1-s2.0-S1751722212000492-main

Diagnosis of functional constipation is as per the ROMEIII criteria

Infants up to 4 years should have at least two symptoms for 1

month prior to diagnosis and those over 4 years at least two of the

following symptoms present for the previous 2 monthsa,b:

SYMPOSIUM: GASTROENTEROLOGY

Management of chronicconstipation in childrenLucy J Howarth

Peter B Sullivan
C Two or fewer defaecations per week
C At least 1 episode of faecal incontinence per week

C Retentive posturing or stool retention.

C Painful or hard bowel movements

C Presence of a large faecal mass in the rectum

C Large diameter stools that may obstruct the toilet

a Without objective evidence of a pathological condition.b Without fulfilling irritable bowel syndrome criteria.

Table 1

AbstractChildren are commonly affected by constipation. Management of chronic

constipation requires a good understanding of the underlying pathophys-

iology. The presentation and management of constipation varies by age.

This review aims to give the reader a clear guide to diagnosis, investiga-

tion, pharmacological and non-pharmacological management of chronic

constipation in children. The way in which pathology can interrupt normal

physiology and features of the clinical history are described. It will outline

the age dependent presentation and management of chronic, functional

constipation based on the best available evidence and examine the

NICE guideline for laxative use in children.

Keywords chronic constipation; clinical diagnosis; age dependent

presentation; red flag symptoms and signs; investigations; laxative

treatment; non-pharmacological treatment

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 gastro-

enterology 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 (Table 1).

Definitions

The 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 envi-

ronmental factors, behavioural problems and genetic predispo-

sition. Environmental factors such as activity level and diet but

Lucy J Howarth BM MRCPCH is a Specialist Registrar in Paediatric

Gastroenterology in the University Department of Paediatrics,

Children’s Hospital, John Radcliffe Hospital, Headington, Oxford, UK.

Conflict of interest: none.

Peter B Sullivan MA MD FRCP FRCPCH is Reader in Paediatric Gastroenter-

ology, Honorary Consultant Paediatrician, University Department of

Paediatrics, Children’s Hospital, John Radcliffe Hospital, Headington,

Oxford, UK. Conflict of interest: none.

PAEDIATRICS AND CHILD HEALTH 22:10 401

also low maternal education level or social circumstance play

a part. The association with behaviours is complex because

constipation can be both caused by and cause changes in

behaviour. Significantly higher rates of constipation have been

reported amongst mothers of constipated children as opposed to

fathers or siblings of a constipated child. A genetic component is

likely to be part of the pathogenesis of functional constipation

but no mutations in specific genes have been linked.

Like many other functional gastrointestinal disorders the

pathophysiology and prognosis are variably understood by

medical practitioners. This results in a large variety of strongly

held beliefs and management strategies. To understand con-

stipation in childhood it is necessary to have a good knowledge

of normal physiology, the wide range of normality and the role of

diet and behaviour.

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 defae-

cation. This angle is 85e105� at rest. The rectum is usually

empty but distension of the rectal wall with stool descending

from the sigmoid colon causes a temporary reflex relaxation of

the internal anal sphincter allowing stool to come into contact

with sensitive receptors in the anal canal. The rectoanal inhib-

itory reflex results in a contraction of the internal sphincter,

inhibiting defecation. The process, however, alerts the indi-

vidual to the presence of stool, liquid or flatus in the rectum. An

indication of the exquisite sensory innervation of the anorectum

is the ability to distinguish between distension caused by solid,

liquid or gas. An inability to do this would have disastrous

social consequences.

Once a child has an opinion about the appropriate time to

respond to this signal, a voluntary process of defaecation is either

begun or overruled. If the sensation on passing stool is pain (for

� 2012 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.paed.2012.03.007


example when the stool is both large and hard) then even very

young children can resist the urge to push. Such stool with-

holding e often misinterpreted as straining to evacuate stool e is

frequent in toddlers. If the individual decides the time is right

then increased intrarectal pressure comes from straining of intra-

abdominal muscles and pelvic floor muscles to push faeces

towards the anal canal. The puborectalis muscle relaxes to allow

the descent of the pelvic floor, straightening the anorectal angle

and inhibiting the internal and external anal sphincters, allowing

faeces to be expelled. In newborn babies and very young infants

the voluntary element of control is not yet developed so defae-

cation occurs following initial distension of the rectal wall

(Table 1).

Pathophysiology of constipation

Whilst the majority of children with chronic constipation will be

considered to have functional, idiopathic constipation, exclusion

of organic causes is important (Figure 2).

Coeliac disease is commonly thought of as causing diarrhoea,

but constipation is seen, possibly due to anorexia or changes in

ileal function or gut motility. Constipation is prevalent in Cystic

Fibrosis, and is under-reported. There is an association with low

total fat absorption and a history of meconium ileus.

Neuromuscular conditions can affect the gut. Smooth

muscle cells and intestinal cells of Cajal play a major role in

normal gut motility. These cells ensure regular contractions of

the colonic wall and propulsion of content. Constipation is

often seen in patients with Cerebral Palsy and Duchenne

Muscular Dystrophy. In patients with spinal muscular atrophy

(SMA) proximal muscle weakness is a cardinal feature. In most

of these patients constipation is a problem because of reduced

abdominal muscle tone as well as disturbed innovation of the

myenteric plexus.

Children with significant developmental delay are more prone

to constipation for a wide variety of reasons depending on their

underlying disorder. For example, children with cerebral palsy

often have dysmotility problems. Disorders that affect the enteric

nervous system such as hereditary sensory and autonomic

neuropathy (previously known as Riley-Day syndrome) are

associated with constipation. Normal gastrointestinal motility is

disturbed by abnormal autonomic function.

Constipation can be a feature of disorders that affect water/

electrolyte balance such as diabetes insipidus. This can lead to

reduced water content i.e. harder stools or as a result of muscle

weakness causedbyelectrolyte imbalance.Otherendocrinediseases

such as MEN3 and hypothyroidism can present with constipation.

It is important that there is a general awareness of the wide

range of rare pathologies that may present with constipation as

effective management depends on an understanding of the

underlying pathophysiology. Constipation should be regarded as

a symptom and not a disease. Anorectal malformations and

Hirschsprung’s disease are amongst the commoner pathologies

underlying very early onset childhood constipation.

History

Pitfalls

Although the ROME III criteria (Table 1) appear self-explanatory,

history-taking can be difficult. Often it 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 chil-

dren may try to open their bowels several times a day. If only

small amounts of soft/liquid stools are passed around the sides of

the obstructive faecal mass, this is termed overflow, or overflow

diarrhoea. Anal canal trauma from passage of hard or large stool

can present with bright red rectal bleeding or severe anal pain.

Pain may exacerbate the problem, as it will inhibit defecation.

Key features in history taking

� Delay in passage of meconium

� Age at onset

� Relation to toilet training

� Toileting history-stool frequency, consistency, pain, soil-

ing, presence of blood

� Stool withholding behaviour

� Urinary symptoms (13% of those with constipation have

urinary symptoms)

� Abdominal pain

� Diet-history of exacerbation with particular foods such as

cow’s milk or evidence of a poor diet low in fruit and fibre.

� General health and developmental milestones

� Family history

� Social history

Age dependent presentation

Newborn e 4 months: ninety nine percent of term infants pass

meconium within the first 24 h 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 without being constipated. It is

unusual for babies to become constipated in the first 4 months

unless they have a congenital/anatomical abnormality, systemic

upset or possibly cow’s milk protein allergy. A change from

breast to formula feeding can result in constipation or the use of

‘hungrier baby’ milk with higher sodium content.

� It is unusual for young babies to develop chronic

constipation.

� Beware of red flags in the history and examination

� Late passage of meconium

� Systemically unwell

� Anatomical anomalies

� Developmental delay

5 months to potty training: during this period infants start to

wean from milk onto a variety of foods. The commonest cause of

constipation in this age group is change in diet and consistency

of stools. As baby rice and high fibre foods are added to an

infant’s diet, stools become more bulky. It is common for

parents to describe long periods of straining and sometimes pain

associated with large diameter stools. Often early constipation




can be treated effectively with change in weaning foods, such as

an increase in fruits such as pear and less baby rice until the

infant’s digestive system has adapted. In babies with reflux, no

response to laxatives or a family history of atopy, a trial of

a dairy-free diet (cow’s milk and soya) may be helpful. A clear

association with cow’s milk protein allergy and constipation has

been demonstrated.1 Many children start to take gluten in their

diet at 9e12 months and if gastrointestinal symptoms including

constipation start at this time then coeliac disease should be

considered.

Toddlers who have had the sensation of pain following the

passage of a hard stool are at high risk of stool withholding and

rapidly worsening constipation. It is important to ask questions

about posturing during a bowel movement as withholding

behaviours can easily be misinterpreted as straining. In toddlers

nearing 3 or at the time of potty training it is very important that

a period of time has passed with soft stools to allow them to gain

confidence and lose their fear of opening their bowels prior to

any attempts to encourage them to use a potty or toilet. Often

subtle manipulations in diet and fluid intake can be helpful.

Some children are prone to constipation and some may drink

insufficient fluid particularly in hot weather. A consultation

with a paediatric dietician is invaluable, but may not be readily

available.

� Constipation is often related to dietary changes

� Do not forget the association with cow’s milk protein

allergy and coeliac disease

� Stool withholding may result from painful defaecation and

can be easily mistaken for straining

Age of toilet training: this is a common time for children to

become constipated. The age at which children start toilet

training varies between and within families. There is evidence

that early toilet training is associated with a higher incidence of

constipation. The optimum time is when a child is able to

communicate their desire to ‘do a poo’, has enough motor

control to be able to overrule an urge if no toilet is available and

can sit and actively strain on a toilet when the time is right. Many

children and families find this stage of development a stressful,

frustrating and unpleasant time. The transition can be very

frightening to young children. The inconvenience of cleaning up

accidents and the patience necessary to encourage young chil-

dren to successfully toilet train should not be underestimated.

Many families need help with this stage of normal development

and may benefit from support groups or parenting classes. Long

standing constipation often starts with difficulties with early

toilet training and adverse toileting behaviour.

� It is always important to ask about the ease of potty

training as this is a common time for constipation to begin

School age children: children generally learn to use their own

toilet at home but need their parents’ ongoing support, praise and

bottom wiping for some years afterwards. When children start

full time school they need to be independent. Schools have

variable amounts of support available for toileting needs of

young reception age children. Toilets may be inaccessible from

the playground or lunch hall and young children are often scared

to go alone, unable to do up buttons or wipe their own bottom.

This is a time where stool withholding and inevitable


constipation is common. One approach that can be helpful is to

try and emphasise the importance of adequate time before school

for breakfast and going to the toilet. Sometimes there are

improvements that can be made to privacy at school or the

decorative state of the toilets to make them more appealing.

There are often significant changes in diet at this time with

children eating school dinners and having to make independent

choices about what they do and don’t eat. Dietetic assessment at

this age is very helpful and it is important to involve the child in

education about healthy eating and a diet that has adequate fruit,

fibre and fluid. Children are usually only allowed to drink water

at school and many prefer juice prior to this and so drink much

less than usual while running around more. This dehydration can

exacerbate constipation.

� Practical tips to improve toileting behaviour such as

ensuring enough time for breakfast can be helpful

� Involve children in advice about lifestyle changes

Older children and early teens: children can become acutely

constipated at any stage following an infection, change in diet,

routine (e.g. moving house or school) or emotional upset. When

reviewing older children early history remains important as

symptoms are often long standing. Eating disorders need to be

considered. Constipation can present with abdominal pain,

nausea, anorexia or soiling. Rarely soiling may occur because of

an involuntary leakage of soft stool around faeces impacted in

the rectum. This will cause significant psychological morbidity.

Older children who have been constipated for some time and

who are soiling regularly are often bullied and become with-

drawn and disengaged with education. Families find the

symptom of soiling understandably difficult to manage and often

feel anger and resentment towards the child who they often

blame for the problem. Treatment must address underlying

issues and offer support to the child and the family.

� Constipation can present with a variety of symptoms and

often families need a lot of reassurance that there is no

serious underlying pathology

� Symptoms have often been longstanding

Key features in examination

� General health, plot on growth chart

� Look for evidence of systemic illness, faltering growth,

anaemia

� Abdominal palpation

� Evidence of faecal loadingþ/� a faecal mass-can be

difficult in the child is obese

� Perianal region and digital rectal examination

� It is important that the perianal region is examined for

signs of fissures, soiling, infection (such as group A

streptococcus) or anatomical anomalies. A rectal exam-

ination should only be performed if it gives additional

information: a sudden gush of stool may be found in

a child with Hirschsprung’s disease post examination.

Hard, impacted stool may be found confirming the need

for a faecal disimpaction

� Neurological exam, including inspection of the lumbar-

sacral spine and examination of the lower limbs

� Spinal abnormalities or spinal cord tumours can present

with constipation (Table 2)



Organic causes of childhood constipation

Structural colorectal Spinal cord Systemic Neuropathic lesions

of intestine

Drugs Other important causes

Anal stenosis Spinabifida Diabetes Hirschsprung disease Opioid analgesia Coeliac disease

Post NEC/IBD stricture Sacral agenesis Hypothyroid Intestinal neuronal

dysplasia

Antacids Cystic fibrosis

Chronic intestinal

pseudoe obstruction

Spinal cord tumours Hypo/hypercalcaemia Iron Cows milk protein allergy

Neurofibromatosis Cholestyramine

Cerebral palsy

Table 2

Investigation of children with chronic constipation

Investigation Indication Change to management

Plain abdominal radiograph Not usually indicated May be useful to exclude sacral agenesis

or other spinal abnormalities.

Occasionally used to provide families with

visual evidence of constipation

Bowel transit studies

Radio eopaque shapes swallowed

daily for 5 days and then an

abdominal radiograph performed

to assess the transit time of the shapes

Not routinely indicated e interpret with

caution as shapes can adhere to the

colonic mucosa.

Useful in children with chronic diarrhoea

or soiling for whom there is uncertainty

about constipation as the underlying cause

If delayed transit shown it is more

acceptable to families to comply with

the advice for a child to undergo

disimpaction of faeces.

Anorectal manometry Not indicated in young children.

Demonstrates whether there is normal

relaxation of the internal anal sphincter

in response to rectal dilation.

Can demonstrate anatomical reasons

underlying constipation. May need

referral to a colorectal surgeon.

Endoscopy May be indicated if there is possibility

of cow’s milk protein enteropathy

May demonstrate eosinophilic enteropathy

Full thickness rectal biopsy To exclude Hirschsprungs disease if delay

in early passage of meconium or only able

to pass paste like stools with long

standing constipation or abdominal distension.

Surgical excision of aganglionic bowel

with temporary colostomy followed by

a later pull through anastamoses

Coeliac screen tissue

transglutaminase or endomysial

antibodies þ immunoglobulin A levels

All children with long standing constipation

not responding to initial management.

If serology positive will need

endoscopic duodenal biopsies and

histological confirmation of the

diagnosis while on full gluten

containing diet.

Gluten free diet should lead to

a resolution of symptoms

Electrolytes and glucose Concerning features of history or examination

or not responding to treatment. Exclude

hypo/hypercalcaemia.

Urine dip-exclude diabetes.

Treat electrolyte abnormality

Thyroid function Infants with early constipation and

developmental delay. Family history of

thyroid disease. Clinical suspicion

Thyroxine replacement.

Fbc and iron studies Iron deficiency anaemia common because

of poor diet. Iron therapy can cause constipation.

Treat iron deficiency anaemia

Table 3


PAEDIATRICS AND CHILD HEALTH 22:10 404 � 2012 Elsevier Ltd. All rights reserved.



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 treat-

ment or there are worrying features then the following investi-

gations may be considered (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 manage-

ment relies on a good relationship with the family and inter-

ventions to treat the underlying cause and not just the symptom

(Figure 1).

Non-pharmacological treatment of constipation

Diet and lifestyle: Education about normal physiology and

healthy eating habits is a cornerstone of management. There is

wide variability in the adequacy of children’s diets and multiple

factors including socioeconomic status, health beliefs of families

and eating habits of individual children. There is a clear corre-

lation between inadequate fibre and fluid intake and also

evidence that it is very difficult to change eating habits of fami-

lies. There is insufficient evidence to suggest a high fibre or high

fluid intake is beneficial and is difficult to comply with.2 A die-

tetic assessment is extremely useful to accurately assess an

individual child’s diet and make recommendations that are likely

to be acceptable/manageable for their family. The recommended

fibre intake in children over 2 is their age in years plus 5 g per

day. Two weetabix provide 3.8 g fibre. The importance of

Figure 1 Non-pharmacological treatment of constipation.


breakfast as a meal and starting the family day earlier to make

time for breakfast, activity and then a relaxed attempt at opening

bowels using the gastrocolic reflex and achieving a clear out prior

to nursery/school is useful advice. Although there is a lack of

trial evidence to support the effectiveness of increased physical

activity in constipation management, it is a common observation

that obesity and lack of physical activity are associated with

constipation.

� A diet sufficient in fruit, fibre and adequate fluid will be

essential to an effective cure.

� Increased activity levels are helpful

Toileting behaviour

Difficulties with the transition from nappies to potty/toilet are

common and it is always useful to help family’s access advice

about toilet training. The basic principal of ignoring failure and

praising success is important to convey. Improving the envi-

ronment in the toileting area can be effective. Some children like

to listen to music or read books while sitting and straining on the

toilet. Breathing techniques can be useful to overcome fear. Some

children find blowing bubbles or blowing up balloons help with

their efforts to push a stool out. It can be helpful for children to

have a foot-stool to rest their feet on while opening their bowels

or a cushioned seat that can be smaller than the full adult sized

seat.

� A non-punitive approach is necessary to improve toileting

behaviour

� Aim to improve the whole toileting experience

Psychological assessment

Many children and families who have been struggling with

chronic constipation benefit enormously from psychological

input. There are many issues which commonly arise such as

toilet phobia, depression, distress from bullying, or abuse and

clinical psychologist have many effective strategies that help

children.

Behaviour modification through reward

Reward schemes are often successful; depend on a consistent

approach and the child being old enough to respond. Star charts

can be used, which can be as simple as a blank sheet of paper

with stars for eating breakfast, sitting on the toilet, taking

medication, doing a poo on the toilet or dealing with relevant

issues. It is important that the rewards are awarded frequently

enough to be seen as valuable by the child.

� Star charts should be used at appropriate ages

Pharmacological treatment

Success of pharmacological treatment 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.

Constipation management is complicated and requires regular

review and assessment particularly at the beginning of laxative

treatment. In children with acute onset constipation or mild

symptoms lifestyle manipulations may be enough. For the

majority seeking medical help it will be necessary to start a laxa-

tive. If the underlying problem is infrequent passage of large, hard

stools then it is logical that a faecal softener should be the first line




treatment. For many children with overflow diarrhoea, soiling or

long standing symptoms disimpaction of large volume, hard stool

in the rectum is essential before any management strategies or

lifestyle changes will have any effect. There is little trial data to

guide stimulant laxative use but there is widespread consensus

amongst specialists that they are often required either to ensure

adequate disimpaction or as a maintenance agent.

A systematic review of the literature showed only 50% of all

children started on laxative treatment followed for 6e12

months are shown to recover and be asymptomatic whilst no

longer on laxatives.3 It is important that expectations are

managed and the length of treatment with laxatives is not

underestimated.

Figure 2


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 trying oral stool softeners and stimu-

lants or sole agent stimulant laxative such as senna or sodium

picosulpahte (elixir) or picolax (sachet) prior to rectal medi-

cation (Figure 2).



Osmotic laxatives

Age Dose Mechanism of action Side effects

Lactulose Infants under 2 1e3 ml/kg Non-absorbable disaccharide

of sugars D-galactose and D-fructose.

Fermented by colonic bacteria

producing hyperosmolar by-products

Relating to fermentation

by-products with excess

gas production leading

to flatulence, bloating

and abdominal cramps.

PEG 3350

(with electrolytes)

Movicol

Only licensed for over

2 years but recommended

by NICE as 1st line for all

0.3e0.8 g/kg/day

maintenance

1e1.5 g/kg/day

disimpaction

Large molecular size. Not absorbed.

Produces a direct osmotic effect.

No impact on electrolyte balance.

Diarrhoea, abdominal

distension, nausea

Table 4


Maintenance treatment

It is good practice to follow-up the initial visit with a phone call

and to review children regularly to ensure adequate dis-

impaction. 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.4,5 The addition of a stimulant laxative such as

senna once stools are soft is often necessary to overcome stool

witholding. There are a wide number of osmotic and stimulant

Stimulant laxatives. As recommended by NICE

Age Dose Mechanism of action

Sodium

picosulphate

Elixir 5 mg/5 ml

Child 1 month

to 4 years

Child 4e18 years

2.5e10 ml od

2.5e20 ml od

Stimulating the mucos

causing peristalsis, and

increased motility and

By bacterial cleavage t

in the colon.

Action after 6e12 h

Bisacodyl Orally

Child 4e18 years

Rectally

Child 2e18 years

5e20 mg od

5e10 mg od

Diphenylmethane laxat

stimulates intestinal fl

secretion and colonic c

Senna Elixir 7.5 mg/5 ml

Child 1 month

to 4 years

Child 4e18 years

2.5e10 ml od

2.5e20 ml od

Anthraquinone laxative

accumulation in the di

metabolism. This occu

comesinto contact with

For this reason, senno

but not by suppository

Docusate

sodium

6 monthse2 years

2e12 years

12e18 years

12.5 mg tds

12.5e25 mg tds

500 mg/day in

divided doses

An anionic surfactant t

of water, allowing wate

softening the stool. Do

affect by increasing cA

mucosal cells which in

Table 5


laxatives available. Trial evidence commonly suffers from

small sample sizes and short duration of follow-up. There have

been recent randomized trials and a meta analysis of efficacy

for PEG 3550. Two systematic reviews compared PEG 3350

with placebo in the treatment of chronic constipation in chil-

dren. PEG 3350 significantly improved pain during defaecation

and increased the number of stools per week but did not

significantly reduce the number of incontinent episodes

(Table 4).6

Side effects

a of both the colon,

the rectum, causing

a feeling of rectal fullness.

he active form is formed

ive, which, when activated,

uid

ontraction

Withdrawn in the United States after

rodent studies suggested carcinogenic

links. Subsequent studies have not

demonstrated an increased risk of

cancer in humans taking

phenolphthalein laxatives

increase fluid and electrolyte

stal ileum and colon after

rs only when the prodrug

intestinal micro-organisms.

sides can be given orally

Changes in the colon produced by

chronic anthraquinone use include

melanosis coli, a benign and

reversible condition. No evidence

exists that anthraquinone laxatives

given in clinically appropriate doses

cause enteric damage

hat reduces surface tension

r to penetrate the intestine,

cusate also has a stimulatory

MP concentrations in colonic

creases contractility.




Stimulant laxatives

Work by increasing intestinal motility. Intermittently stimulant

laxatives receive adverse press and as the side effects can be more

prominent. As the safety and long term efficacy in children is not

proven, the use of stimulants should be regularly reviewed (Table 5).

Practice points

C The diagnosis of functional constipation in childhood should

be clinical and be based on fulfilling the ROME criteria

C It is important to exclude underling pathology that either

directly or indirectly causes constipation as a symptom

C Investigations shouldbe tailored to childrenwhohaveconcerning

signs or symptoms and be based on the clinical history

C It is important to be aware of the differences in presentation at

different ages, and underlying causes of constipation

C Treatment should be targeted on the underlying cause and be

based on lifestyle modification and effective use of appro-

priate laxatives

C Management of constipation benefits from a multidisciplinary

team approach and families need ongoing support to improve

the success of treatment

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 non-pharmacological

treatment of constipation is crucial to its successful management.

With the development of chronic constipation, possibly exac-

erbated by stool withholding, the rectum changes from being

highly sensitive to distension by stool to a large, distended sac

unresponsive to distension. Moreover, the longer the condition

persists themore likely it is that therewill be histological changes in

the lining (mucosa) of the rectum. Atrophy of the rectal muscula-

ture with degeneration (focal muscle fibre vacuolation) of muscle

or even muscle fibre disappearance has been found in all chroni-

cally constipated children where this has been looked for. These

changes are long-lasting and manometric (pressure) studies show

that abnormal anorectal function is still present many years after

the cessation of treatment and recovery from chronic constipation.

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 frus-

trated. It is important to provide targeted and appropriate life

style 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 non-

pharmacological treatment of constipation is crucial to its

successful management. A

REFERENCES

1 Borrelli O, Barbara G, Di Nardo G, et al. Am J Gastroenterol 2009; 104:

454e63;

Cafferelli C, Coscia A, Baldi F, et al. Characterization of irritable bowel

syndrome and constipation in children with allergic diseases. Eur J

Pediatr 2007; 166: 1245e52.

2 Sullivan PB, Alder N, Shrestha B, Turton L, Lambert B. Effectiveness of

using a behavioural intervention to improve dietary fibre intakes in

children with constipation. J Hum Nutr Diet 2012; 25(1): 33e42.


3 Pijpers MA, Bongers ME, Benninga MA, Berger MY. Functional con-

stipation in children: a systematic review on prognosis and predictive

factors. J Pediatr Gastroenterol Nutr 2010; 50: 256e68.

4 Burnett CA, Juszczak E, Sullivan PB. Nurse management of intractable

functional constipation: a randomised controlled trial. Arch Dis Child

2004; 89: 717e22.

5 Sullivan PB, Juszscak E, Burnett C. Parent Satisfaction in a nurse-Led

clinic compared with a paediatric gastroenterology clinic for the

management of intractable, functional constipation. Arch Dis Child

2006; 91: 499e501.

6 Tabbers MM, Boluyt N, Berger M, Benninga MA. Diagnosis and treat-

ment of functional constipation. Eur J Pediatr 2011; 170: 955e63.

FURTHER READING

Choung Rok Seon, Nilay D Shah, Denesh Chitkara, et al. Direct medical

costs of constipation from childhood to early adulthood: a population-

based birth cohort study. JPGN 2011; 52: 47e54.

Constipation in children and young people. Diagnosis and management

of idiopathic childhood constipation in primary and seconday care.

National Institute of Clinical Excellence Guideline, www.nice.org.uk/

guideline/CG99; May 2010.

Kiefte-de Jong JC, Escher JC, Arends LR, et al. Infant nutritional factors and

functional constipation in childhood: the generation r study. Am J

Gastroenterol 2010; 105(4): 940e5.

Peeters B, Benninga MA, Hennekam RC. childhood constipation; an

overview of genetic studies and associated syndromes. Best Practice

Res Clin Gastroenterology 2011; 25: 73e88.

Rajindrajith Shaman, Devanarayana Niranga Manjuri. constipation in

children: novel insight into epidemiology, pathophysiology and

management. J Neurogastroenterol Motil 2011; 17.


http://www.nice.org.uk/guideline/CG99

http://www.nice.org.uk/guideline/CG99


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