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''This page is for '''pediatric''' patients; for adult patients see [[constipation]].''
==Background==
==Background==
*Functional constipation is the most common, but must evaluate for concerning/organic causes (see DDX)
*There is a wide range of normal frequency of stools and no widely-accepted definition of pediatric constipation.
**In general, stool frequency decreases with age, ranging from 3 per day in neonates/infants to 1.5 per day in young children, reaching adult frequency by roughly 3 yo.<ref>Baaleman DF, Wegh CAM, de Leeuw TJM, van Etten-Jamaludin FS, Vaughan EE, Schoterman MHC, Belzer C, Smidt H, Tabbers MM, Benninga MA, Koppen IJN. What are Normal Defecation Patterns in Healthy Children up to Four Years of Age? A Systematic Review and Meta-Analysis. J Pediatr. 2023 Oct;261:113559. doi: 10.1016/j.jpeds.2023.113559. Epub 2023 Jun 16. PMID: 37331467.</ref>
*Prevalence ranges from 1-30%<ref>Van den Berg, et al. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol. 2006. Oct. 101(10):2401-9.</ref> and comprises a significant proportion of pediatric ED visits.


==Diagnosis==
 
==Clinical Features==
[[File:BristolStoolChart.png|thumb|Bristol Stool Chart.]]
*Most patients note some combination of withholding/infrequent defecation, painful defecation, or crampy abdominal pain
**This can include stools that are too large, too hard, and/or painful to pass
*May be associated with [[abdominal pain (peds)|abdominal cramping]], rectal discomfort, withholding behavior, encopresis
*May be complicated by [[rectal bleeding]], [[anal fissures]], [[fecal impaction]]
*'''Should have a benign "soft" abdominal exam (vs. more concerning abdominal pathologies)'''
 
===Red flags===
*Significant or constant/unrelenting [[abdominal pain (peds)|abdominal pain]]
*[[Failure to thrive]]
**Delayed meconium passage
**Bilious vomiting
**Melena
**Severe abdominal distention
**[[Fever]]


==Differential Diagnosis==
==Differential Diagnosis==
===Pediatric Constipation===
{{Infant Constipation}}
====Infants====
*Hirschsprung’s disease
*Congenital anorectal malformations
*Neurologic disorders
*Encephalopathy
*Spinal cord abnormalities: myelomeningocele, spina bifida, tethered cord
*Cystic fibrosis
*Metabolic causes
**[[Hypothyroidism]]
**[[Hypercalcemia]]
**[[Hypokalemia]]
**diabetes insipidus
*[[Heavy-metal poisoning ]]
*Medication side effects


====Children (older than 1 year)====
===Children (older than 1 year) Constipation===
*Functional constipation (>95% of cases)
*Functional constipation (>95% of cases)
*Organic causes
*Organic causes
**Hirschsprung’s disease  
**[[Hirschsprung's disease]]
**Metabolic causes
**Metabolic causes
***[[Hypothyroidism]]
***[[Hypothyroidism]]
***[[Hypercalcemia]]
***[[Hypercalcemia]]
***[[Hypokalemia]]
***[[Hypokalemia]]
***Diabetes insipidus
***[[Diabetes insipidus]]
***[[Diabetes Mellitus]]  
***[[Diabetes Mellitus]]  
**Cystic fibrosis  
**[[Cystic fibrosis]]
**Gluten enteropathy  
**Gluten enteropathy  
**Spinal cord trauma or abnormalities  
**Spinal cord trauma or abnormalities  
Line 41: Line 48:
{{Pediatric abdominal pain DDX}}
{{Pediatric abdominal pain DDX}}


==Treatment==
==Evaluation==
===Workup===
[[File:Constipation(lots).png|thumb|Stool burden that may be consistent with constipation on [[KUB]]. '''Use of a KUB to diagnose constipation in pediatric patients is generally NOT indicated,''' as other serious pathology may also result in the imaging findings.]]
;Use of a KUB to diagnose constipation in pediatric patients is generally NOT indicated, as [[acute appendicitis]] and other serious pathology may also result in increased stool burden. If the abdominal exam is concerning, proceed to ultrasound/CT.
*''In many cases, may require no workup and diagnosis can be made clinically''
*Consider digital rectal exam
**Although generally not necessary, this may be done to assess for organic causes or to assess for disimpaction success
*Consider abdominal labs
**CBC
**Chemistry ([[hypokalemia]] or [[hypercalcemia]])
**LFTs + lipase
**Coagulation studies (PT, PTT, INR), as a marker of liver function
*Consider [[TSH]] if concern for [[hypothyroid]] related [[constipation]]
*Consider diagnostic imaging
**'''Constipation should not cause abdominal tenderness on exam'''
**Ultrasound if concern for [[intussception]], biliary pathology, and/or beginning of [[appendicitis]] workup
**CT abdomen/pelvis with IV contrast if concern for surgical abdomen
***CT may show stool burden in colon/rectum
 
===Diagnosis===
*'''Note that the emergency physician's primary role is to rule out organic and life-threatening causes of constipation'''
**[[Acute appendicitis]] and other causes of surgical abdomen may present as constipation, in which case the primary emergency medicine goal is ruling out these other conditions
*Pediatric constipation is frequently a clinical diagnosis; the ROME IV criteria may be utilized to diagnose pediatric constipation, but this is not necessary to do in ED
 
==Management==
''While acute disimpaction (oral, rectal, or both) in the ED may be helpful, maintenance therapy (to prevent stool re-impaction) and family education is equally important and may prevent future ED visits.''
 
===Infants===
*Dietary interventions
**Not yet begun solid foods
***Sorbitol-containing juices (eg, apple, prune, or pear), which help increase stool water content and frequency
***For infants four months and older, starting dose: 2-4 ounces of 100-percent fruit juice per day
***Karo syrup, add 1 tsp to 4 oz cooled, boiled water; give 1 oz of solution to baby just before feeds twice a day until stool softens
**Who have begun solid foods<ref>Baby Care Advice. http://www.babycareadvice.com/babycare/microsites/infant_constipation/infant_constipation.old.htm.</ref>
***Sorbitol-containing fruit purees (e.g. pureed prunes).
***Substitute multigrain or barley cereal for rice cereal
***Recommended fiber intake in grams = child's age in years + 5 <ref>Mulhem E, Khondoker F, Kandiah S. Constipation in Children and Adolescents: Evaluation and Treatment. Am Fam Physician. 2022 May 1;105(5):469-478. PMID: 35559625.</ref>
*Disimpaction
**Rectal: Consider glycerin suppositories or lubricated rectal thermometer as forms of rectal disimpaction; however, this may create tolerance if used frequently
**PO: Consider [[Polyethylene glycol 3350]] 0.4 g/kg/day PO as a first-line agent, followed by [[Lactulose]] 1 mL/kg PO as a second-line agent
**Note that enemas are often not recommended for infants < 2 years due to increased risk of iatrogenic electrolyte derangements or rectal perforation.<ref>Soumoy MP, Bachy A. Danger des lavements phosphatés chez le nourrisson [Risk of phosphate enemas in the infant]. Arch Pediatr. 1998 Nov;5(11):1221-3. French. doi: 10.1016/s0929-693x(98)81238-4. PMID: 9853060.</ref>
 
===Toddlers and children===
*WITHOUT withholding behavior, bleeding, or [[anal fissure]]
**Fiber: age + (5 to 10) grams daily
**Adequate fluid intake: 32-64 ounces [960-1920 mL] per day
*WITH withholding behavior, pain while defecating, [[rectal bleeding]] or [[anal fissure]]
**[[Polyethylene glycol 3350]](e.g., Miralax) is the first-line treatment 0.4 g/kg/day MAX 6 days or [[Lactulose]] 1 mL/kg PO
*Enemas
**Saline enema, 5-10 mL/kg
**Mineral oil enema, 15-30 mL/year
**Sodium phosphate (Fleet) enema, approximately 1 oz for 2-4 yo, 2.25 oz for 5-11 yo, 4.5 oz for > 12 yo <ref>Neal S. LeLeiko, Sarah Mayer-Brown, Carolina Cerezo, Wendy Plante; Constipation. Pediatr Rev August 2020; 41 (8): 379–392. https://doi.org/10.1542/pir.2018-0334</ref>
*Stimulants such as [[Bisacodyl]] (Dulcolax) PO/suppository and [[Senna]] can be used as short term medications but are less studied in clinical trials compared to polyethylene glycol<ref>Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74. doi: 10.1097/MPG.0000000000000266. PMID: 24345831.</ref>
 
==Disposition==
*Outpatient pediatrician follow-up
*Consider urgent vs nonurgent referral to a pediatric gastroenterologist if red-flag symptoms are present


==See Also==
==See Also==
*[[Constipation]]
*[[Constipation]]
*Tables on neonatal constipation differential and normal stool/urine output<ref>Helman, A. Morgenstern, J. Ivankovic, M. Long, B. Reid, S. Swaminathan, A. EM Quick Hits 25 – Cerebral Venous Thrombosis, Diphenhydramine Alternatives, Abdominal Compartment Syndrome, Neonatal Constipation, Intubating Metabolic Acidosis. Emergency Medicine Cases. January, 2021. https://emergencymedicinecases.com/em-quick-hits-jan2021/ Accessed 1/26/2021</ref>.


==Source==
==References==
<references/>


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:GI]]
[[Category:GI]]

Latest revision as of 16:54, 29 January 2025

This page is for pediatric patients; for adult patients see constipation.

Background

  • Functional constipation is the most common, but must evaluate for concerning/organic causes (see DDX)
  • There is a wide range of normal frequency of stools and no widely-accepted definition of pediatric constipation.
    • In general, stool frequency decreases with age, ranging from 3 per day in neonates/infants to 1.5 per day in young children, reaching adult frequency by roughly 3 yo.[1]
  • Prevalence ranges from 1-30%[2] and comprises a significant proportion of pediatric ED visits.


Clinical Features

Bristol Stool Chart.
  • Most patients note some combination of withholding/infrequent defecation, painful defecation, or crampy abdominal pain
    • This can include stools that are too large, too hard, and/or painful to pass
  • May be associated with abdominal cramping, rectal discomfort, withholding behavior, encopresis
  • May be complicated by rectal bleeding, anal fissures, fecal impaction
  • Should have a benign "soft" abdominal exam (vs. more concerning abdominal pathologies)

Red flags

Differential Diagnosis

Infant Constipation

Children (older than 1 year) Constipation

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

Evaluation

Workup

Stool burden that may be consistent with constipation on KUB. Use of a KUB to diagnose constipation in pediatric patients is generally NOT indicated, as other serious pathology may also result in the imaging findings.
Use of a KUB to diagnose constipation in pediatric patients is generally NOT indicated, as acute appendicitis and other serious pathology may also result in increased stool burden. If the abdominal exam is concerning, proceed to ultrasound/CT.
  • In many cases, may require no workup and diagnosis can be made clinically
  • Consider digital rectal exam
    • Although generally not necessary, this may be done to assess for organic causes or to assess for disimpaction success
  • Consider abdominal labs
    • CBC
    • Chemistry (hypokalemia or hypercalcemia)
    • LFTs + lipase
    • Coagulation studies (PT, PTT, INR), as a marker of liver function
  • Consider TSH if concern for hypothyroid related constipation
  • Consider diagnostic imaging
    • Constipation should not cause abdominal tenderness on exam
    • Ultrasound if concern for intussception, biliary pathology, and/or beginning of appendicitis workup
    • CT abdomen/pelvis with IV contrast if concern for surgical abdomen
      • CT may show stool burden in colon/rectum

Diagnosis

  • Note that the emergency physician's primary role is to rule out organic and life-threatening causes of constipation
    • Acute appendicitis and other causes of surgical abdomen may present as constipation, in which case the primary emergency medicine goal is ruling out these other conditions
  • Pediatric constipation is frequently a clinical diagnosis; the ROME IV criteria may be utilized to diagnose pediatric constipation, but this is not necessary to do in ED

Management

While acute disimpaction (oral, rectal, or both) in the ED may be helpful, maintenance therapy (to prevent stool re-impaction) and family education is equally important and may prevent future ED visits.

Infants

  • Dietary interventions
    • Not yet begun solid foods
      • Sorbitol-containing juices (eg, apple, prune, or pear), which help increase stool water content and frequency
      • For infants four months and older, starting dose: 2-4 ounces of 100-percent fruit juice per day
      • Karo syrup, add 1 tsp to 4 oz cooled, boiled water; give 1 oz of solution to baby just before feeds twice a day until stool softens
    • Who have begun solid foods[3]
      • Sorbitol-containing fruit purees (e.g. pureed prunes).
      • Substitute multigrain or barley cereal for rice cereal
      • Recommended fiber intake in grams = child's age in years + 5 [4]
  • Disimpaction
    • Rectal: Consider glycerin suppositories or lubricated rectal thermometer as forms of rectal disimpaction; however, this may create tolerance if used frequently
    • PO: Consider Polyethylene glycol 3350 0.4 g/kg/day PO as a first-line agent, followed by Lactulose 1 mL/kg PO as a second-line agent
    • Note that enemas are often not recommended for infants < 2 years due to increased risk of iatrogenic electrolyte derangements or rectal perforation.[5]

Toddlers and children

  • WITHOUT withholding behavior, bleeding, or anal fissure
    • Fiber: age + (5 to 10) grams daily
    • Adequate fluid intake: 32-64 ounces [960-1920 mL] per day
  • WITH withholding behavior, pain while defecating, rectal bleeding or anal fissure
  • Enemas
    • Saline enema, 5-10 mL/kg
    • Mineral oil enema, 15-30 mL/year
    • Sodium phosphate (Fleet) enema, approximately 1 oz for 2-4 yo, 2.25 oz for 5-11 yo, 4.5 oz for > 12 yo [6]
  • Stimulants such as Bisacodyl (Dulcolax) PO/suppository and Senna can be used as short term medications but are less studied in clinical trials compared to polyethylene glycol[7]

Disposition

  • Outpatient pediatrician follow-up
  • Consider urgent vs nonurgent referral to a pediatric gastroenterologist if red-flag symptoms are present

See Also

  • Constipation
  • Tables on neonatal constipation differential and normal stool/urine output[8].

References

  1. ↑ Baaleman DF, Wegh CAM, de Leeuw TJM, van Etten-Jamaludin FS, Vaughan EE, Schoterman MHC, Belzer C, Smidt H, Tabbers MM, Benninga MA, Koppen IJN. What are Normal Defecation Patterns in Healthy Children up to Four Years of Age? A Systematic Review and Meta-Analysis. J Pediatr. 2023 Oct;261:113559. doi: 10.1016/j.jpeds.2023.113559. Epub 2023 Jun 16. PMID: 37331467.
  2. ↑ Van den Berg, et al. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol. 2006. Oct. 101(10):2401-9.
  3. ↑ Baby Care Advice. http://www.babycareadvice.com/babycare/microsites/infant_constipation/infant_constipation.old.htm.
  4. ↑ Mulhem E, Khondoker F, Kandiah S. Constipation in Children and Adolescents: Evaluation and Treatment. Am Fam Physician. 2022 May 1;105(5):469-478. PMID: 35559625.
  5. ↑ Soumoy MP, Bachy A. Danger des lavements phosphatés chez le nourrisson [Risk of phosphate enemas in the infant]. Arch Pediatr. 1998 Nov;5(11):1221-3. French. doi: 10.1016/s0929-693x(98)81238-4. PMID: 9853060.
  6. ↑ Neal S. LeLeiko, Sarah Mayer-Brown, Carolina Cerezo, Wendy Plante; Constipation. Pediatr Rev August 2020; 41 (8): 379–392. https://doi.org/10.1542/pir.2018-0334
  7. ↑ Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74. doi: 10.1097/MPG.0000000000000266. PMID: 24345831.
  8. ↑ Helman, A. Morgenstern, J. Ivankovic, M. Long, B. Reid, S. Swaminathan, A. EM Quick Hits 25 – Cerebral Venous Thrombosis, Diphenhydramine Alternatives, Abdominal Compartment Syndrome, Neonatal Constipation, Intubating Metabolic Acidosis. Emergency Medicine Cases. January, 2021. https://emergencymedicinecases.com/em-quick-hits-jan2021/ Accessed 1/26/2021
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