Paediatric Constipation NCP

Definition 1) Determine if constipation present, confirmed

“The subjective complaint of passage of abnormally
delayed or infrequent passage of dry, hardened fae-
ces often accompanied by straining and/or 2)
pain” *1+.
Acute
Short-term, lasting < 2 weeks without presence of
faecal mass in the abdomen and can be treated
with adequate fluid intake and a high fibre diet.
*1,2+.
Chronic
Lasting > 8 weeks, can be organic or functional.
(1) Organic constipation is due to an underlying
medical condition such as Hirschsprung dis-
ease, anorectal malformations and hypothy-
roidism etc. *1+
(2) Functional constipation has no specific organic
cause, can be due to pain, fever, dehydration,
psychological issues, toilet training, family his
tory and medications. Painful defecation is a
common cause as faeces become dry and
hard in the colon over time if withholding and
not defecating *1+.
Diagnosis [1]
by presence of 2 or more findings from chart
above *1+.
If confirmed, then perform further history and
physical examination to determine if it is or-
ganic or functional *1+.
Assessment [3]
Anthropometric: (Birth to 24 months) Length-for-
age, Weight-for-age, Weight-for-length & Head cir-
cumference. (2-19 years of age) Height-for-age,
Weight-for-age.
Biochemistry: None
Clinical: Digestive system— Abdominal distension,
bloating, cramping, pain, bowel function, including
flatus, (type, frequency, volume), fever and vom-
iting.
Client history: Personal history—Age (prematurity),
Changes in routine, initiation of toilet training, re-
cent acute illness, medications.
Food/Nutrition-related history :
> Breast milk intake (number of feedings in a 24
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.