Pediatric Functional Constipation

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Definition

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.

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:

File:Screen Shot 2019-04-01 at 12.29.22 PM.png

Figure 1: Bristol Stool Chart Scale on left for identifying seven types of stool. On right a conceptual framework diagram illustrating the interconnectedness of functional bowel disorders.

• 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.

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.

FC definition is not to be confused with:

Intractable constipation: Constipation not responding to treatment for at least 3 months. 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.

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. Long term constipation can develop into fecal impaction. Fecal impaction can cause pain and vomiting, and may require emergency treatment or hospitalization.

Prevalence

The prevalence of pediatric FC ranges from 0.7-29.6%. The wide range reported may be due to the use of different FC criteria and cultural influences. Peak incidence of constipation occurs at the time of toilet training, median age of onset approximately 2.3 years, with no sex differences. 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.

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. 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. 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.

Pathological Process

File:Viscious Cycle of Pediatric Constipation.png

Figure 2: Constipation Cycle

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

• 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
• Positive family history of FC
• 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

• 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
• Bowel dysfunction is also strongly associated with dysfunctional voiding as 50% of children with dysfunctional voiding present with constipation or fecal incontinence

Diagnostic Procedures

Medical History: First step in diagnosing, should include factors such as age of onset, passage of first meconium, frequency and consistency of stools, abdominal pain, fecal incontinence, withholding behaviour, dietary history, vomiting, weight loss, stressful life events, neurodevelopment delay, and inquiring about positive family history for gastrointestinal disease.

Physical Exam: growth parameters, abdominal exam (looking for distension, tenderness, and palpable faecal masses), inspection of perianal region (examine for abnormally placed external sphincter, possible anal fistules/fissures, inflammation, and signs indicating sexual abuse), exam of lumbosacral region.

Rectal digital Exam: Conflicting evidence on whether this is always necessary for diagnosing FC. According to the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, if only one of the ROME IV criteria is present and diagnosis of FC is uncertain, a rectal exam will be necessary. Administering health provider will need understand how functional constipation is often correlated with a strong fear of rectal examination.

Abdominal Imaging: Due to low correlation between clinical and radiological appearance, abdominal ultrasound is a more reliable alternative.

Anorectal Manometry: An anorectal manometry can be a useful screening tool in older children with untreatable constipation with suspicion of Hirschsprung disease.

Laboratory Testing: for chronic constipation cases, allergy testing bay be required. Although the physiological process remains unclear, it is recommended that allergic inflammation of the internal sphincter may lead to increased anal pressure at rest.

Outcome Measures

Outcome Measure	Use
The Bristol Stool Scale or Amsterdam Infant Stool Scale	Report stool consistency
Paediatric Quality of Life Inventory	Review effects of functional constipation and fecal incontinence on quality of life (physical, psychosocial, and family functioning components)
Childhood Bladder and Bowel Dysfunction Questionnaire	Identifying frequency of symptoms with concomitant bowel and bladder disorders in children aged 5 to 12 years of age
Vancouver Symptom Score for Dysfunctional Elimination Syndrome
Bowel movement and symptom diary

Medical Management

add text here relating to management approaches to the condition

Physiotherapy Intervention

Pelvic Floor therapy

Exercises

Posture

Massage

Equipment

Environment

Communication Approach

Resources

Royal Children's Hospital Foundation and Queen'sland Health - "Managing Chronic Constipation and Soiling in Children - Conquering Poos Guide"