Pediatric Functional Constipation: Difference between revisions
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== Risk Factors == | == Risk Factors == | ||
* History of painful defecation | |||
* Chronic constipation during infancy | |||
* Prematurity | |||
* Improper psychological development | |||
* Lowered muscle tone | |||
* Male sex (especially in early infancy and at pre-school age) | |||
* Cow's milk intolerance | |||
* Inadequate nutrition (diet poor in fibre, rich in fats and sugars, sweet drinks) | |||
* Low level of physical activity | |||
* Sexual abuse | |||
* Psycho emotional background which can be commonly associated with stress, desire for control, fears and phobias surrounding changes in normal routine (examples including: toilet training, starting/changing nursery, family changes, etc.) | |||
* Children may also ignore the urge to have a bowel movement because their attention is focused on other more interesting activities. | |||
Psycho emotional background which can be commonly associated with stress, desire for control, fears and phobias surrounding changes in normal routine (examples including: toilet training, starting/changing nursery, family changes, etc.) | |||
Children may also ignore the urge to have a bowel movement because their attention is focused on other more interesting activities. | |||
== Clinical Presentation == | == Clinical Presentation == | ||
* May exhibit unusual positions, for example toddlers arch their back, stand on their tiptoes, and wriggle or fidget, or they may squat | |||
* Abdominal distension and pain | |||
* Excessive postprandial fullness | |||
* Loss of appetite | |||
* Encopresis | |||
* Blood and mucus in the stool | |||
* Nausea | |||
* Vomiting | |||
* Abnormally slow weight gain | |||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
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Definition[edit | edit source]
Overview
Constipation can be broadly described as infrequent bowel movements of hard or dry stool. It can be further categorized into two subtypes, Organic and Functional Constipation. Organic constipation happens in 5% of pediatric cases, and is the result of structural, neurologic, toxic/metabolic or intestinal disorders. This overview will focus on Functional Constipation (FC), which is more common and involving reasons beyond organic causes[1].
ROME IV Diagnostic Criteria for FC:
Must include 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome[2]:
· 2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years
· At least 1 episode of fecal incontinence per week
· History of retentive posturing or excessive volitional stool retention
· History of painful or hard bowel movements
· Presence of a large fecal mass in the rectum
· History of large diameter stools that can obstruct the toilet
After appropriate evaluation, the symptoms cannot be fully explained by another medical condition[2].
NB: The ROME IV revisions published in May 2016, highlight that while functional bowel disorders (functional diarrhea, functional constipation, IBS with predominant diarrhea [IBS-D], IBS with predominant constipation [IBS-C], and IBS with mixed bowel habits) have their own distinct diagnostic criteria, they are considered to be on a continuum rather than independent entities (see Figure 1) and may share similar treatment strategies[4].
FC definition is not to be confused with:
Intractable constipation: Constipation not responding to treatment for at least 3 months[5]. For children with severe intractable constipation that is unresponsive to pharmacological management, referral to a specialized pediatric gastroenterologist is recommended. Surgery may be indicated as a last resort[6].
Fecal impaction: Hard mass in the lower abdomen identified during a physical exam, or a dilated rectum filled with a large amount of stool on rectal examination, or excessive stool in the distal colon viewed on abdominal Xray[5]. Long term constipation can develop into fecal impaction. Fecal impaction can cause pain and vomiting, and may require emergency treatment or hospitalization[7].
Prevalence
The prevalence of pediatric FC ranges from 0.7-29.6%[8]. The wide range reported may be due to the use of different FC criteria and cultural influences[2]. Peak incidence of constipation occurs at the time of toilet training, median age of onset approximately 2.3 years, with no sex differences[9][2]. FC is distributed equally amoung different socio-economic backgrounds, with no relationship to family size, ordinal position of the child in the family, or parental age. Boys with constipation have high rates of fecal incontinence compared to girls[2].
Impact
There are higher healthcare costs associated with children with constipation, mostly because of ambulatory care costs and, to a lesser degree, costs related to hospitalizations and emergency room visits[10]. Constipation symptoms may lead to reduction in health-related quality of life, poor school performances and difficult social interactions at a time that the child is known to lay social and educational foundations[11]. Despite currently available treatment options, quality of care in FC is limited by lack of guidance for management, a poorly defined condition characteristics, and insufficient data on drug and alternative therapies[12].
Pathological Process[edit | edit source]
Functional constipation in children is most often due to a history of painful defecation, or social reasons. As a result a child will hold on to the stool, leading to greater absorption of water through the rectal mucosa and hardening of the stool, making it progressively more difficult to evacuate. This leads to a viscous cycle of retention, in which the rectum becomes increasingly distended, resulting in overflow incontinence, loss of rectal sensation and eventually the loss of normal urge to defecate.
Children are prone to develop functional constipation during 3 periods:
1. After the introduction of cereals and solid food
2. During toilet training
3. During the start of school
Each of these milestones has the potential to convert defecation into an unpleasant experience.
In older children, diets low in fiber and high in dairy may lead to hard stools that are uncomfortable to pass and can cause anal fissures. Anal fissures cause pain with stool passage, leading to a similar vicious circle of delayed bowel movements, resulting in harder stool that is more painful to pass.
Risk Factors[edit | edit source]
- History of painful defecation
- Chronic constipation during infancy
- Prematurity
- Improper psychological development
- Lowered muscle tone
- Male sex (especially in early infancy and at pre-school age)
- Cow's milk intolerance
- Inadequate nutrition (diet poor in fibre, rich in fats and sugars, sweet drinks)
- Low level of physical activity
- Sexual abuse
- Psycho emotional background which can be commonly associated with stress, desire for control, fears and phobias surrounding changes in normal routine (examples including: toilet training, starting/changing nursery, family changes, etc.)
- Children may also ignore the urge to have a bowel movement because their attention is focused on other more interesting activities.
Clinical Presentation[edit | edit source]
- May exhibit unusual positions, for example toddlers arch their back, stand on their tiptoes, and wriggle or fidget, or they may squat
- Abdominal distension and pain
- Excessive postprandial fullness
- Loss of appetite
- Encopresis
- Blood and mucus in the stool
- Nausea
- Vomiting
- Abnormally slow weight gain
Diagnostic Procedures[edit | edit source]
add text here relating to diagnostic tests for the condition
Outcome Measures[edit | edit source]
add links to outcome measures here (see Outcome Measures Database)
Medical Management[edit | edit source]
add text here relating to management approaches to the condition
Physiotherapy Intervention[edit | edit source]
add text here relating to the differential diagnosis of this condition
Resources[edit | edit source]
add appropriate resources here
References[edit | edit source]
- ↑ Consolini DM. Constipation in Children - Pediatrics [Internet]. Merck Manuals Professional Edition. Merck Manuals; 2018 [cited 2019Apr1]. Available from: https://www.merckmanuals.com/en-ca/professional/pediatrics/symptoms-in-infants-and-children/constipation-in-children?query=Constipation in Children
- ↑ 2.0 2.1 2.2 2.3 2.4 Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May 1;150(6):1456-68.
- ↑ Beyond Fiber and Laxatives: Advising Patients with Chronic and Refractory Constipation-Article [Internet]. Powerpak.com. 2019 [cited 1 April 2019]. Available from: https://www.powerpak.com/course/content/116231
- ↑ Schmulson MJ, Drossman DA. What is new in Rome IV. Journal of neurogastroenterology and motility. 2017 Apr;23(2):151.
- ↑ 5.0 5.1 Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of pediatric gastroenterology and nutrition. 2014 Feb 1;58(2):258-74.
- ↑ Koppen IJ, Lammers LA, Benninga MA, Tabbers MM. Management of functional constipation in children: therapy in practice. Pediatric Drugs. 2015 Oct 1;17(5):349-60.
- ↑ Harvard Health Publishing. Constipation and Impaction [Internet]. Harvard Health. 2016 [cited 2019Apr1]. Available from: https://www.health.harvard.edu/a_to_z/constipation-and-impaction-a-to-z
- ↑ Mugie SM, Benninga MA, Di Lorenzo C. Epidemiology of constipation in children and adults: a systematic review. Best practice & research Clinical gastroenterology. 2011 Feb 1;25(1):3-18.
- ↑ Malowitz S, Green M, Karpinski A, Rosenberg A, Hyman PE. Age of onset of functional constipation. Journal of pediatric gastroenterology and nutrition. 2016 Apr 1;62(4):600-2.
- ↑ Choung RS, Shah ND, Chitkara D, Branda ME, Van MT, Whitehead WE, Katusic SK, Talley NJ. Direct medical costs of constipation from childhood to early adulthood: a population-based birth cohort study. Journal of pediatric gastroenterology and nutrition. 2011 Jan;52(1):47-54.
- ↑ Bongers ME, van Dijk M, Benninga MA, Grootenhuis MA. Health related quality of life in children with constipation-associated fecal incontinence. The Journal of pediatrics. 2009 May 1;154(5):749-53.
- ↑ Sood M, Lichtlen P, Perez MC. Unmet Needs in Pediatric Functional Constipation. Clinical pediatrics. 2018 Nov;57(13):1489-95.
