Constipation in Infants and Children

1. Constipation in Infants and Children Jason Dranove, MD Levine Children’s Hospital Carolinas Medical Center Division of Pediatric Gastroenterology, Hepatology, and Nutrition 2011

3. Newborns • First meconium stool usually within the first 36 hours of birth in normal newborns • 90% pass stool within 24 hours • This may happen later in preterm infants without underlying structural defects • First week of life normal newborn has 4 stools per day, with some variability • Breastfed infants can stool with each feeding or only once every 7 to 10 days • Formula fed infants tend to stool more regularly than breastfed infants • Soy formulas known to cause harder stools • Protein Hydrolysate and Elemental formulas associated with looser stools

4. Delayed passage of meconium • Intestinal Obstruction / Anatomical Malformation • Hirschsprung’s Disease • Meconium Ileus • Functional Ileus • Small left colon • Maternal Drugs • Hypothyroidism

5. Normal Frequency of Bowel Movements Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology & Nutrition. 43(3):e1-e13, September 2006.

6. Constipation in Infants and Toddlers At least two of the following present for at least one month • Two or fewer defecations per week • At least one episode of incontinence after the acquisition of toileting skills • History of excessive stool retention • History of painful or hard bowel movements • Presence of a large fecal mass in the rectum • History of large-diameter stools that may obstruct the toilet

7. Infantile Dyschezia In children less than 6 months old • At least 10 minutes of straining and crying • Successful passage of a soft stool • Otherwise healthy and thriving

8. Constipation in Children 4-18 YO Children with developmental age of at least 4 to 18 years Two of the following present for at least two months • Two or fewer defecations per week • At least one 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 may obstruct the toilet

9. Nonretentive Fecal Incontinence Must include all of the following in a child with a developmental age at least 4 years • Defecation into places inappropriate to the social context at least once per month • No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject’s symptoms • No evidence of fecal retention

10. Functional vs. Organic -- Functional • Over 95% of Constipated children has functional constipation • Functional: persistent, difficult, infrequent, or seemingly incomplete defecation without evidence of underlying structural or metabolic defect • Most commonly due to with-holding after a painful bowel movement • Presents most commonly at three age periods • At introduction of cereals and solid foods • At toilet training • At the start of school

11. Functional Constipation • Classic History • Child has a painful bowel movement • When urge to have a bowel movement happens, the child consciously withholds stool by contracting their external anal sphincter and gluteal muscles • The child might rise on their toes, rock back and forth, stiffen their buttocks and legs, assume unusual postures, and often will hide in a corner • Eventually, the rectum habituates to the stimulus of the enlarging fecal mass, the urge to defecate subsides, and the retentive behavior becomes almost second nature or subconscious • Can develop soiling (encopresis)

12. Functional vs. Organic -- Organic • Accounts for less than 5% of all constipation • Anatomic malformations • Metabolic causes • Neuropathic conditions • Intestinal nerve and muscle disorders • Drugs • Hypotonia • Miscellaneous

13. Distinguishing Functional vs. Organic -- History • Presentation in neonatal period more likely to be organic as compared to older children • Clues from history (red flags) • Delayed growth • Delayed passage of meconium • Urinary incontinence or bladder disease • Passage of blood (unless attributable to an anal fissure) • Constipation from birth or very early infancy • Acute onset of constipation • Vomiting • Signs of systemic illness, multisystem involvement • Recurrent respiratory infections • History of sexual, physical, or emotional abuse

14. Functional vs. Organic – Physical exam clues • Abdominal distension • Findings of spinal dysraphism • Patulous anus • Absent cremasteric reflex (boys) • Absent anal wink • Pigmentation, dimples, or tufts of hair over lumbosacral region • Anorectal malformation • Anteriorly displaced anus • Sensory or motor defects of the lower extremities • Inability to insert a pinky in the anal canal • Gush of stool after a rectal exam upon which no stool is felt in the rectal vault

15. Clues to Hirschsprung’s disease • Aganglionic bowel extending for variable lengths from the internal anal sphincter • 75-80% confined to rectosigmoid • Incidence about 1:5000 • Male to female 4:1 • Almost exclusively a disease of full term infants • 80-90% diagnosed within first 3 years • Mean age of diagnosis is 2.6 months

16. Barium enema for Hirschsprung’s Transition zone

17. Other Metabolic Causes of Constipation • Celiac disease • Hypothyroidism • Spinal dysraphism • Cystic Fibrosis • Botulism • Hypokalemia / Hypercalcemia • Lead poisoning

18. Evaluation of Constipation Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology & Nutrition. 43(3):e1-e13, September 2006.

19. Overall approach to management • Determine whether fecal impaction present • Treat impaction if present • Initiate treatment with oral medications • Provide parental education • Close follow up • Adjust medications as necessary

20. Management and Treatment of Constipation -- > 1 YO • Red Flags Present • Yes – Evaluate further • No – Presume and treat functional constipation • Is a fecal impaction present (mass of stool felt on abdominal exam or large rectal fecal mass on DRE) • If not comfortable performing rectal exam – KUB can help • Yes – Disimpact with oral or rectal medication, then move to maintenance medication • If fail disimpaction, refer to Pediatric GI • No – Start maintenance treatment with with education, diet, medication • Continued …..

21. Management and treatment of Constipation > 1 YO • Maintenance therapy • Effective – Attempt to wean after several months of success • Ineffective – Reassess, re-educate, increase or change medications • If effective on second try – go into maintenance phase and attempt to wean again in future • If ineffective on second trial of treatment • T4, TSH, Calcium, Celiac panel (total IgA and anti ttG IgA antibody), lead level • If abnormal, treat as indicated • If tests normal, refer to pediatric GI

22. Pediatric GI • After referral is made • Determine appropriate workup • Vast majority of referral patients can be managed without much diagnostics • When refractory to treatment, consider further workup • Anorectal manometry • Barium enema • Spine MRI • Radio-opaque marker studies • Full thickness rectal biopsy • Colonic manometry

23. Management and treatment of Constipation -- < 1 YO • Similar to that of Children > 1 YO • Differences • If delayed passage of meconium • Refer to Pediatric GI or Surgery for rectal biopsy • If rectal biopsy normal – sweat test • 1st line treatment can be diet alone • Prune or apple juice, 2-4 ounces a day

24. Education • Family friendly explanation of constipation • Reassure that this is not a willful or defiant behavior • Maintain consistent, positive, supportive attitude • Avoid punishment • Establish a reward system

25. Twice a day for 10-15 minutes after breakfast and dinner Gastrocolic reflex Sit up straight Thighs parallel to ground Good foot support Valsalva maneuver to increase abd pressure Blow up balloon No distractions Reasonable reward system Toilet Hygiene

26. Disimpaction • Impaction • a hard mass in the lower abdomen identified during physical examination, or • A dilated rectum filled with a large amount of stool on rectal exam, or • Excessive stool in the colon identified by radiography • Disimpaction • Oral • Rectal • Oral and Rectal • Best determined after discussion with family • Manual

27. Disimpaction • LCH approach • High dose Polyethylene Glycol (Miralax) • Age 1-2 • 2 teaspoons of Miralax with 4 oz of clear liquid and drink repeat every hour until stool is clear • Age 3-5 • 4 capfuls of Miralax in 24 ounces of Gatorade given 4 oz q 30 – 60 minutes until gone • Age 6-11 • 6 capfuls of Miralax in 32 oz of Gatorade given 4 oz q 30-60 minutes until gone • Age 12 and older • 8 capfuls of Miralax in 32 oz of Gatorade given 4 oz q 30-60 minutes until gone • Stimulant laxative • Age 3-11 • Bisacodyl 5 mg at beginning and end of cleanout • Age 12 and up • Bisacodyl 10 mg at beginning and end of cleanout

28. Enema • Fleets Phosphosoda enema • < 2 YO not recommended • 2 – 4 YO = 33.75 ml (1/2 of a Pediatric Fleets enema <Pedia Lax>) • 5-11 YO = 67.5 ml (full Pediatric Fleets enema <Pedia-Lax>) • 12 YO and up – 118 ml (adult Fleet enema) • Retention of enema • Hyperphosphatemia • Hypocalcemia • Never give more than one enema per day • If enema not evacuated, do not give a second enema

29. Goals of treatment • 1 to 2 soft (mashed potato or soft ice cream) consistency stools per day • Resolution of soiling • Return of rectal sensation • Empowerment of child • Make defecation a positive experience

30. Non absorbed sugars • Juices • Prune • Apple • White grape juice • Increase osmotic load and draw water into bowel • OK to use after roughly 2 mo of age

31. Lactulose • Second line in infants < 6 mo not responding to juice • Limited role in those over 6 mo secondary to success of PEG 3350 • Comes 10 g / 15 ml • Dose = 1-3 ml/kg/day in single or divided doses • Usually start ½ to 1 teaspoon a day and increase as needed • Side effects • Cramps, flatulence, “colicky” behavior

32. PEG 3350 • Safe for use down to 6 months of age • Comes 17 grams in a cap • Roughly 4 teaspoons is in one cap (1 teaspoon = roughly 4 to 5 grams of PEG 3350 • Easier to dose by teaspoon in infants • Typical dose for maintenance is roughly 0.7 g/kg/day • In older children typically start at max of 17 grams twice a day but can increase if needed • Technically no max dose • If not responding to 34 grams a day in older child or roughly 1 g/kg/day in younger child, consider adding a stimulant laxative, re-education, or referral

33. Sample Treatment regimen for older child (non infant) • Start Miralax at discussed doses • Increase or decrease dose by small amounts until desired effect is reached • Follow up within 1 month • Aggressive Approach • After 8 weeks of soft daily bowel movements, begin to taper by small amounts every couple of weeks (1/4 of dose at a time is a good guide) until BM achieved without laxative • If stools become hard again during taper, increase to the last effective dose and maintain for another 8 weeks • Conservative approach • Continue laxatives for 6 months of soft daily bowel movements, then wean slowly

35. Stimulants • Senna • Comes 8.8 mg/5ml or 8.8 mg tabs • 2-6 YO – 2.5 to 7.5 ml a day • 6-12 YO – 5-15 ml a day • Try to limit to periodic dosing • With regular use drug can lose effectiveness • Anecdotal evidence • Bisacodyl • 0.2 mg/kg/dose, max 10 mg per dose • Comes in 5 and 10 mg tabs • Use intermittently or for short periods • Has very high side effect profile • Cramping, diarrhea, abdominal pain, nausea

36. Others • Mineral oil • Do not use for < 1 YO due to aspiration risk • Magnesium citrate • Magnesium hydroxide • Karo Syrup • Suppositories

37. Diet • Controversial whether dietary changes can treat constipation • Mild constipation • Increase fluid intake • Increase fiber intake • Goal is age + 5 in grams per day • Mild to severe constipation • Diet alone unlikely to treat constipation • Role of excessive cow’s milk intake • controversial

38. Inpatient bowel cleanout • Polyethylene Glycol Electrolyte solution • 100 ml / kg up to max of 4 liters • Likely will need Nasogastric administration • Can run at rates up to 1 L per hour • Personal experience • Run in over 8 hours • If stool not clear may repeat • If severe impaction not responding • Consult Pediatric Gastroenterology • Manual Disimpaction under anesthesia

39. Treatments Not recommended • Milk and Molasses enema • Soap suds enema • Tap water enema • Oral Phosphosoda • Nephropathy • FDA warning

40. Non retentive encopresis • Soiling in the absence of fecal impaction or constipation • Cause unknown • High correlation with attention deficit and psychological comorbidities • Up to 40% were never fully toilet trained • Treatment • Unfortunately limited • Psychologist • Regimented toileting schedule

41. Colonic Manometry

42. Colonic Manometery

43. Anorectal Manometry

44. Anorectal Manometry

45. Case 1 3 YO male with infrequent, hard bowel movements. Stools can clog the toilet. He has a normal physical and is thriving? --What is the diagnosis --Is any workup indicated --What is the treatment?

46. Case 2 18 month old female Constipation, abdominal distension, poor growth, frequent wheezing and chronic cough Mom can not remember if she passed meconium within 1st day of life What is the differential diagnosis? Would you do any workup?

47. Case 3 3 month old male, full term infant Abdominal distension, poor growth, has developed vomiting Rectal exam – can not get pinky into anal canal Differential diagnosis? Workup?

48. Case 4 • 3 YO female. Was doing well until about 9 months of age, then started to fall off growth curve. Has distended abdomen, extremity wasting, no history of respiratory infection. Differential diagnosis Workup?

49. Case 5 • 2 YO female with constipation since birth • Did pass meconium on day of life 1 • No abdominal distension, normal growth • Physical exam reveals a pit over the lumbosacral area with hair covering it? • Differential diagnosis • Workup

50. Question 1 • What is the appropriate screening test for celiac disease • A. Anti gliadin antibody • B. HLA DQ2-DQ8 genotype • C. Ttg IgG and serum IgA • D. Ttg IgA and serum IgA • E. TgG Iga alone