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DOI 10.1007/s12098-013-1133-5
Chronic Constipation
Jaya Agarwal
Received: 23 April 2013 / Accepted: 10 June 2013 / Published online: 14 August 2013
# Dr. K C Chaudhuri Foundation 2013
Abstract The lack of information about management of but if stools are soft and passage is painless then it cannot be
chronic constipation in children amidst general physicians termed as constipation.
has necessitated this review. A literature search in PubMed
was conducted with regard to epidemiology, clinical fea-
tures, investigation and management of chronic constipation Prevalence
in children. English language studies published over the last
20 y were considered and relevant information was extracted. The worldwide prevalence of functional constipation in chil-
Constipation is a common problem among children; the dren varies from 0.7 % to 29.6 % [3, 4]. The exact burden of
commonest cause is functional (95 %). An elaborate history this problem in Indian context is not known. Nonetheless it is
and thorough physical examination are only essential things a frequent presenting complaint of substantial number of pa-
required to make a diagnosis of functional constipation. Man- tients in any pediatric or general physician outpatient clinic.
agement consists of disimpaction, followed by maintenance Encopresis or soiling which is the involuntary leakage of feces
therapy with oral laxative, dietary modification and toilet into the undergarments may be an indication of constipation. An
training. A regular follow-up with slow tapering of laxative epidemiological study in Sri Lanka reported that fecal inconti-
is the must for effective treatment. Early withdrawal of laxa- nence occurred in 2 % of the general pediatric population, of
tive is the commonest cause of recurrence. which 82 % was associated with constipation [5].
enforcement) may help in some cases. Reinforcement of spon- (proctoclysis) is better than normal saline enema. For infants,
taneous use of the toilet and keeping clean underwear should be glycerine suppositories should be used for disimpaction.
done. Persistent use of diapers delays toilet training. Maintenance treatment besides regular of laxatives, high
Diet modification means increased intake of fluids and fibre diet and toilet training are essential component to
absorbable and non-absorbable carbohydrate. Ideal fiber in- prevent accumulation of feces in rectum. Options for laxa-
take is age in years + 5 g. High fiber diet includes whole grains, tives with their doses are given in Table 4. A recent Cochrane
whole pulses/beans, green leafy vegetables, fruits like guava, review concluded that in children with constipation, PEG is
pomegranate, dates, amla, apple with peel. One should avoid superior to lactulose for the outcomes of stool frequency per
fine wheat flour (maida) and its products like noodles, vermi- week, form of stool, relief of abdominal pain and the need for
celli, bakery products and predominantly milk-based diet. additional products [8]. Few things to be kept in mind are
Pharmacological therapy consists of disimpaction and titrate dose according to response, correct dose is the one that
maintenance laxative therapy. Drugs commonly used are produces at least one soft stool daily without any soiling.
listed in Table 4. Maintain initial “correct dose” for minimum of 3–4 mo and
Disimpaction should be done if fecoliths are palpable per thereafter attempt gradual tapering. Follow up at 2 wk after
rectally or felt on abdominal examination. It can be done by disimpaction and then monthly till regular bowel movement
either oral or rectal route. Oral route is preferred as it’s nonin- is achieved. Check stool frequency and compliance to drug
vasive while rectal route is invasive and adds to fear of the and toilet training. Therapy is required for long duration,
child. According to results from a prospective trial, rectal 6 mo to 1 y in majority. Rescue treatment with stimulants
enema treatment and oral laxative treatment are equivalent as (senna, bisacodyl) may be required for a short course in
first-line therapy in children with rectal fecal impaction [7]. For refractory cases but it’s contraindicated in infants. Follow-
oral disimpaction Polyethylene glycol with or without electro- up is essential after stopping drug therapy as relapses are
lytes is given at dose of 25 mL/kg/h upto 1,000 mL/h until clear common. An algorithm for management is given in Fig. 1.
colonic content is evacuated or given as 1–1.5 g/kg/d over 4 h/d
for 3 d as home disimpaction. Ryle’s tube may be required for
administration in small children. Single dose of prokinetic i.e., Outcome
5 to 10 mg of metoclopramide by mouth 15 to 30 min before
the lavage can be given to prevent nausea and vomiting. In a systematic review, treatment success was achieved in
Disimpaction by enema should be resorted to only in few 60 % (± laxative use) at 1 y of therapy and 56±11.3 %
cases with no response to oral route. Phosphate enema recovered and were off laxatives at 5–10 y of follow up [9].
Polyethylene glycol Osmotic laxative For disimpaction: Dissolve 1 pack in Nausea, bloating, cramps, vomiting
(PEG 3350 and PEG 4000) 2 L of water then @ 20 mL/kg/h max
1 L/h total 4–5 L
Maintenance dose 0.2–0.8 g/kg/d
Lactulose Osmotic laxative 1–3 mL/kg/dose in 2–3 doses Bloating, abdominal distension
Lactitol Osmotic laxative 1–3 mL/kg/dose in 2–3 doses Bloating
Magnesium hydroxide Osmotic laxative 1–3 mL/kg in 1–2 divided doses Abdominal distension, hyper magnesemia, metallic
taste. Avoid in patient with renal failure
Docusate sodium Lubricant 100–400 mg in divided doses Cramps, abdominal pain
Mineral oil Lubricant 1–3 mL/kg/d once daily or in divided dose Not for infants
Lipoid pneumonia if aspirated
Bisacodyl Stimulant <2 y: 5 mg suppository Abdominal pain, diarrhea
5 mg/10 mg tab ≥2 y: 10 mg suppository
5 mg suppository >6 y: 1–2 oral tablets (5 mg)
Senna Stimulant 2–4 y: 3.75–15 mg/d Abdominal pain, skin rash and fixed drug eruption rarely
Tab 12 mg 4–6 y: 3.75–30 mg/d
6–18 y: 7.5–30 mg/d
Sodium picosulfate Stimulant <4 y: 2.5–10 mg once a day Abdominal cramps, diarrhea
Tab 10 mg 4–18 y: 2.5–20 mg once a day
Syp 5 mg/5 mL
1024 Indian J Pediatr (December 2013) 80(12):1021–1025
No Yes
No
No Yes
Organic etiology?
Gradual weaning
Specialized tests
Stop medication
Follow-up
However constipation persisted in nearly 30 % into adulthood Role of Funding Source None.
[10]. Early withdrawal of laxative is the commonest cause of
recurrence. Other common reasons of therapy failure are fixed
dose laxative therapy, with no disimpaction done at start or no References
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