chronic constipation in children
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Chronic constipation in children
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- Chronic constipation in children Anshu Srivastava Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India
- 2 yr 2 yr 3 yr SGPGI Constipation 3 yr boy Stool freq 1/day Once in 7-8 days Stool: hard, large size Painful defecation Withholding manoeuvre No blood with stool Milk intake: 1 liter/ day No h/o enterocolitis: abdominal distension, fever, loose stools No h/o drug intake Passed stool on day 1 of life Normal growth Developmentally normal Lactulose Enemas Modified diet Soiling
- Anthropometry Height : 87.5cm Weight : 12 kg OFC : 47cm Age Appropriate No pallor, edema
- Examination Per abdomen: Not distended Fecoliths palpable in left iliac fossa Inspection of anal area: Normal position No perianal tags Anal wink present. No anal fissure Soiling of undergarments present Per rectal: Normal anal sphincter tone Hard stool present in the rectum No gush of air after removing the finger No blood
- Examination CVS and RS: NAD CNS: Normal muscle tone Power: 4/5 DTRs Normal Planters reflexes- Flexor response Gait: Normal Sensations: Touch and pain present Good urinary stream Back and spine: Normal
- Functional Constipation with soiling Onset After 1 yr of age Fecoliths, Withholding maneuver Normal Growth No Enterocolitis Possibility
- Clarity of terminology Fecal incontinence Organic Functional Constipation associated Fecal impaction Large fecal mass Rectum Abdomen
- Red flags on history Age of onset 48hr) Failure to thrive Absence of withholding Absence of soiling Bladder dysfunction Extra-intestinal symptoms No response to conventional therapy ? PCNA 2002;49:27-51
- Red flags on examination FTT Abdominal distension Pilonidal sinus Midline pigmentary abnormalities Patulous anus, anteriorly placed anus Empty rectum Gush of liquid stool & air from rectum after finger withdrawal Absent anal wink, cremastric reflex Lower limb weakness
- Investigations Bil Conj Protein Albumin AST ALT SAP Jan 2010 1.3 0.2 7.8 4.2 54 42 134 Hb TLC DLC Platelets PF Jan 2010 11.1 11400 60/36/4 323000 NCNC Thyroid function tests (from elsewhere) Normal Barium enema (done elsewhere)- Megacolon Not s/o Hirschsprungs disease
- Algorithm for evaluation Constipation Red flags on evaluation Functional constipation Assess fecal impaction Disimpact Investigate and manage No No Yes yes Dietary advise Toilet training Maintenance Laxative therapy Follow up - response and compliance - dose titration - recurrence of impaction
- Clear Fecal Retention Prevent Future Retention Promote Regular Bowel Habit Management-treatment plan
- Management contd. Clearance of fecal retention: Dis-impaction of stools Admitted Polyethylene glycol (PEG) with electrolytes: 20ml/kg/hr till disimpaction achieved End point of disimpaction: Passage of clear fluid of nearly same color and consistency as being used for disimpaction
- Management contd. Counseling of parents: Acquired disorder and curable Toilet training: Diet chart: high fiber diet Maintenance: Laxative Polyethylene glycol (Dose: 1g/kg/day) sachet (12 g)/ day
- Dietary advise Preferred food Whole grains Whole pulses/beans Green leafy vegetables, beans Fruits-guava, pomengranate, dates, amla, apple with peel Avoid X Refined wheat flour Arhar, dhuli moong Predominant milk diet Banana, papaya, mango Ideal fiber intake- age in years + 5 g Healthy nutritious diet with adequate fluid intake Some benefit that fibre is better than placebo Ped 2011;128:753
- Diet chart: High Fiber Diet - , , , , I ( ) / ( ) I , , , , , I
- Drug Dosage Side effects Bisacodyl 6y-1-2 oral tablets (5 mg) Abdo pain, diarrhea. Senna 2-4y:3.75-15mg/d 4-6y: 3.75-30mg/d 6-18y: 7.5-30mg/day Abdo pain Skin rash and fixed drug eruption rare Sodium picosulfate
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