Constipation in Pediatric Emergency

Constipation is defined as hard stools that are difficult to pass. Defecation may be painful and may be less frequent than normal. There is a wide range of normal stool frequency: normal breastfed infants may have a stool following each feed or only one every 7–10 days; bottle-fed infants and older children will usually have a bowel action at least every 2–3 days. Constipation occurs more commonly in older children when they have been switched from breast milk or formula to cow’s milk. Constipation may be associated with abdominal pain, reduced appetite and irritability. Vomiting is rarely a sign of constipation alone.

Children may develop constipation as a result of:

• a natural tendency related to reduced gut motility

• a poor diet

• a toddler behavior pattern

• inadequate fluid intake (sometimes after acute illness)

• reduced activity

• painful anal conditions, e.g. fissures

• sometimes following sexual abuse.

Organic causes are rare after early infancy.

Assessment

All infants under 3 months should be discussed with the registrar or consultant. They may require referral for exclusion of Hirschsprung disease. Suggestive symptoms and signs include delayed passage of meconium, vomiting, failure to thrive, abdominal distension and a positive family history.

Do not perform a rectal examination—it is rarely helpful and usually traumatic to the child. An inspection of the anus is important to exclude painful conditions. Acute anal fissures are generally posterior and may occur after passage of a large stool or may complicate inflammation of the perianal skin, e.g. in pinworm (or threadworm) infestation. Perianal cellulitis is caused by group A streptococcal infection and is characterised by induration and marked erythema of the perianal skin with mucopurulent exudate. An abdominal X-ray is not helpful in the initial assessment and should not be ordered. Remember that urine infections are more common in constipated children and should be sought if symptoms are suggestive.

Assesment Constipation in Pediatric Emergency

Management

Carers need to be reassured about the safety of laxatives in children. Rectal medications should be avoided in the first instance and not prescribed without discussion with a consultant. Management can be divided into three main steps

Step 1

Initially give a high fibre diet with adequate fluid intake, adequate exercise and regular toileting.

Step 2

The child will need laxatives, including a stool softener and an aperient.

A suggested regime is: Parachoc or Lactulose; plus sennakot

• Liquid paraffin (<5 years: 10 ml daily; 6–12 years: 15 ml daily). Parachoc should be avoided if there is an increased risk of aspiration, e.g. in cerebral

palsy with bulbar involvement. Children may be given up to 25 ml of Parachoc per dose.

• Lactulose (<5 years: 5 ml b.i.d.; >5 years: 10 ml b.i.d.). Children may be given up to 25 ml of Lactulose per dose.

• Senna granules: (2–6 years: 1/2 teaspoon nocte; 6–12 years: 1 teaspoon nocte). The maximum daily dose of Sennakot granules should be 3 teaspoons per day

Abdominal pain may occur as a side effect. Increased doses may be required in some children with chronic constipation. The dose should be titrated to achieve at least one soft stool per day.

If overflow incontinence is present, warn families that it may worsen initially with treatment.

Step 3

Rarely patients may require admission to achieve bowel emptying. Treatment will involve a bowel preparation agent either Picoprep (Picolax in the UK) sachets (sodium picosulphate 10 mg, magnesium oxide 3.5 mg, citric acid 12.0 g, aspartame 36 mg): <2 years—1/4 sachet; 2–4 years—1/2 sachet; 4–9 years—3/4 sachet, repeating in 6 hours if no response; or colonic lavage solution (e.g. Golytely: orally or via a nasogastric tube).

Disposition

All patients should be referred for follow up in a general pediatric clinic within 7 to 10 days.