Pediatric Functional Constipation
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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: Is a 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 an 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, the median age of onset is approximately 2.3 years, with no sex differences[9][2]. FC is distributed equally amongst 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 higher 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, and also to a lesser degree 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 crucial time when children are creating the foundations for learning and social interactions[11]. Despite currently available treatment options, quality of care in FC is limited by lack of guidance for management, 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[14][1]. 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 leave the body[2]. This leads to a vicious cycle of retention, in which the rectum becomes increasingly distended, resulting in overflow incontinence, loss of rectal sensation and eventually the loss of the normal urge to defecate[2].
Children are prone to develop functional constipation during 3 periods:
1. After the introduction of cereals and solid food
2. Toilet training
3. When starting school[1]
Each of these milestones has the potential to convert defecation into an unpleasant experience[1].
In older children, diets low in fibre 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 cycle of delayed bowel movements, resulting in harder stool that is more painful to pass[1].
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
- 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[14].
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[14]
- Bowel dysfunction is also strongly associated with dysfunctional voiding[15]
Diagnostic Procedures[edit | edit source]
Medical History: Is the first step in diagnosing. Interview with parents 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[16].
Physical Exam: Should include growth parameters, abdominal exam (looking for distension, tenderness, and palpable faecal masses), inspection of perianal region (examine for abnormally placed external sphincter, possible anal fistulas/fissures, inflammation, and signs indicating sexual abuse), and include an exam of lumbosacral region[16][14].
Rectal digital Exam: There is conflicting evidence on whether this is always necessary for diagnosing FC[16]. 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[16]. The health provider completing the exam should take into consideration how functional constipation is often correlated with a strong fear of rectal examination[14].
Abdominal Imaging: Due to low correlation between clinical and radiological appearance, abdominal ultrasound is a more reliable alternative[16].
Anorectal Manometry: An anorectal manometry can be a useful screening tool in older children with untreatable constipation with suspicion of Hirschsprung disease[17]. The test can help with determining anal pressures, rectal sensation and presence of reflexes required for bowel movements.
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[18].
Outcome Measures[edit | edit source]
Outcome Measure | Description/Use |
---|---|
The Bristol Stool Scale or Amsterdam Infant Stool Scale | Provides visuals that assist with reporting stool consistency[19] |
Paediatric Quality of Life Inventory | Review effects of functional constipation and fecal incontinence on quality of life (includes physical, psychosocial, and family functioning components)[20] |
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[21] |
Dysfunctional Voiding Scoring System | To quantify or grade the severity of abnormal voiding behaviours of children[22] |
Bowel movement and symptom diary | Helps to track after each toilet sit: date, stool description, sitting time, whether or not any stool came, whether or not underwear was clean or dirty, when/how much medication was given that day, and any pain or other symptoms |
Medical Management[edit | edit source]
Each management program must be adapted to meet the needs of the individual child and their family. Usually such a program consists of six steps, not necessarily in this order: the evacuation of faeces/faecal stones accumulated in the rectum (when necessary), a change in dietary habits, toilet training, behavioural treatment, family support, and pharmacotherapy[14].
Non- Pharmacological Management[14] | Pharmacological Management [14] |
---|---|
Education | Osmotic Laxatives |
Behavioural Treatment | Psychotherapy |
Biofeedback | Stimulants |
Increase fibre intake | Softeners |
Increase fluid intake | Bulk-producing Agents |
Exercise | Serotonin Receptor Agonists |
Spasmolytics | |
Probiotics |
The most effective and recommended method of treatment is non pharmacological intervention, which is safe, has no side effects, and brings long-term benefits. Unfortunately, some children fail to respond to this management and they require pharmacological treatment[14].
Physiotherapy[edit | edit source]
Pelvic Floor physiotherapy: Is able to provide specialized pelvic floor assessment and treatment, often complimentary to medical management by a patient's primary care provider. Depending on the patient and their family there are a variety educational and treatment tools that a physiotherapist will be able to provide, there is no universal standardized care plan. However, several have been proposed - using a combination of education, voiding and defecation diaries, toilet training, breathing and relaxation exercises and pelvic floor muscle training (involving exercises and biofeedback)[23].
Physiotherapy for FC focuses on improving coordination between the abdominal and pelvic floor musculature. The strength of physiotherapy is that physical exercises are combined with cognitive and behavioural elements, such as education and toilet training. There have been few trials completed researching the effects of physiotherapy in children with FC, although physiotherapy is expected to give optimal results in children with recent symptom onset[24].
Intervention Strategies | Description |
---|---|
Exercises | 1. Walking in Semi Squat position |
2. Invisible chair | |
3. Frog Squat | |
4. Increasing level of activity --regular physical activity promotes core strength, body awareness and can help reduce stress | |
Biofeedback | Children with FC may have unstable or tensed posturing on the toilet, which prevents the pelvic floor muscles from being able to relax properly[21]. Biofeedback techniques can assist with retraining pelvic floor strength, coordination and rectal sensation. Biofeedback techniques vary considerably among researchers. The most common techniques include anorectal manometry to display sphincter pressures or electromyography (EMG) to display electrical muscular activity[25]. |
Posture | Review toilet posture: 1. Bottom at the back of the toilet seat, feet resting on a stool so that knees are apart and slightly higher than the hips 2. With a straight back, lean forward so the hips are bent 3. Let the tummy bulge forward between the thighs 4. Allow anus (or choose another word with the child such as door or gate, to help them visualize) . Keep breathing slowly and gently, waiting 6. Think about how they feel. Empty or full? Sit for at least 3 minutes[26]. |
Massage | Abdominal "I Love U" Massage along the path of the large intestine: 1) moving from right to left, 2) form the letter "I" by stroking from right hip bone up to right rib cage using moderate pressure, 3) next form the "L" by stroking the letter "I" up to the right ribcage and then across the abdomen to the left ribcage, 4) Finally make the letter U by combing letters "I" and "L" and then finishing by stroking from left ribcage down to left hip bone.
Can start with 5-10min of massage. |
Equipment | 1. Toilet needs to be positioned and at an appropriate level that the child feels comfortable, relaxed, and secure when using it. Consider a child sized toilet seat/insert[26]. Insert can have handles on the side, allows for better leverage when the child is getting ready to "push." |
2. Secure stool to help provide stability and allow for better stool motility, stool should allow for knees to slightly higher than hip height[26]. | |
Environment | 1. Revamp bathroom to make it more comfortable for the child. Is it too dark? have off putting odours? cobwebs present[26]? |
2. Consider making bathroom time more inviting, for example by adding child's favourite pictures[26], and allowing them to take their time in the bathroom. | |
3. Ensure toilet paper is within reach. If child is struggling with wiping consider flushable wet wipes[26]. | |
Breath work | The diaphragm and pelvic floor muscles work together to generate pressure, relax anal sphincters, and lengthen the pelvic floor muscles when having a bowel movement. These are often uncoordinated in children with constipation[21].
1. Deep belly breathing: practice smelling the flowers and blowing out the candles. Can also use other items to assist with breathing exercises, windmill toy, and when not on the toilet can practice blowing bubblies using a straw in a drink. 2. Progressive muscle relaxation: using imagery to help child visualize squeezing and relaxing certain muscles of the body. For example squeezing a lemon and dropping the lemon, "strong pose" showing off arm muscles and letting it go, squeezing through a tunnel and jumping out the other side, etc. |
Behavioural Approach | 1. Toileting routine - help to re-establish automatic signal to use the bathroom. This signal often starts when the stomach is stretched after mealtimes, 20 |
2. Encourage participation - charts, stickers, -- | |
Communication | 1. Recording with bowel diary |
2. How parents react |
Resources[edit | edit source]
Evidently Cochrane: Easing the Strain: put your feet up for constipation
MERCK MANUAL Constipation in Children
Canadian Pediatric Society - Managing Functional Constipation in Children
Canada's Food Guide - Healthy Eating for Parents and for Children
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 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 2.5 2.6 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.
- ↑ Poddar U. Approach to constipation in children. Indian pediatrics. 2016 Apr 1;53(4):319-27.
- ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 Gibas-Dorna M, Piątek J. Functional constipation in children–evaluation and management. Przeglad gastroenterologiczny. 2014;9(4):194.
- ↑ Combs AJ, Van Batavia JP, Chan J, Glassberg KI. Dysfunctional elimination syndromes—how closely linked are constipation and encopresis with specific lower urinary tract conditions?. The Journal of urology. 2013 Sep;190(3):1015-20.
- ↑ 16.0 16.1 16.2 16.3 16.4 Levy EI, Lemmens R, Vandenplas Y, Devreker T. Functional constipation in children: challenges and solutions. Pediatric health, medicine and therapeutics. 2017;8:19.
- ↑ 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.
- ↑ Sopo SM, Arena R, Greco M, Bergamini M, Monaco S. Constipation and cow's milk allergy: a review of the literature. International archives of allergy and immunology. 2014;164(1):40-5.
- ↑ Kuizenga-Wessel S, Heckert SL, Tros W, van Etten-Jamaludin FS, Benninga MA, Tabbers MM. Reporting on outcome measures of functional constipation in children—a systematic review. Journal of pediatric gastroenterology and nutrition. 2016 Jun 1;62(6):840-6.
- ↑ Kovacic K, Sood MR, Mugie S, Di Lorenzo C, Nurko S, Heinz N, Ponnambalam A, Beesley C, Sanghavi R, Silverman AH. A multicenter study on childhood constipation and fecal incontinence: effects on quality of life. The Journal of pediatrics. 2015 Jun 1;166(6):1482-7.
- ↑ 21.0 21.1 21.2 van Engelenburg-van Lonkhuyzen ML, Bols EM, Bastiaenen CH, Benninga MA, de Bie RA. Childhood bladder and bowel dysfunction questionnaire: development, feasibility, and aspects of validity and reliability. Journal of pediatric gastroenterology and nutrition. 2017 Jun 1;64(6):911-7.
- ↑ Akbal CE, Genc Y, Burgu B, Ozden E, Tekgul S. Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population. The Journal of urology. 2005 Mar;173(3):969-73.
- ↑ van Engelenburg–van Lonkhuyzen ML, Bols EM, Benninga MA, Verwijs WA, Bluijssen NM, de Bie RA. The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial. BMC pediatrics. 2013 Dec;13(1):112.
- ↑ van Summeren JJ, Holtman GA, Lisman-van Leeuwen Y, Louer LE, van Ulsen-Rust AH, Vermeulen KM, Kollen BJ, Dekker JH, Berger MY. Physiotherapy plus conventional treatment versus conventional treatment only in the treatment of functional constipation in children: design of a randomized controlled trial and cost-effectiveness study in primary care. BMC pediatrics. 2018 Dec;18(1):249.
- ↑ Lee HJ, Jung KW, Myung SJ. Technique of functional and motility test: how to perform biofeedback for constipation and fecal incontinence. Journal of neurogastroenterology and motility. 2013 Oct;19(4):532.
- ↑ 26.0 26.1 26.2 26.3 26.4 26.5 Royal Children's Hospital Foundation. Managing chronic constipation and soiling in children - conquering poos, a guide to parents & carers. 2012 [cited1 April 2019] Available from: http://www.brisbanenorthphn.org.au/content/Document/Pathways/pathways_parenthandout.pdf