• Past medical history – in particular history of atopy
clinical signs of
• Developmental history
hypothyroidism
• Family history – in particular of constipation
• Social history
Food History of atopy Trial elimination diet
intolerances Recurrent abdominal Cow’s milk protein
pain antibodies
Table 2
Other symptoms of Tissue
It can be a useful educational tool particularly in those present- Coeliac disease transglutaminase
ing predominantly with soiling, where there may be doubt as to
Electrolyte Any symptoms/signs Potassium
the diagnosis.
abnormalities associated with Calcium
Solid marker transit studies may demonstrate delayed colonic
electrolyte abnormality
transit time (CTT) but the diagnostic and prognostic role of this is
e.g. renal tubular
limited.7 Not all children with constipation have a prolonged CTT
acidosis, William’s
and, in those who do, it is unclear if this is a cause or effect of
syndrome
the constipation. CTT may be helpful in directing specific thera-
peutic intervention, for example, biofeedback if there is evidence
Cystic fibrosis Failure to thrive Sweat test
of segmental delay.
Intestinal obstruction
Anal manometry is not used routinely but may help identify
History of respiratory
children with abnormal defecation dynamics – in particular con-
symptoms
traction rather than relaxation of external sphincter – which may
Family history
be amenable to biofeedback training.

Spinal Urinary symptoms MRI spine


Management pathology Abnormal neurological
examination of
A multidisciplinary approach to care, addressing medical, behav-
lower limbs/spinal
ioural and motivational issues, has been shown to be the most
examination
effective. This may be best achieved through a dedicated consti-
pation service and nurse-led clinics have been shown to be very TSH, thyroid stimulating hormone; T4, thyroxine; MRI, magnetic resonance
effective.8–10 imaging.
The aim of treatment is to achieve and maintain regular bowel
movements free of symptoms. The accepted approach comprises Table 3
education, clearance of faecal impaction and maintenance of reg-
ular bowel movements with laxatives whilst adopting strategies
to prevent recurrence through lifestyle advice and reconditioning ­ nderstanding of the underlying physiology, allowing demys-
u
of normal bowel habit. On-going support to the child and fam- tification of the condition, the removal of blame and explana-
ily should be provided throughout the treatment regimen. Any tion of the management plan. Families may believe that their
underlying organic cause should be treated appropriately but child with faecal incontinence has diarrhoea and so under-
management of the resultant constipation may also be required. standably may be reluctant to start any treatment that they
perceive will increase symptoms. The use of age-appropriate
Education diagrams and booklets will help with the explanation. Parental
Education is fundamental to the treatment of constipation. concerns about a possible underlying organic cause or use of
It is imperative that both the child and their family have an laxatives should be addressed. Advice about lifestyle changes,

PAEDIATRICS AND CHILD HEALTH 18:10 438 © 2008 Elsevier Ltd. All rights reserved.
Symposium: Gastroenterology

such as increasing fluid and fibre intake and increasing exercise


should be given at onset and reinforced regularly at follow-up
Explanation and Education
­appointments.

Medication Is there evidence of faecal impaction?


There is little evidence as to which laxative is most effective. (If NO then continue to maintenance phase)
There is some evidence on osmotic laxatives. One randomised
controlled trial showing macrogols to be more effective than if YES
lactulose.11 There is insufficient evidence on the use of stimulant
laxatives.12
Evacuate retained faeces
For faecal impaction, our normal practice (see Figure 2) is
to use macrogol ‘3350’ (Movicol® Paediatric Plain) in the first Macrogol ‘3350’ (Movicol Paediatric Plain) – [initially 2 sachets
instance. It is usually well-tolerated and can be disguised in a for 2–4 year olds, 4 sachets for 5–11 year olds, increasing by
1–2 sachets a day as required]
variety of fluids and foodstuffs. Faecal incontinence often deteri-
orates at the onset of treatment and families should be supported If unsuccessful – additional stimulant laxative e.g. sodium
picosulphate or admission to hospital for bowel wash-out with
to continue treatment during this period. However, following
Klean Prep via nasogastric tube
adequate disimpaction, faecal incontinence would usually cease
quickly and the child regains some rectal sensation. Therefore,
persistence of faecal incontinence usually suggests an inadequate If above unsuccessful then consider enema*
clearout and the need for additional treatment. or manual evacuation *
Laxatives are then continued to maintain regular soft bowel
motions, reducing the pain associated with defecation. In tod- Once successful disimpaction
dlers it is important to maintain this until successful toilet train-
ing occurs. As a regular bowel habit develops and the child
becomes more confident in opening their bowels, the laxatives Maintain regular bowel habit
can be gradually reduced. It is beneficial to empower families Use regular laxative – choice dependent of personal preference
to make adjustments to the dose of laxative in order to prevent and compliance of child.
over- or under-treatment between appointments. e.g. Iso-osmotic laxatives e.g. macrogol ‘3350’; Osmotic
Motivation and adherence with treatment can wane during laxatives e.g. lactulose; Stimulant laxatives e.g. sodium
this maintenance phase and compliance may improve by chang- picosulphate; Faecal softener e.g. liquid paraffin
ing the formulation of the laxative (powder, syrup, tablets, gran- Titrate laxative dose according to response
ules) or trying an alternative treatment. Whilst suppositories and
enemas can have a place in treatment of constipation, they are AND
often unpopular with families and we tend to avoid their use if
possible.
Develop regular toilet routine and preventative measures
Behaviour modification and support Behavioural management with development of good toileting
Considering the role of toilet avoidance and withholding in con- routine
stipation it is important to re-instate a regular toilet routine as Optimise diet and fluid intake
part of the treatment plan. Encourage the child to sit on the toilet Encourage regular exercise
after meals, reinforcing this with sticker charts or other reward
systems. Recording progress in a diary may be useful to rein-
force motivation and may allow early recognition of recurrence. If poor response to treatment
Toddlers often request a nappy on for defecation. This usually Address any behavioural or psychological issues
resolves spontaneously as they become more confident about Consider poor compliance or lack of motivation
passing stool.
Review social issues e.g. school issues, family support
Additional support may be required from clinical psycholo-
Consider organic cause or developmental problems
gists, for example, when children develop an extreme fear of
using the toilet or display other behavioural difficulties. Refusal Consider repeat clear out
to use school toilets has been shown to be a major risk factor13
* rarely used unless oral route unsuccessful
and contact with school staff can be very helpful.
The ‘Bog Standard’ and ‘Water is Cool in Schools’ ­campaigns –
which are organised by Education and Resources for Improving Figure 2 Flow chart for management of chronic constipation.
Childhood Continence (ERIC) – aim to improve the standard of
school toilets and to increase public awareness of fluid require- Role of surgery
ments and the provision of water in schools. Surgery has a role in a minority of children. In intractable con-
Biofeedback training, which aims to reverse abnormal defeca- stipation, the initial step should be to re-assess the medical
tion dynamics, may have a role to play alongside the standard ­management by ensuring adequate clear-out and addressing
combination of laxative and behavioural therapy.14 issues with compliance, motivation, behavioural or ­psychological

PAEDIATRICS AND CHILD HEALTH 18:10 439 © 2008 Elsevier Ltd. All rights reserved.
Symposium: Gastroenterology

factors. If, despite this, medical therapy fails, further surgi- 8 Nolan T, Debelle G, Oberklaid F, Coffey C. Randomised trial of
cal interventions such as internal anal sphincter myectomy or laxatives in treatment of childhood encopresis. Lancet 1991; 338:
injection of botulinum toxin can be considered. In children with 523–527.
intractable soiling, formation of an antegrade continence enema 9 Poenaru D, Roblin N, Bird M, et al. The pediatric bowel management
(ACE) stoma may be helpful, allowing daily washout of the colon clinic: initial results of a multidisciplinary approach to functional
and socially acceptable symptom relief.4 ACE procedure or other constipation in children. J Pediatr Surg 1997; 32: 843–848.
surgery such as colostomy or ileostomy should only be consid- 10 Burnett CA, Juszczak E, Sullivan PB. Nurse management of
ered after family counselling. intractable functional constipation: a randomised controlled trial.
Arch Dis Child 2004; 89: 717–722.
11 Voskuijl W, de Lorijn F, Verwijs W, et al. PEG 3350 (Transipeg)
Prognosis
versus lactulose in the treatment of childhood functional
The duration of time children may suffer with constipation can constipation: a double blind, randomised, controlled, multicentre
be several years but up to 70% will become symptom-free off trial. Gut 2004; 53: 1590–1594.
laxatives. However, up to one-third continue to be symptom- 12 Price KJ, Elliott TM. Stimulant laxatives for constipation and soiling
atic after 6 years of treatment.15 No factor has been consistently in children. Cochrane Database Syst Rev 2001(3) CD002040.
highlighted as a determinant of prognosis and psychological and 13 Inan M, Aydiner CY, Tokuc B, et al. Factors associated with
behavioural difficulties are not significantly higher in those that childhood constipation. J Paediatr Child Health 2007; 43: 700–706.
do not improve. Psychological input may be beneficial given 14 Loening-Baucke V. Modulation of abnormal defecation dynamics
the disabling affect chronic constipation can have on a child. It by biofeedback treatment in chronically constipated children with
has been demonstrated that childhood chronic constipation can encopresis. J Pediatr 1990; 116: 214–221.
extend into adulthood. 15 Procter E, Loader P. A 6-year follow-up study of chronic constipation
and soiling in a specialist paediatric service. Child Care Health Dev
2003; 29: 103–109.
Future
There is some suggestion that probiotics may be helpful but fur-
ther research is required. National Institute for Clinical Excel- Practice points
lence guidelines on childhood constipation are being developed
and are due for release in 2010. ◆ • The vast majority of children do not have an underlying
organic cause for their constipation
• Chronic constipation reduces quality of life for the child and
family
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PAEDIATRICS AND CHILD HEALTH 18:10 440 © 2008 Elsevier Ltd. All rights reserved.