CONSTIPATION

Normal stool frequency

<1 month age: 3-4 times/day
1 month to 1year age: 1.5-2 times/day
1 to 2 year age: 1-2 times/day,mostly formed
older than 2 year age :1 time/day

Constipation: definition
A delay or difficulty in defecation sufficient to cause significant
distress to the patient is defined as constipation.
ACUTE CONSTIPATION: duration is less than 4 week
CHRONIC CONSTIPATION: duration 4 weeks or more

FECAL INCONTINENCE : passage of stools in the undergarment.

(a) Constipation-associated fecal incontinence
(b) non-retentive fecal incontinence: diagnosed only if there is no
constipation and normal anal sphincter tone, and symptoms last for
more than 2 months in a child with a developmental age of≥4 years.
REFRACTORY CONSTIPATION: Constipation not responding to optimal
conventional treatment for at least 3 months, despite good
compliance.

DEFINITION OF CONSTIPATION FOR USE IN INDIAN

CHILDREN
• Duration of more than 4 weeks for all ages; and Presence of ≥2 of
the following:
(a) Defecation frequency ≤2 times per week,
(b) Fecal incontinence ≥1 times per week after the acquisition of
toileting skills,
(c) history of excessive stool retention,
(d) history of painful or hard bowel movements,
(e) presence of a large mass in the rectum or on per abdomen
examination,
(f) history of large-diameter stools that may obstruct the toilet

Important precipitating factors of functional constipation :

 Premature initiation of toilet training (normally toilet
training should start not before 24 months in a
developmentally normal child)
 Drugs and inter-current illnesses
 Quick and abrupt transition of diet e.g. liquid to solid,
breastfeeding to bottle feeding
 Dhange in local environment (start of schooling) and
psychosocial factors

.
 EVALUATION
 Lower abdomen should be palpated for fecoliths (soft
or hard indentable masses).
 In the absence of abdominal fecoliths, anal fissure or anal
malformations,
 digital rectal examination(DRE) (index finger in an older child or
little finger inan infant) helps in the following:
(a) presence of fecal impaction
(b) Hirschprung’s disease (emptyrectum, gush of stools/air on
withdrawal of finger),
(c) sacral mass lesion (palpable mass).
(d) DRE INDICATED IN
o red flag symptoms or signs
o onset <6 months of age
o non-responders despite good compliance to therapy
o patients presenting withfecal incontinence to
differentiate between constipation related and non-
retentive incontinence
Red flags suggestive of organic constipation:
(a) delayed passage of meconium,
(b) onset in early infancy,
(c) ribbon or pellet stools,
(d) bilious vomiting,
(e) uniform abdominal distension,
(f) failure to thrive,
(g) recurrent lower respiratory infections,
(h) cold intolerance,
(i) neuro-developmental delay or regression,
(j) gush of stools on DRE,
(k) anal malformations,
(l) abnormal neurological examination (paraspinal, lower limbs
and anorectal reflexes).
 Medications and Dosages for Disimpaction
RAPID RECTAL DISIMPACTION
Glycerin suppositories Infants and toddlers
Phosphate enema <1 yr 60 mL
>1 yr 6 mL/kg body weight,
up to 135 mL twice
SLOW ORAL DISIMPACTION IN OLDER CHILDREN
Over 2-3 Days
Polyethylene glycol 25 mL/kg body weight/hr, up to 1,000
with electrolytes mL/hr until clear fluid comes from the anus
Over 5-7 Days
Polyethylene without 1.5 g/kg body weight/day for 3 days
electrolytes
2 mL/kg body weight twice/day for 7
Milk of magnesia
days
Mineral oil 3 mL/kg body weight twice/day for 7 days
Lactulose or sorbitol 2 mL/kg body weight twice/day for 7 day
MAINTENANCE THERAPY OF CONSTIPATION
TYPICAL DOSES FOR LONG-TERM TREATMENT (YEARS)
1-3 mL/kg body weight/day,
Milk of magnesia >1 mo
divided into 1-2 doses
1-3 mL/kg body weight/day,
Mineral oil >12 mo
divided into 1-2 doses
1-3 mL/kg body weight/day,
Lactulose or sorbitol >1 mo
divided into 1-2 doses
0.7 g/kg body weight/day
Polyethylene glycol 3350 >1 yr
(max 17.5 g/day)
FOR SHORT-TERM TREATMENT (MONTHS)
5 mL (1 tablet) with
1-5 yr
breakfast, max 15 mL daily
Senna syrup, tablets
2 tablets with breakfast,
5-15 yr
maximum 3 tablets daily
20-30 mL/day ( glycerin
Glycerin enemas >10 yr
and normal saline)
Bisacodyl suppositories >10 yr 10 mg daily