Dr. B.R.Thapa *
Additional Professor and Head, Division of Pediatric Gastroenterology, Hepatology and Nutrition
Postgraduate Institute of Medical Educational and Research, Chandigarh. *
Constipation is a symptom of underlying disorder and is more common in male as compared to female children. It is a very common problem in pediatric age group. 10-25% of all patients attending pediatric gastroenterology clinics are constituted by various fecal elimination disorders. About 1.3-5% of children suffering from chronic constipation have problem of encopresis. Chronic constipation is a real challenge to the parents, children as well as for the pediatricians to understand and to treat it effectively. The presence of encopresis adds to the parental anxiety and has a great impact on the overall development of the child in the society. This warrants a meticulous and well planned approach to manage a child with constipation.
Constipation is defined subjectively a feeling of unsatisfactory evacuation. The other accompaniments could be passage of too small stool, too hard stool, too difficult to expel, too frequent and incomplete evacuation. But the objective and well accepted definition of constipation is passage of stools twice or less per week. Based upon the symptomatology certain criteria have been used in literature to define constipation. The guidelines of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition defines constipation as a delay or difficulty in defecation present for 2 or more weeks and sufficient to cause significant distress to the patient. Loening Bauke criteria also called as IOWA criteria to define constipation has been used widely in various randomized controlled studies. According to this constipation is labeled when two out of the following symptoms are present in last three months:
- Less than 3 bowel movements per week,
- Encopresis more than once per week,
- Large amounts of stool every 7-30 days (large enough to clog the toilet) and
- Palpable abdominal or rectal mass on physical examination. Recently an attempt has been made to define the functional gastrointestinal disorders in children called Rome II criteria. But these criteria are too cumbersome and are difficult to follow and in general practice are not of much help.
Encopresis: Encopresis is the involuntary passage of formed, semi-formed or liquid stool in the child's underwear. Largely this is considered to be functional when there is no organic or anatomic cause or medication responsible for it after the age of 4 years. This is equivalent to enuresis in children and is also called overflow incontinence when there is chronic constipation. Before this age it is very difficult to recognize because, diapers are used and moreover, voluntary control on the act of defection may not be achieved. This emphasizes the fact that encopresis could be functional or overflow incontinence.
Fecal soiling: Fecal soiling is any amount of stool deposited in the underwear, independent of whether functional or organic or anatomic lesion is present.
Fecal incontinence: Fecal incontinence is fecal soiling in the presence of an organic or anatomic lesion such as anal malformation, anal surgery, anal trauma, meningomyelocele and other neurological and muscle diseases affecting the anorectal area and perineum. There is no retaining capacity due to lack of reflexes involved in retention of stool and act of defection. But some authors have used these terms interchangingly in the literature.
Approach to constipation: While taking history special attention should be paid towards the toilet habits, which include character of stools in the toilet, in the underwear and stool withholding maneuvers. Age of onset of constipation is also important. Constipation starting from neonatal life gives clue towards developmental anomalies of anorectal area or colon. Delayed passage of meconium gives clue of Hirschsprung's disease. Associated abdominal pain may be the sole symptom of constipation in 50% children with RAP. It is important to enquire about dietary habits of the child. Consumption of excess of milk, juices and/or other drinks, junk foods and bakery products may lead to constipation. In the modern era, children largely depend upon low fiber diet and this becomes important factor for onset of constipation. Less consumption of cereals, pulses, vegetables and fruits can result into constipation. Inadequate and low fiber diet are responsible for less production of stool. One must also enquire about the associated conditions like enuresis, UTI or any psychiatric problems. There is loss of appetite due to delayed stomach emptying and slow transit time due to colo-gastric reflex. There may be poor weight gain.
Patients should be thoroughly examined especially abdomen and anal region. Abdominal examination may reveal a lump in the left iliac fossa of suprapublic area due to retention of fecal matter in the sigmoid and descending colon. Sometimes whole of the colon may be palpable. Rectal digital examination should be carried out. In case of acquired constipation, hard fecal matter is felt just at the entry of the finger in the anal canal on digital rectal examination. In case of HD the rectum is empty whereas the fecal matter is felt high up and on withdrawal of finger fecal matter may gush out. In presence of active and fissure digital rectal examination should be avoided because this can enhance the anal injury. Neurological examination including perianal sensation testing should be done. Investigations in case of simple constipation are not required. Plain X-ray abdomen can give idea about the impacted fecal matter in whole of colon and rectum. Investigations like anorectal manometry, surface perianal electromyography, intestinal transit determination, defecography and defecation stimulation are not commonly required. These are needed in intractable situations when rectoanal dyssynergia is suspected. Full thickness rectal biopsy to demonstrate the absence of ganglion cells is required for the diagnosis of Hirschsprung's disease. Barium enema study may help to pick up Hirschsprung's disease.
Treatment: Treatment of constipation is aimed at:
Treating the cause
The treatment of underlying precipitation factor and evacuation should start simultaneously. After evacuation, the passage of normal stools should be maintained.
Acute simple constipation: Acute constipation is usually mild and easy to treat proper diary should be maintained by the parents. Enough fluids and carbohydrate-rich diet takes care of constipation in infants. At the same time the toilet training should also be imparted. This is very common in children. Parents must be educated and reassured that it is not pathological. One has to eliminate the precipitating factor. Treat local causes like anal fissure, boil or dermatitis effectively. Procedures like enemas, finger evacuation/disimpaction, finger dilatation and frequent use of suppositories should be avoided. But encourage use of high fiber diet in terms of cereals, pulses, vegetables and fruits. Adequate fluid intake is advised to keep proper hydration. Initially laxatives can be used. Encourage toilet training simultaneously. Laxatives can be given for 7-10 days but prolonged use should be discouraged. If this is not properly treated can result into chronic constipation.
Purgation: Large dose of mineral oil (liquid paraffin) or castor oil or other osmotic agents can effectively evacuate rectum. Usually repeated doses are required. These are not used in children.
Surgery: Surgical disimpaction is required rarely in severe constipation, failed medical treatment, mental retardation and fearful situation with poor compliance. Surgery is the definite treatment of Hirschsprung's disease (HD) and other anorectal congenital anomalies in children.
Maintenance Therapy: The goals of maintenance therapy are:
- To maintain adequate frequency,
- To avoid continued passage of large stools and,
- To prevent withholding/retention of stools. Retraining medications include stool softeners or bulk-forming agents or osmotic agents. The laxatives used are milk of magnesia, liquid paraffin, lactulose, lactitol etc in the dosage of 1-3 ml/kg body weight. These should always be given twice a day. Recently reported PEG for maintenance phase in the dose of 0.26 - 0.8 g/kg/day has been shown to be very effective and safe even for long term use. The maintenance therapy has to continue for 4-6 months depending upon the response. Routine use of bisacodyl, castor oil, senna and phenolphthalein is not recommended in children. These stimulate the peristalsis, active electrolyte transport and fluid movements. Cisapride a prokinetic agent can be used in paraplegics, pseudo-obstruction, diabetics, chronic constipation etc. Prebiotics and probiotics have been shown to be effective but more studies are required. Combination of various agents is effective to avoid recurrence of constipation. The most commonly used drugs/agents along with dosage and side effects.
Dietary modifications: Encourage breast-feeding during early infancy and cereal supplementation should be started after 4 months of life. Diets rich in high fiber are bran based cereals, pulses, fruits, vegetables etc. For older children and adults daily intake of 20 g of bran is quite effective to avoid constipation. In younger children the fiber requirement can be calculated as age in years plus 5. This gives the daily requirement of fiber in grams for that particular age (eg for 5 years + 5 = 10 g) 8. Intake of plenty of fluids is encouraged. Excess of drinks in form of milk, sugar, water, juices and cold drinks to be avoided. Bakery products and junk foods to be discouraged. Mechanism by which dietary unabsorbed carbohydrates known as prebiotics increase the stool bulk.
Retraining/Toilet training: There should be positive reinforcement for toilet sitting and defection. Toilet timing should be regular. Child should sit in squatting position for 5-10 minutes once or twice a day after the meals to take advantage of gastrocolic reflex. For proper sitting in the English type of latrines adequate foot rest should be provided to the children, so that the flexion of knee joints and hip joints is possible. Idea is to straighten the anorectal angle, so that stools can flow out easily. Positive reinforcement at home and by the physician is very important. Parents should be prepared to have verbal acclaim and selective awards for desired behavior, initiation of toileting, use of toilet, production of stool, acknowledging the cleaning after defection and for repeated successes.
Biofeedback: Biofeedback is required when other measures are not working and there is anorectal dyssynergia. This helps in relaxation of EAS and levator ani muscles. This is only possible above 5 years of age because co-operation of patient is very important. It is effective in 50-80% patients. Take the benefit of conditioning reflex in morning and evening like to move in front of toilet, to drink water, put the tap on and sitz bath. Multidisciplinary behavioral treatment is effective in chronic constipation and defection process in HD in children.
Follow up: Long follow up is required. In case the progress is very good the treatment can be weaned off after 6 months, but rest of the protocol is term of high fiber diet and toilet training should continue for 2-3 years to avoid relapse. Appropriate psychiatric consultation should be taken when required. If there is atypical presentation or poor response. Pathological cause must be ruled out.
Outcome and Prognosis: Outcome with appropriate above mentioned therapeutic modalities is excellent in 45-100% of individuals. Moderate response may be seen in 20-30% whereas 25-35% may have failure. Good prognostic indicators are better compliance, adequate intake of high roughage diet and self-confidence to achieve the success. Poor prognostic indicators are hearing disabilities, disobedience, fearlessness, school time soiling, teen age occurrence, mental retardation, severe motor disability, associated disorders and neurogenic cause. In a recent study this has been shown that 30% of children suffering from constipation continue to be constipated during puberty.
Prevention: Prevention of colonic dysfunctions have received much less attention but attending pediatrician can play important role by providing anticipatory counseling in terms of appropriate feeding advice, high fiber diet, interpretation of normal bowel habits, counseling life issues of the child and early detection of problem and intervention.
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