Constipation in Kids

The Silent Giant. The Big Brown Elephant in the room: Constipation… Does it make you want to run and hide? Or leave it for someone else to sort out?

Join us for a structured approach to the diagnosis and management of constipation.  And let us know your favourite recipe, or a few poo pearls…

Outline: Constipation PEMcast

[cp] Intro & welcome to the PooCast; disclaimer

[et] Background / relevance

Definition (infrequent passage of hard stools) vs wide range of normal (rule of ten):
“difficulty in defecation for 2 weeks or more”
“painful passage of stools”

[mc] Incidence – the Silent Giant
Common! About 1/3rd of kids will have constipation at some time in their life
7% of ED visits (as primary complaint)

[et] Differential diagnoses & their features

• Most are Idiopathic (“Functional”): should not have significant pain / tenderness
• Hirschprung’s Disease – presents as neonate or from birth (10% of those delayed passage of meconium >48hrs), diagnosed on rectal biopsy (by Paediatric Surgeon)
• Imperforate anus
• Spinal dysraphism
• Metabolic (thyroid, calcium)
• Medications (opiates)
• Bowel obstruction including intussusception

[cp] Presenting symptoms

• decreased stool frequency
• painful / difficult passage of stool
• bleeding (fissure)
• “diarrhea” from overflow incontinence
• abdo pain – colicky / crampy – exclude other causes
• decreased appetite
• grumpiness/irritability

[mc] Other history

• Delayed passage of meconium? (Hirschsprung’s)
• Frequent respiratory infections or Failure to Thrive (Cystic Fibrosis)
• Abdominal distension
• Bilious vomiting
• Systemically unwell
• Urinary incontinence
• Dehydration risks: recent illness, fluid intake, (weather, exercise), diet
• Usual abdo pain questions

[et] Signs on Examination

• General appearance, hydration
• Abdo examination:
  • distension
  • tenderness
  • palpable lumps (indentable, in LLQ)
• Back: signs of spinal dysraphism
• Legs: neurologic examination

[cp] Investigations

Usually none
AXR controversy: radiation risk (7 CXRs, from XRayRisk.com) vs aid to compliance,
Piggy-Bank concept: $1 in, 50c out…
Dangerous allure of “The Magic of Tests”
Freedman 2013: AXR associated with other diagnoses ?reflecting diagnostic uncertainty
Investigations when alternative diagnosis suspected

Management

Disimpaction, Maintenance, Behaviour modification

[mc] Education: Longer-term follow-up, supportive attitude, star charts, understanding of stretched bowel (long-term), dedicated clinics, consistent message

[et] Dietary advice: fruit, vegetables, fibre, fluid intake, brown pasta/rice, skin on fruits

[timestamp 23:49]
[cp] Types/classes of medications (options) & how they work, pro’s & con’s

[mc] Stool softeners (docusate, paraffin oil)

[et] Macrogols & Osmotic agents (Poly-Ethylene Glycol 3350 +/- electrolytes, lactulose): titrateable, mixable, “water chaser”

[cp] Lubricants (glycerine suppositories)

[mc] Stimulants (senna, sennosides): can cause cramps, atonic bowel (long term use)

[et] Clearout vs maintenance phase

[cp] Role of enemas (controversy): rarely needed, psychological

[mc] Surgical procedures eg ACE (Antegrade Colonic Enema), caecostomy

[cp] NICE guideline CG99: Constipation in Children & young people (quick overview)

[et] local (PMH) guideline (written action plans)

[mc] other guidelines in the world include Royal Children’s Hospital Melbourne RCH.org.au

[ALL] Personal favourite recipes / approaches

[cp] Summary & goodbye

References

Freedman SB, Thull-Freedman J, Manson D, Rowe MF, Rumantir M, Eltorki M, Schuh S.
Pediatric Abdominal Radiograph Use, Constipation, and Significant Misdiagnoses.
J Pediatr. 2013 Oct 12.
doi:pii: S0022-3476(13)01102-5. 10.1016/j.jpeds.2013.08.074. [Epub ahead of print]
PubMed PMID: 24128647.