This document provides guidelines for diagnosing and managing paediatric constipation. It defines constipation and distinguishes between acute and chronic types. For diagnosis, it outlines key components to assess like stool patterns, symptoms, and history. Dietetic treatment goals are to restore normal bowel habits and treat constipation. For acute constipation, it recommends increasing fibre and fluid intake. For chronic constipation, initial treatment involves disimpaction and laxatives before increasing fibre. Medication side effects like dehydration are also discussed.
This document provides guidelines for diagnosing and managing paediatric constipation. It defines constipation and distinguishes between acute and chronic types. For diagnosis, it outlines key components to assess like stool patterns, symptoms, and history. Dietetic treatment goals are to restore normal bowel habits and treat constipation. For acute constipation, it recommends increasing fibre and fluid intake. For chronic constipation, initial treatment involves disimpaction and laxatives before increasing fibre. Medication side effects like dehydration are also discussed.
This document provides guidelines for diagnosing and managing paediatric constipation. It defines constipation and distinguishes between acute and chronic types. For diagnosis, it outlines key components to assess like stool patterns, symptoms, and history. Dietetic treatment goals are to restore normal bowel habits and treat constipation. For acute constipation, it recommends increasing fibre and fluid intake. For chronic constipation, initial treatment involves disimpaction and laxatives before increasing fibre. Medication side effects like dehydration are also discussed.
Definition 1) Determine if constipation present, confirmed
by presence of 2 or more findings from chart “The subjective complaint of passage of abnormally above *1+. delayed or infrequent passage of dry, hardened fae- ces often accompanied by straining and/or 2) If confirmed, then perform further history and pain” *1+. physical examination to determine if it is or- Acute ganic or functional *1+. Short-term, lasting < 2 weeks without presence of Assessment [3] faecal mass in the abdomen and can be treated Anthropometric: (Birth to 24 months) Length-for- with adequate fluid intake and a high fibre diet. age, Weight-for-age, Weight-for-length & Head cir- *1,2+. cumference. (2-19 years of age) Height-for-age, Chronic Weight-for-age. Lasting > 8 weeks, can be organic or functional. Biochemistry: None (1) Organic constipation is due to an underlying Clinical: Digestive system— Abdominal distension, medical condition such as Hirschsprung dis- bloating, cramping, pain, bowel function, including ease, anorectal malformations and hypothy- flatus, (type, frequency, volume), fever and vom- roidism etc. *1+ iting. (2) Functional constipation has no specific organic Client history: Personal history—Age (prematurity), cause, can be due to pain, fever, dehydration, Changes in routine, initiation of toilet training, re- psychological issues, toilet training, family his cent acute illness, medications. tory and medications. Painful defecation is a common cause as faeces become dry and hard in the colon over time if withholding and Food/Nutrition-related history : not defecating *1+. > Breast milk intake (number of feedings in a 24 Diagnosis [1] hour period & duration of feedings).
> Infant formula intake (Formula type, concentra-
Key compo- Potential findings in Potential findings in nents <1 year old child >1 year old child tion & number of feedings in a 24 hour period, vol- ume per feeding). Stool patterns < 3 complete stools/ < 3 complete stools/ week (type 3 or 4). week (type 3 or 4). A large hard stool. Faecal incontinence. > Food & fluid intake (Amount, types of foods, Rabbit droppings Rabbit droppings meal/snack pattern & variety). (Type 1). (Type 1). > Macronutrient intake (fat and cholesterol intake, Symptoms Bleeding, straining, Poor appetite that pain when defe- resolves if passed a protein intake, carbohydrate intake, fibre intake- cating. large stool. Retentive posturing: total, soluble & insoluble). tiptoed, arched back etc. > Micronutrient intake (Vitamin and Mineral/ Straining and pain. element intake). History Episodes of constipa- Same as a <1 year tion. old child > Knowledge/Beliefs/Attitudes of caregiver & child. Previous/current Painful hard stools anal fissure > Physical activity and function. Dietetic Treatment & Rationale and treats acute constipation *1+. Goal: Restore normal bowel habits, where stools 3. Promote adequate fluid intake as per the New are soft and passed without discomfort at least 3 Zealand Reference Values throughout and after times a week. If chronic functional constipation medical treatment.*7,8+. then treat rectal impaction and promote normal Rationale: Adequate fluid intake is important partic- muscular tone in lower colon *3+. ularly when osmotic laxative treatment is initiated Acute constipation as fluid losses are higher and there is an ↑ risk of dehydration which in turn may worsen constipation ↑Increase total dietary fibre intake and ensure ad- *7,8+. equate fluid intake *1,4+. 4. At present, there is insufficient evidence to pro- Rationale: If acute constipation is not identified and mote the use of novel infant formulas (differing quickly resolved appropriately = leads to anal fis- amounts of partly hydrolysed whey protein, casein, sure and/or progress to chronic functional constipa- lactose, magnesium and the addition of prebiotics tion *1+. or palmitic acid) for the treatment of chronic func- Chronic functional constipation tional constipation *9,10+. 1. ↑ Dietary fibre and fluid intake is not recom- Rationale: Switching infant formulas may delay the mended as the first line of treatment, particularly initiation of appropriate medical treatment. when disimpaction is required. *5.6+ 5. Dietary fibre supplements for children with chronic functional constipation can not be recom- Rationale: (1) Modifying the dietary fibre and fluid mended *11, 12+. intake solely does not address the cause of chronic constipation, which in turn may delay appropriate Rationale: At present, there is insufficient evidence medical therapy, especially if disimpaction and laxa- to show that supplements can effectively treat chil- tive therapy is required. (2) If a child has rectal im- dren with chronic functional constipation. paction, ↑ fibre intake without medical treatment may lead to soiling (3) If caregivers are advised to ↑ fibre intake initially, the lack of progress in their Medications & Side effects child may hinder future efforts to ↑ fibre intake) *1, Osmotic Laxatives (polyethylene glycol, Magnesium 5-6+.. hydroxide, Lactulose & Sorbitol) *1+. ↑ Fluid losses and ↑ risk of dehydration = Im- 2. Once disimpaction has been performed (if neces- portant to consume adequate amount of fluid each sary) and laxative therapy has begun, promote a day as per NRV guidelines. balanced diet that includes fibre-rich foods while Stimulant Laxatives (Senna& Bisacodyl) ensuring energy and essential nutrient require- ↑ Peristaltic activity, ↑ salt and water losses *1+. ments are met to prevent constipation in the future *1+. Stool softeners (Docusate sodium) Incorporates water and fat into the stool *1+. Rationale: A balanced diet that is rich in fibre con- taining foods such as whole grain cereals, breads, vegetables, fruits and cooked legumes may prevent future episodes of chronic functional constipation References *1+ Bardisa-Ezcurra L, Ullman R, Gordon J. Diagnosis and management of idiopathic childhood constipa- tion: summary of NICE guidance. BMJ: British Medical Journal (Online). 2010 Jun 1;340. *2+ Loening-Baucke V. Prevalence, symptoms and outcome of constipation in infants and toddlers. The Journal of pediatrics. 2005 Mar 31;146(3):359-63. *3+ Marg A, Anderson J, Bertani S, Firus S, Carla F, Hartman B et al. Gastrointestinal System - Pediatric Constipation Practice Guidance Toolkit. http://www.pennutrition.com.ezproxy.massey.ac.nz/ KnowledgePathway.aspx?kpid=8534&tkid=20324&secid=20549 (accessed 23 January 2016). *4+ Loening-Baucke V. Prevalence, symptoms and outcome of constipation in infants and toddlers. The Journal of pediatrics. 2005 Mar 31;146(3):359-63. *5+ Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gas- troenterology Nursing. 1998 Jul 1;21(4):156-61. *6+ Kokke FT, Scholtens PA, Alles MS, Decates TS, Fiselier TJ, Tolboom JJ, Kimpen JL, Benninga MA. A die- tary fiber mixture versus lactulose in the treatment of childhood constipation: a double-blind random- ized controlled trial. Journal of pediatric gastroenterology and nutrition. 2008 Nov 1;47(5):592-7. *7+ Young RJ, Beerman LE, Vanderhoof JA. Increasing oral fluids in chronic constipation in children. Gas- troenterology Nursing. 1998 Jul 1;21(4):156-61. *8+ Benninga MA, Voskuijl WP, Taminiau JA. Childhood constipation: is there new light in the tunnel?. Journal of pediatric gastroenterology and nutrition. 2004 Nov 1;39(5):448-64. *9+ Bongers ME, De Lorijn F, Reitsma JB, Groeneweg M, Taminiau JA, Benninga MA. The clinical effect of a new infant formula in term infants with constipation: a double-blind, randomized cross-over trial. Nu- trition journal. 2007 Apr 11;6(1):8. *10+Pina DI, Llach XB, Ariño-Armengol B, Iglesias VV. Prevalence and dietetic management of mild gas- trointestinal disorders in milk-fed infants. World journal of gastroenterology. 2008 Jan 14;14(2):248. *11+ Castillejo G, Bulló M, Anguera A, Escribano J, Salas-Salvadó J. A controlled, randomized, double- blind trial to evaluate the effect of a supplement of cocoa husk that is rich in dietary fiber on colonic transit in constipated pediatric patients. Pediatrics. 2006 Sep 1;118(3):e641-8. *12+ Loening-Baucke V, Miele E, Staiano A. Fiber (glucomannan) is beneficial in the treatment of child- hood constipation. Pediatrics. 2004 Mar 1;113(3):e259-64.