Treatment Guideline Chart

Constipation is a delay or difficulty in bowel movement persisting for ≥2 weeks.
It is a common digestive problem, not a disease, and usually not serious caused by changes in diet and early toilet training.
Constipation in children generally first happens in the toddler stage, between ages 2 and 4 years, with studies showing variation in gender-specific prevalence.
Functional constipation is  the one that cannot be explained by any anatomical, physiological, radiological or histological abnormalities.
Organic constipation is with identifiable physiological or organic cause.
Chronic constipation is the constipation that lasts for >8 weeks.

Constipation%20in%20children Patient Education

Patient Education

  • Family education includes providing information on the mechanism of constipation
  • Encourage parents to have a consistent, positive and supportive attitude during treatment
  • Knowing the precipitating factors of constipation helps remove anxiety of parents and caregivers and encourages them to be involved in its management
  • Educate the parents on the proper timing and techniques of toilet training
    • Toilet training should only be started when the child is developmentally ready or shows signs of readiness, and using a relaxed approach
    • A potty chair or foot support (if adult-sized toilet is used) should be provided
  • Treatment may be long and irregular and characterized by improvement alternating with relapses

Lifestyle Modification

Behavioral Therapy

  • Aims to regularize toilet habits, discourage stool withholding and improve understanding of defecation dynamics
  • To establish a regular bowel habit, recommend scheduled toileting appropriate for the child’s developmental stage, with adequate time for bowel movement
    • Encourage the child to sit on the toilet for 5-10 minutes after meals; when in school, it is alright for the child not to go to the toilet
    • Advise parent to give child enough time to spend in the toilet when child shows signs of withholding stool
  • Straining techniques such as relaxation of legs and feet, taking a deep breath then pausing while pushing while holding one’s breath, should be taught to the child
  •  Maintain a bowel diary of stool frequency and consistency which can be discussed during clinic visits
    •  For positive reinforcement, encourage and reward the child’s efforts and not the results
  •  It may be of benefit to refer to a mental health provider for intervention if behavioral problems interfere with treatment, but it is discouraged to do it routinely

Biofeedback Therapy

  • Uses devices (electrical or mechanical) in order to increase awareness of physiological functions of anal sphincter by providing the patient with visual, verbal and/or auditory information and enhances self-control on body functions
  • With the rise of the rectal pressure, patients are taught external anal sphincter relaxation
  • Demonstrated efficacy in correcting abnormal defecation dynamics in previous studies but failed to show additional benefit in the treatment of chronic childhood constipation
  • Currently used only for children with pelvic floor dyssynergia and short-term treatment of intractable constipation
  • Not to be used for ongoing treatment of children with functional constipation

Dietary Modification

  • Although commonly recommended for treatment of functional constipation, it is discouraged to use dietary modification alone as 1st-line treatment
  • For infants, the following are recommended:
    • Continue breastfeeding
    • For formula-fed infants, partially or extensively hydrolyzed infant formulas with prebiotics offer a good alternative for managing functional constipation
    • Helpful for infants are complex carbohydrates [eg carob bean gum, galacto-oligosaccharides (GOS), inulin] and sorbitol present in some juices, eg apple, prune, pear, which increase stool frequency and fecal water content
    • Barley malt extract or corn syrup can be used as stool softeners
  • A high-fiber diet is encouraged to help form soft bulky stool in children
    •  A 0.5 g/kg body weight intake of fiber is recommended in children >2 years
    •  A balanced diet with fruits, vegetables, and whole grains is appropriate for treatment
  •  A double-blind crossover study demonstrated intolerance to cow’s milk may result in constipation; however, withholding milk from the diet should be done only on the advice of a specialist, as it is not a common occurrence
    • May consider elimination of cow's milk protein for at least 2 weeks in patients unresponsive to other interventions especially if with atopic symptoms
  • Probiotics (eg Lactobacillus sp, Bifidobacterium sp) may help improve stool frequency and consistency; however studies are limited and further trials are needed to support the use of probiotics in children with functional constipation
  •  Increased intake of fluids is also recommended; however, studies have shown that doing so only increased urine output and had no effect in output or consistency of stool and did not improve stool frequency
    •  Increase intake of absorbable and non-absorbable carbohydrates especially sorbitol, found in some juices like prune, pear and apple juice
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