MANAGEMENT OF THE CONSTIPATED PATIENT IN THE PEDIATRIC SETTING John T. Stutts, MD, MPH University of Louisville Department of Pediatrics Division of Pediatric Gastroenterology DISCLOSURE • The speaker has been a part of the speaker bureau for Abbott Nutrition in the past. LOUISVILLE.EDU DEFINITION • Constipation: “A delay or difficulty in defecation, present for ≥ 2 weeks and sufficient to cause significant distress to the patient.”1 • Encopresis: “The involuntary loss of formed, semi-formed, or liquid stool in the child’s underwear, in the presence of functional constipation after the child has reached a developmental age of 4 years.”1 LOUISVILLE.EDU CONSTIPATION: PREVALENCE • As many as 3% of visits to the primary care physician.1 • As many as 25% of visits to the pediatric gastreoenterologist.1 • 16 – 37% of otherwise healthy 4 to 11 year old children have constipation.2-6 LOUISVILLE.EDU IN YOUR CLINIC ….. • Constipation is the #1 cause of abdominal pain. • If the chief complaint is abdominal pain …. think constipation until proven otherwise. LOUISVILLE.EDU IN YOUR CLINIC ….. • A question not to ask: - Is your child constipated? • A better question that will give you a clearer picture: - How many days does your child skip between bowel movements? LOUISVILLE.EDU FUNCTIONAL VS. ORGANIC • Functional Constipation - An umbrella term describing persistent, difficult, infrequent or seemingly incomplete defecation without evidence of a primary anatomic or biochemical cause.7 - Accounts for greater than 95% of constipation-related symptoms in children and infants, except those during the neonatal period when organic causes are more likely.7 LOUISVILLE.EDU FUNCTIONAL: ETIOLOGY • 3 critical time periods - Introduction of cereals/solids - Toilet training - Start of school LOUISVILLE.EDU FUNCTIONAL • Infant Dyschezia - At least 10 minutes of straining and/or crying before successful passage of soft stool in an otherwise healthy infant < 6 mos of age. - The symptom is due to failure to relax the pelvic floor during the defecation effort and resolves spontaneously.8 LOUISVILLE.EDU FUNCTIONAL • Fecal Incontinence - In children with constipation, there is no clear difference in the pathophysiology or psychology between children with and without fecal incontinence.9 LOUISVILLE.EDU FUNCTIONAL: TREATMENT • 2 phases to treatment - Phase 1: The Cleanout - Phase 2: Maintenance Phase 1 is arguably the most important! LOUISVILLE.EDU FUNCTIONAL: CLEANOUT OPTIONS • Enemas - Phosphate Enemas Adult (≥ 3 yoa) Pediatric (< 3 yoa) - SMOG (Saline, Mineral Oil, Glycerin) - Milk and Molasses • Magnesium Citrate - 1 oz per year of age to a max of 10oz - once daily x 3-6 days - not for infants/toddlers • Polyethylene glycol - “multiple doses” vs “the gallon” LOUISVILLE.EDU FUNCTIONAL: MAINTENANCE OPTIONS • Osmotic - Polyethylene glycol (1 capful = 17 grams) 3 yoA ½ capful Q day 6 yoA ½ capful BID *10 yoA 1 capful BID 13 yoA 1 – 1 ½ capfuls BID 18 yoA 1 – 2 capfuls BID LOUISVILLE.EDU FUNCTIONAL: MAINTENANCE OPTIONS • Osmotic - Milk of Magnesia ≤ 1 year 2 – 6 years 7-8 years ≥ 9 years 1-2 tsp BID 2 tsp BID 1 T BID 2 T BID - Lactulose 1 – 3 mL/kg/day LOUISVILLE.EDU FUNCTIONAL: MAINTENANCE OPTIONS • Lubricant - Mineral Oil • Not recommended • Lipoid pneumonia if aspirated • Stimulant - Senna ≤ 2 yrs 2 – 4 yrs 5 – 6 yrs 7 – 9 yrs ≥ 10 yrs ¼ - 1 tsp BID ½ - 1 tsp BID 1 tsp BID 1 tablet BID 2 tablets BID LOUISVILLE.EDU HOW DO WE COME OFF THE LAXATIVE? • Fiber is the KEY! AGE DOSE 1 – 3 years 15 grams/day 4 – 8 years 20 grams/day 9 – 12 years 25 grams/day ≥ 13 years 30 grams/day • Wean the laxative slowly!! LOUISVILLE.EDU SO WHEN IS IT MORE THAN JUST CFC? • The question of Organic etiology… LOUISVILLE.EDU ORGANIC CONSTIPATION • Organic causes are responsible for fewer than 5% of cases of constipation in children. LOUISVILLE.EDU ORGANIC CONSTIPATION • Anatomic - Anal stenosis Imperforate anus Anteriorly displaced anus Pelvic mass (sacral teratoma) • Metabolic - Hypothyroidism Hypercalcemia Hypokalemia Cystic Fibrosis Diabetes Mellitus Celiac disease MEN type 2B • Neuropathic - Tethered cord • Intestinal nerve/muscle disorder - Hirschsprung's disease - Visceral myopathies • Abnormal abdominal musculature - Prune-belly - Down syndrome - Gastroschisis • Connective tissue disorders - Scleroderma LOUISVILLE.EDU ORGANIC CONSTIPATION • Medications - Opiates - Antacids - Phenobarbital • Miscellaneous - Cow’s milk protein intolerance - Lead ingestion - Botulism10,11 LOUISVILLE.EDU COW’S MILK PROTEIN ALLERGY/INTOLERANCE • 0.3 – 7.5% of normal infants • Think about this in the infant who has constipation in association with rhinitis, dermatitis or bronchospasm • Options: - Dairy elimination for the breast feeding mother - Casein Hydrolysate formulas - Elemental amino acid-based formulas12,13 LOUISVILLE.EDU HIRSCHSPRUNG'S DISEASE • More than 90% of normal infants, but only 10% of infants with Hirschsprung's disease, pass meconium within the first 24 hours of life.14 LOUISVILLE.EDU HIRSCHSPRUNG'S DISEASE • A motor disorder of the colon caused by failure of neural crest cells to migrate completely during colonic development. • The result … the affected segment of the colon fails to relax causing a functional obstruction.14 LOUISVILLE.EDU HIRSCHSPRUNG'S DISEASE • Consider in the following circumstances: The “classic triad” present in 82% of cases. - Delayed passage of meconium (after 48 hours of life) - Abdominal distention - Vomiting - Onset of symptoms in the first week of life - A transition zone on contrast enema14 LOUISVILLE.EDU HIRSCHSPRUNG'S DISEASE: DIAGNOSIS • Rectal exam – The “Wine Goblet” Explosion… VS H.D. CFC LOUISVILLE.EDU HIRSCHSPRUNG'S DISEASE: DIAGNOSIS • Unprepped contrast enema - If H.D. present, a transition zone will be seen ~ 70% of the time. • Anorectal manometry - When the rectal balloon is inflated, reflex relaxation of the internal anal sphincter fails to occur. LOUISVILLE.EDU HIRSCHSPRUNG'S DISEASE: DIAGNOSIS • Rectal suction or full-thickness biopsy ═ The definitive test - absence of ganglion cells - high acetylcholinesterase accumulation on staining LOUISVILLE.EDU CYSTIC FIBROSIS • Constipation is common • DIOS = Distal Ilial Obstruction Syndrome LOUISVILLE.EDU TETHERED CORD SYNDROME • What is it exactly? Stretch-induced dysfunction of the caudal spinal cord and conus caused by attachment of the filum terminale to inelastic structures caudally. LOUISVILLE.EDU TETHERED CORD SYNDROME • Associated signs/symptoms - constipation - bladder dysfunction - weak lower extremity reflexes • Diagnosis - MRI of the lumbosacral spine • Treatment - Neurosurgical release LOUISVILLE.EDU ORGANIC PEARLS • If since the neonatal period, there has been constipation (especially with delayed passage of meconium)…. do an unprepped contrast enema. LOUISVILLE.EDU ORGANIC PEARLS • If a patient has recurrent UTIs, consider constipation as an etiology due to mechanical effects of the distended rectum pressing on the bladder. LOUISVILLE.EDU ORGANIC PEARLS • If the patient has FTT, RAP and constipation (+/- anemia), consider celiac disease. LOUISVILLE.EDU ORGANIC PEARLS • If there is spinal dysraphism or neurological impairment of the lower extremities and/or daytime wetting in association with constipation, obtain an MRI of the lumbosacral spine. LOUISVILLE.EDU ORGANIC PEARLS • If there is impaired linear growth and depressed reflexes…. consider hypothyroidism. LOUISVILLE.EDU ORGANIC PEARLS • If at risk of electrolyte disturbances (metabolic abnormalities or unable to tolerate adequate fluids)….. check a serum Calcium. LOUISVILLE.EDU ORGANIC PEARLS • If at risk for lead toxicity…. test for it. LOUISVILLE.EDU ORGANIC PEARLS • If the H & P remains equivocal for etiology, don’t be afraid to get a KUB …. but remember the readings can be inconsistently interpreted. So, don’t be afraid to look at the film yourself. LOUISVILLE.EDU Thank you! REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Baker SS, Liptak GS, Colletti RB, et.al. Constipation in infants and children: evaluation and treatment. J Ped Gastro Nutr 1999;29(5):612-626. Issenman RM, Hewson S, Pirhonen D, et. al. Are chronic digestive complaints the result of abnormal dietary patterns? Am J Dis Child 1987;141(6):679-682. Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary school children. Amb Child Health 1998;4:277-282. de Araújo Sant’Anna AM, Calҫado AC. Constipation in school-aged children at public schools in Rio de Janeiro, Brazil. J Ped Gastroenterol Nutr 1999;29(2):190-193. Zaslavsky C, Ávila EL, Araújo MA, et. al. Constipaҫão intestinal da infância – um estudo de prevalência. Rev AMRIGS 1988;32:100-102. Maffei HVL, Moreira FL, Oliveira WM, et. al. Constipaҫão intestinal em escolare. J Pediatr 1997;73:340-344. Thompson WG, Longstreth GF, Drossman DA, et. al. Functional bowel disorders and functional abdominal pain. Gut 1999;45:1143. Hyman PE, Milla PJ, Benninga MA, et. al. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology 2006;130:1519. Benninga MA, Bϋller HA, Heymans HS, et. al. Is encopresis always the result of constipation? Arch Dis Child 1994;71:186. DiLorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am 2001;30:269. Thiessen PN. Recurrent abdominal pain. Pediatr Rev 2002;23:39. Magazzu G, Scoglio R. Gastrointestinal manifestations of cow’s milk allergy. Ann Allergy Asthma Immunol 2002;89:65. Turunen, et al. Lymphoid hyperplasia and cow’s milk hypersensitivity in children with chronic constipation. J Pediatr 2004;145:606. Lewis NA, et. al. Diagnosing Hirschsprung’s disease: increasing the odds of a positive rectal biopsy result. J Pediatr Surg 2003;38:412.