In addition to the resource discussed below, please see and review:
Before Diagnosing Pediatric Functional Constipation – Be Sure To Rule Out More Serious Problems
Posted on July 15, 2016 by Tom Wade MD
Pediatric Constipation From Emergency Medicine Cases And The J Pediatr Gastroenterol Nutr
Posted on March 19, 2016 by Tom Wade MD
Parents: Trust Your Instincts – Help From The University Of Iowa Stead Family Children’s Hospital – Mother Suspects Hirschsprung Disease
Posted on December 28, 2018 by Tom Wade MD
In this post I review and excerpt the excellent Constipation podcast from PedsCases by Harrison Anzinger Dec 27, 2018.
The show notes (podcast transcript) are an excellent quick review and really worth reading after listening to the podcast or when needing a quick review.
Here are excerpts:
This podcast focuses on developing an approach to constipation in children. After listening to this podcast the learner should be able to: understand the pathophysiology of constipation in pediatric patients, differentiate between organic and functional constipation, diagnose functional constipation from history and physical exam using the Rome IV guidelines, and develop an approach to treating functional constipation. This episode was developed by Harrison Anzinger, a second-year medical student at the University of Alberta, in collaboration with Dr. Jason Silverman, a pediatric gastroenterologist at the Stollery Children’s Hospital and Assistant Professor at the University of Alberta.
Related Content
- Podcast: Chronic Abdominal Pain
- Podcast: Acute Abdominal Pain
- Case: Abdominal Pain in an 8 year old
- Case: Abdominal Pain in a 4 month old female
The Bristol Stool Chart is used to characterize the child’s stool.
Here are excerpts from the transcript:
Differential Diagnosis
Constipation can be subdivided based on etiology into organic and functional constipation.
Organic constipation is caused by an underlying anatomical or physiological abnormality. In
contrast, functional constipation is constipation in the absence of an organic cause.
We will begin by talking about functional constipation, which is responsible for the vast majority of constipation cases in children.While the majority of cases of constipation are functional, it is critical to consider organic causes of constipation. While rare, due to the possibility of serious underlying disease, an organic
cause should be considered for all patients presenting with constipation. Any underlying pathophysiology that reduces or prevents the movement of feces through the colon can lead to
constipation. The entire differential diagnosis of organic constipation is large and beyond the scope of this podcast. However, it’s important to understand that organic constipation should be considered on your differential and may present with a diverse set of signs and symptoms. We will now briefly discuss several of the more common causes of organic constipation and the red flag signs and symptoms they may present with.• Firstly, is Hirschsprung disease, which is caused by a congenital absence of ganglion
cells in the distal rectum, preventing the rectum from relaxing. Hirschsprung often presents as failure to pass meconium within 48 hours of life. Hirschsprung disease should be considered in constipated children younger than 1 month, or if there is a family history.• Next, we have Hypothyroidism can be congenital or acquired. It can present with a goiter, fatigue and poor growth, in additional to constipation.
• Celiac Disease is an autoimmune enteropathy caused by gluten exposure. It may present with abdominal pain, failure to thrive (FTT), and other GI symptoms such as vomiting, abdominal distention and anorexia. Celiac disease should also be considered if there is a family history.
• Next, Cystic Fibrosis is a complex multisystem disease of chloride transporters. It can presents with respiratory symptoms and GI symptoms such as failure to thrive, malabsorption and meconium ileus.
• Spinal cord anomalies such as spina bifida or tethered cord can impair the neurologic supply to the bowels. They may have other associated findings such as spasticity of
the lower limbs, hyperreflexia or gait changes.• Furthermore, Anorectal malformations such as imperforate anus or anal stenosis can cause constipation. These can often be seen on anorectal inspection. Anal stenosis may also present as thin, ribbon like stools.
• Lastly, several classes of drugs, such as opioids, antacids, antihypertensives,
anticholinergic, and antidepressants are associated with constipation. (6)The diagnosis of functional constipation is based on the Rome IV criteria, and can be made based on history and physical exam alone as long as no organic etiologies are suspected. To meet the Rome IV criteria, a child must meet 2 or more of the criteria at least once per week for at least one month. Furthermore, children with a developmental age greater than 4 must meet insufficient criteria for irritable bowel disorder. The Rome IV criteria are as follows:
1. 2 or fewer defecations per week
2. History of retentive posturing or excessive stool retention
3. History of painful or hard bowel movements
4. Presence of large fecal mass in the rectum (fecal impaction)
5. History of large diameter stools that may obstruct the toilet if toilet trained.
6. At least 1 episode of incontinence per week after the acquisition of toileting skills
7. Lastly, after an appropriate evaluation, the patient symptoms must not be fully explained
by another medical condition (5,7)During the history a patient should be asked about the frequency and consistency of their stools, oftentimes patients and families can have a hard time describing their stools, so showing
them a visual representation like the Bristol Stool Chart can make the conversation much
easier. The Bristol stool chart is a method of standardizing stool description and displays a
range of 7 stool shapes and consistencies.Children with functional constipation typically appear generally well. The are growing normally,
and other than the possible presence of a palpable fecal mass, have few outward signs. Therefore, a complete physical exam is important primarily to identify red flags indicating an organic etiology.In the absence of red flags, functional constipation is typically diagnosed on history and physical exam alone. (1,9) While historically abdominal X-rays were used to assist in diagnosis of functional constipation, they are of low diagnostic accuracy and have little evidence to justify their use. (8)
The goals of treatment are to generate 1-2 soft, painless stools per day and to prevent fecal impaction. (1) All patients require education on life style and diet changes that can reduce or even
completely resolve constipation symptoms on their own. Some patients will also require more comprehensive medical management, involving daily stool softeners, and sometimes fecal disimpaction [Fecal impaction can be diagnosed by history]. [See pp 6 + 7 of the PDF for detailed therapeutic recommendations including how to manage disimpaction when needed. Disimpaction is managed by oral medications.]
And here is the summary from the podcast transcript:
Conclusion/Summary
If you are like me, you are probably feeling overwhelmed with information. Let’s take a minute to summarize the key points from the podcast.
1. Functional constipation is by far the most common form of constipation in kids. It is
often caused by purposeful retention to avoid painful stools or to avoid using the toilet. Functional constipation is diagnosed on history and physical exam based on
the Rome IV guidelines
2. While organic constipation is rare, it should be screened for on history and physical exam to avoid missing underlying pathology.
3. The treatment of functional constipation involves education, fecal disimpaction, maintenance therapy with stool softeners, behavioural modifications, and dietary
modifications. The goal of treatment is to have 1 to 2 soft, painless stools per day.
4. Constipation is often a chronic problem. Patients should be followed up regularly to
ensure continued success and prevent recurrence.
5. If treatment for constipation is unsuccessful or an organic cause of constipation is
suspected, refer to pediatric gastroenterology.Works Cited
1. Rowan-Legg, A; Canadian Paediatric Society CPC. Managing functional constipation in
children. Paediatr Child Heal. 2016;16(10):661–5. Available from:
https://www.cps.ca/en/documents/position/functional-constipation
2. North American Society for Pediatric Gastroenterology Hepatology and Nutrition.
Constipation. Fact Sheet. 2010. Available from:
https://www.gikids.org/files/documents/digestive%20topics/english/Constipation.pdf
3. Bardisa-Ezcurra L., Ullman, R., and Gordon, J. Diagnosis and management of idiopathic
childhood constipation: summary of NICE guidance. BMJ. 2010;340(7758):1240–2.
Available from: https://www.bmj.com/cgi/doi/10.1136/bmj.c2585
4. Healthy bowel habits for children. Canadian Pediatric Society. 2018;1-3. Available from:
https://www.caringforkids.cps.ca/handouts/healthy_bowel_habits
5. Benninga, M.A., Nurko, S., Faure, C., Hyman, P.E., Roberts, I.S.J., et al. Childhood
functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016;150:1443–55.
6. The Hospital for Sick Children. Management of Functional Constipation. 2015;1–8.
Available from: https://www.sickkids.ca/clinical-practice-guidelines/clinical-practiceguidelines/export/CLINS195/Main Document.pdf
7. Hyams, J.S., Lorenzo, C.D., Saps, M., Shulman, R.J., Staiano, A., and Tilburg, M.V.
Childhood functional gastrointestinal disorders: Child/Adolescent. Gastroenterology.
2016;150:1456–68.
8. Pensabene, L., Buonomo, C., Fishman, L., Chitkara, D., Nurko, S. Lack of utility of
abdominal x-rays in the evaluation of children with constipation: comparison of different
scoring methods. J Pediatr Gastroenteriol Nutr. 2011;51(2):155–9.
9. Tabbers, M.M., Dilorenzo, C., Berger, M.Y., Faure, C., Langendam, M.W., Nurko, S., et al.
Evaluation and treatment of functional constipation in infants and children: Evidence-based
recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr.
2014;58(2):258–74.
