Constipation (peds)

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

Background

Clinical Features

There is a wide range of normal frequency of stools
Hard stools or painful defecation
May be associated with abdominal pain, 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)

Differential Diagnosis

Infant Constipation

Constipation
Hirschsprung's disease
Congenital anorectal malformations
- Imperforate anus
Bowel obstruction
Neurologic disorders
Encephalopathy
Spinal cord abnormalities: myelomeningocele, spina bifida, tethered cord
Meconium ileus
- Cystic fibrosis
Metabolic causes
Heavy-metal poisoning
Medication side effects

Children (older than 1 year) Constipation

Functional constipation (>95% of cases)
Organic causes
- Hirschsprung's disease
- Metabolic causes
- Cystic fibrosis
- Gluten enteropathy
- Spinal cord trauma or abnormalities
- Neurofibromatosis
- Heavy-metal poisoning
- Medication side effects
- Developmental delays
- Sexual abuse

Pediatric Abdominal Pain

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.

Consider basic labs
Consider abdominal ultrasound and/or CT
Consider UA

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.

Diagnosis

Consider and, if necessary, rule out other more concerning diagnoses first
Pediatric constipation is typically a clinical diagnosis

Management

Infants

Glycerin suppositories or rectal stimulation with a lubricated rectal thermometer can be used if there is very hard stool in rectum, but may cause irritation and develop tolerance.

Not yet begun solid foods
- Sorbitol-containing juices (eg, apple, prune, or pear)
- 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^[1]
- Sorbitol-containing fruit purees (e.g. pureed prunes).
- Substitute multigrain or barley cereal for rice cereal

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) 0.4 gms/kg/day MAX 6 days

Disposition

Outpatient

References

↑ Baby Care Advice. http://www.babycareadvice.com/babycare/microsites/infant_constipation/infant_constipation.old.htm.
↑ 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

Authors:

[1] Baby Care Advice. http://www.babycareadvice.com/babycare/microsites/infant_constipation/infant_constipation.old.htm.

[2] 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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