Symposium: gastroenterologyManagement of chronic constipation in children☆
Introduction
Constipation, derived from the Latin ‘constipare’, meaning ‘to cram together’, is the commonest gastrointestinal disorder comprising up to 25% of referrals to tertiary paediatric gastroenterology clinics. In primary, secondary and tertiary care, there are more consultations for constipation management than for other periodic, chronic conditions such as asthma or migraine. Chronic constipation is a heterogeneous group of disorders, and is often late-presenting. It is defined by infrequent and or difficult passage of stools, and is a clinical diagnosis that should be based on symptoms that fulfil the ROME III criteria (see Table 1).
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Prevalence
The reported prevalence of constipation varies from 0.8 to 28% and the condition has a wide geographic variability, with the highest reported prevalence in the USA and the lowest in Finland. Pathogenesis is multifactorial with research focussing on environmental factors, behavioural problems and genetic predisposition. Environmental factors such as activity level and diet but also low maternal education level or social circumstance play a part. The association with behaviours is complex because
Physiology of defaecation
Enteric content enters the colon via the ileocaecal valve. Stools are formed by the progressive absorption of water, and are propelled along the colon to the rectum. Stool is stored until a socially acceptable time to defecate. The rectum stores and eliminates stool through a complex mechanism involving pelvic floor muscles, the autonomic and somatic nervous systems. The anorectal angle, formed by the anal sphincter complex and puborectalis muscle is crucial to successful storage and
Pathophysiology of constipation
Whilst the majority (more than 90%) of children with chronic constipation will be considered to have functional, idiopathic constipation, exclusion of organic causes is important (summarised in Table 2). Constipation is also an important side effect of several classes of medicines and is commonly encountered in children receiving opiates, antacids or iron.
Coeliac disease is commonly thought of as causing diarrhoea, but constipation is seen, possibly due to anorexia or changes in ileal function
Pitfalls
Although the ROME III criteria (Table 1) appear self-explanatory, history-taking can be difficult. The key features in history are described in Box 1. Care must be taken. Often history depends upon reports by parents or other carers, and may be subject to over- or under-reporting bias. Functional constipation may often present late, or with abdominal pain or spurious diarrhoea. A large faecal mass in the rectum gives the sensation of incomplete evacuation and children may try to open their
Newborn – 4 months
99% of term infants pass meconium within the first 24 hours following delivery. Very low birth weight or premature infants can have non-pathological delay in opening their bowels. 94% of children with Hirschsprung's Disease and 25% of those with cystic fibrosis have initial delay in the passage of meconium. Newborn babies generally have a higher stool frequency of around 4/day but there is particularly high variability amongst breast-fed babies who can sometimes not open their bowels for days
Investigations
At all ages, if the history and examination are suggestive of functional constipation and there are no abnormal findings on examination, further investigations are not indicated. If a child has long standing constipation that has been resistant to treatment or there are worrying features then the following investigations may be considered [see Table 3].
Management
The overall aim of management of childhood constipation should be rapid diagnosis and restoration of regular, pain free bowel movements at the appropriate time in the appropriate place with the minimum amount of laxatives possible. Effective management (summarised in Figure 1) relies on a good relationship with the family and interventions to treat the underlying cause and not just the symptom.
Pharmacological treatment
Success of pharmacological treatment (summarised in Figure 2, Figure 3) relies on addressing the underlying causes of constipation and the non-pharmacological advice should be reviewed and reinforced each time a child comes to clinic. When medicines are required for treatment it is helpful to divide the treatment regimen into disimpaction and maintenance therapies [see below].
Constipation management is complicated and requires regular review and assessment particularly at the beginning of
Disimpaction
Disimpaction can be achieved at home but families will need support. Children are asked to drink large volumes of PEG 3350 which can be difficult to tolerate. A stimulant laxative is added if disimpaction has not been achieved by 2 weeks. In practice, in severe cases may require enemas. A recent RCT compared daily enemas with 1.5 g/day PEG 3350 and found no significant difference in efficacy or in behaviour scores, measuring fear/distress, caused by the treatment. The NICE guideline recommends
Maintenance treatment
It is good practice to follow up the initial visit with a phone call and to review children regularly to ensure adequate disimpaction. Constipation is often most effectively managed in the community by a specialist nurse who forms a relationship with the family and provides regular support over the phone and in clinic. The addition of a stimulant laxative such as senna once stools are soft is often necessary to overcome stool withholding. Stimulant laxatives work by increasing intestinal
Discussion
Constipation is a distressing symptom for children and their families and is time consuming and difficult medical problem to manage. Management of constipation can be dispiriting as often symptoms persist and families often become very frustrated. It is important to provide targeted and appropriate lifestyle advice. Laxatives alone will rarely be sufficient to cure any patient of chronic constipation. While most children are unable to entirely change their lifestyle the importance of the
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This article is based on a previously published article of the same name, published in this journal issue 22(10): 401–8.