Constipation (peds)

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

Background

  • There is a wide range of normal frequency of stools and no widely-accepted definition of pediatric constipation.
  • Prevalence ranges from 1-30%[1]

Clinical Features

Bristol Stool Chart.
  • Most patients note some combination of infrequent defecation, painful defecation, or both.
    • 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)

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.
  • Consider digital rectal exam
  • Consider abdominal panel
    • 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 UA
  • 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
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
    • In patients with concerning symptoms/risk factors, ultrasound/CT can confirm diagnosis and rule out more emergent conditions
  • Pediatric constipation is frequently 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[2]
    • Sorbitol-containing fruit purees (e.g. pureed prunes).
    • Substitute multigrain or barley cereal for rice cereal

Toddlers and children

Disposition

  • Outpatient

See Also

  • Constipation
  • Tables on neonatal constipation differential and normal stool/urine output[3].

References

  1. Van den Berg, et al. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol. 2006. Oct. 101(10):2401-9.
  2. Baby Care Advice. http://www.babycareadvice.com/babycare/microsites/infant_constipation/infant_constipation.old.htm.
  3. 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