Chronic Functional Constipation

in Infants and Children

2019
• Functional constipation is a common problem among children.
• The prevalence worldwide is about 3% and it is accounting for about
3–5% of all visits to pediatricians.
• Functional constipation is characterized by infrequent bowel
movements, hard and/or large stools, painful defecation, sometimes
in combination with fecal incontinence, and is often accompanied by
abdominal pain
Rome IV criteria (Hyams et al. 2016).
1. Two or fewer defecations in the toilet per week in a child of a
developmental age of at least 4 years
2. At least one episode of fecal incontinence per week
3. History of retentive posturing or excessive volitional stool retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large diameter stools that can obstruct the toilet
Fecal incontinence
• Fecal incontinence (also known as encopresis or soiling) is defined by
repetitive passage of stool (voluntary or involuntary) in children 4
years of age and older
Diagnostic Criteria for nonretentive fecal
incontinence
• At least a 1-month history of the following symptoms in a child with a
developmental age older than 4 years:
• 1. Defecation into places inappropriate to the sociocultural context.
• 2. No evidence of fecal retention.
• 3. After appropriate medical evaluation, the fecal incontinence cannot
be explained by another medical condition.
3.1.1 Oral Medication Polyethylene Glycol
(PEG) 3350 and 4000
• PEG 3350 without electrolytes: Fecal disimpaction 1–1.5 g/kg/day
dissolved in approximately 10 mL/kg body weight of water or flavored
beverage (for a maximum of six consecutive days) (Tabbers et al.
2014).
• PEG 3350 with electrolytes: 25 mL/kg/h to a maximum of 1,000 mL/h
by nasogastric tube until stool appears clear or 20 mL/kg/h for 4
h/day (Tabbers et al. 2014).
Adverse Effects
Very common Nausea, bloating, or feelings of fullness in the
stomach/abdomen
Less often Stomach/abdominal cramps, vomiting, and anal
irritation
Mineral Oil (Liquid Paraffin)
• Dosing Recommendations (for Rectal Disimpaction)
• Oral 15–30 mL/year of age, up to 240 mL
• Slow disimpaction Children and adolescents – 3 mL/kg twice daily for
7 days (Pashankar 2005)

Gastrointestinal Abdominal cramps, diarrhea, nausea, and oily

rectal leakage
(large doses)
• In the most current consensus report on childhood functional
constipation from ESPGHAN, an NASPGHAN oral disimpaction is
preferred, because it is bettertolerated by children than enemas
(Tabbers et al. 2014; Philichi 2018).
Sodium Phosphate
• Mechanism of Action Sodium phosphate exerts an osmotic effect in
the intestine by drawing water into the lumen of the gut, producing
distention, and promoting peristalsis and evacuation of the bowel
(Hoekman and Benninga 2013).
• Dosing Recommendations (Tabbers et al. 2014) 1–18 years 2.5 mL/kg,
max 133 mL/dose (monobasic sodium phosphate monohydrate 19 g
and dibasic sodium phosphate heptahydrate 7 g per 118 mL delivered
dose (133 mL))
Normal Saline (Sodium Chloride)
• Dosing Recommendations (Tabbers et al. 2014) Neonate 1 kg, 10 mL
>1 year 6 mL/kg once or twice/day (up to 20 mL/kDa/day)
3.2 Long-Term Use/Maintenance Therapy
• Polyethylene Glycol (PEG) 3350 Maintenance therapy 0.2–0.8
mg/kg/day
• Lactulose is recommended in case PEG is not available. It is
considered to be safe for all ages (Tabbers et al. 2014). Dosing
Recommendations (Tabbers et al. 2014) 1–2 g/kg once or twice/day
Senna (Also Known as Sennoside or Senna
Glycoside)
• Only one pediatric study compared senna to PEG in children with
anorectal malformations (28 participants). It was conducted as
randomized controlled crossover design, including a washout period.
This study was terminated early because the interim analysis showed
a clear benefit toward senna ( p ¼ 0.026) (Santos-Jasso et al. 2017).

• Dosing Recommendations (Tabbers et al. 2014) 2–6 years 2.5–5 mg

once or twice/day 6–12 years 7.5–10 mg/day >12 years 15–20
mg/day