constipation%20in%20children
CONSTIPATION IN CHILDREN

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.

Principles of Therapy

  • Treatment goals in general include evacuation, pain-free bowel movement, & formation of regular bowel habits

Pharmacotherapy

Disimpaction

  • If fecal impaction is present, initial therapy is to evacuate the colon
    • Fecal impaction is identified through a physical exam finding of palpable stool on abdominal & rectal exam & excessive stool on abdominal x-ray
  • Disimpaction may be done with oral or rectal medications or a combination of these two & in uncontrolled clinical trials, these had been effective
    •  It is important to discuss options with the family regarding treatment choice

Oral Disimpaction

  • Eg high-dose Mineral oil, Polyethylene glycol (PEG) electrolyte solutions, high-dose Magnesium citrate, Magnesium hydroxide, Sorbitol, Lactulose, Senna, or Bisacodyl
  • Preferred due to its non-invasiveness but adherence may be difficult
  • PEG is the recommended 1st-line therapy for children presenting with fecal impaction

Rectal Disimpaction

  • Considered only when oral medications have failed & only with the child or family’s consent
  • May be done with saline or phosphate soda enemas or a mineral oil enema followed by a phosphate enema
    • Glycerin suppositories in infants is recommended but enema to be avoided
    • Bisacodyl suppositories in older children are used
    • Soap suds, tap water & magnesium are potentially toxic & are not recommended
  • Digital disimpaction is not recommended or discouraged
  •  Follow-up is needed within one week for children undergoing disimpaction

Maintenance Therapy

  • Following disimpaction, maintenance therapy is then started & may be needed for several months
  • Monitoring is essential during this time to ensure the child does not become reimpacted & to address issues such as adherence & toileting
  • Frequency of clinic visits is individualized based on the child’s needs & of the family’s
  • It is recommended that the same person or team perform the reassessment
  • Laxatives are advantageous in children until they are able to maintain regular toilet habits
  • Clear evidence is lacking as to which laxative is superior
  • Discontinuation of maintenance therapy may be considered if the child has developed regular bowel habits

Bulk-forming Laxatives

  • Eg Ispaghula (Psyllium), Methylcellulose
  • Used for treatment & prolonged prophylaxis of patients with constipation without outlet obstruction
  • Often used as first-line treatment & only used if increased dietary fiber is ineffective
  • Water-absorbing organic polymers that increase fecal mass & make it softer & easier to pass, adequate intake of fluid is important

Enemas

  • Eg Glycerol, Sodium chloride, Sodium phosphate, Phosphate enemas
  • Not recommended for infants
    • Increases risk for mechanical trauma to rectal wall, abdominal distention, vomiting
  • Disimpaction with enemas is a recommended option for children
  •  Phosphate enemas are used after disimpaction with the use of other enema

Lubricants

  • Eg Mineral oil
  • Not recommended in infants
  • Used for managing acute or subacute constipation
  • Soften stool & ease its passage by decreasing water absorption from the gastrointestinal (GI) tract

Osmotic Laxatives

  • Eg poorly absorbed electrolytes Magnesium hydroxide, Magnesium citrate, Magnesium sulfate, & poorly absorbed disaccharides Lactulose & Sorbitol, & PEG 3350/4000
  • For long-term treatment of constipation that is difficult to manage, low-dose Polyethylene glycol (PEG) electrolyte solution may be used
  • PEG with or without electrolytes is recommended as first-line maintenance therapy & Lactulose should be considered if PEG solutions are not available
  • Lactulose & Sorbitol are used in infants as stool softeners
  • Produces an osmotic effect in the colon resulting in distention & peristalsis promoting bowel emptying
  • Changes water distribution in the stool causing fluid retention in the colon through osmosis, good fluid intake is essential

Stimulant Laxatives

  • Eg Anthraquinones (Senna, Cascara, Danthron), diphenylmethanes (Bisacodyl), Castor oil, Glycerol, Sodium picosulfate
  • In the maintenance period, it is not recommended to use stimulant laxatives for a prolonged time
    • It is also not recommended in infants
  • Used as a “rescue therapy” when taken intermittently or for short periods
  •  Directly stimulates colonic nerves, increase peristalsis in the GI tract, induce water & salt secretion in the colon

Stool Softeners

  • Eg Docusate sodium, Liquid paraffin
  • Stool softeners may be combined with a stimulant
    • While softening stool, the stimulant increases peristaltic activity in the GI tract
  • Used for prophylaxis in acute & subacute settings
  •  Surface-active agents that allow absorption of fat & water into the stool making it softer & easier to pass
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