ORIGINAL ARTICLE: GASTROENTEROLOGY
Pediatric Constipation in the Emergency Department:
Evaluation, Treatment, and Outcomes


Stephen B. Freedman, yJennifer Thull-Freedman, zMaggie Rumantir,
y
Mohamed Eltorki, and zSuzanne Schuh
ABSTRACT
Objectives: Limited knowledge exists surrounding the pharmacologic
management of pediatric constipation in the emergency department (ED)
setting and the success of interventions. Our primary objective was to
determine whether enema administration is associated with 7-day ED
revisits for persistent symptoms. Secondary objectives focused on assessing
other predictors of ED revisits.
Methods: We conducted a retrospective cohort study of children <18 years
old, diagnosed as having constipation (International Classification of
Diseases-10 codes F98.1 nonorganic encopresis, K59.0 constipation) in a
pediatric ED in Toronto, Canada, between November 2008 and October 2010.
Results: A total of 3592 visits were included; 6% (n ¼ 225) were associated
with a revisit. Children with revisits more frequently had vomiting (28% vs
17%, P ¼ 0.001), more pain (5.7  3.6 vs 4.6–3.6 of 10, P ¼ 0.01), and
underwent more blood tests (19% 05, 11%, 95% confidence interval [CI] of
the difference 3%–14%] and diagnostic imaging (62% vs 47%, 95% CI of
the difference 9%–22%). Children administered an enema were 1.54 times
more likely to revisit the ED than those who did not receive an enema (8.6%
vs 5.5%, 95% CI of the difference 1.1%–5.2%, P ¼ 0.001). Type of enema
administered varied by age (P < 0.001). Regression analysis identified the
following independent predictors of revisits: diagnostic imaging (odds ratio
[OR] 1.54, 95% CI 1.15–2.06), vomiting (OR 1.45, 95% CI 1.07–1.98),
enema administration (OR 1.40, 95% CI 1.05–1.88), and significant medical
history (OR 1.26, 95% CI 1.04–1.53).
Received December 18, 2013; accepted April 9, 2014.
From the
Sections of Paediatric Emergency Medicine and Gastroenter-
ology, Alberta Children’s Hospital Research Institute, the ySection of
Paediatric Emergency Medicine, Alberta Children’s Hospital, University
of Calgary, Calgary, Alberta, and the zDivision of Paediatric Emergency
Medicine, Department of Paediatrics, Faculty of Medicine, Hospital for
Sick Children, Toronto, Ontario, Canada.
Address correspondence and reprint requests to Stephen B. Freedman,
MDCM, MSc, Section of Paediatric Emergency Medicine, Alberta
Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, Alberta,
Canada T3B 6A8 (e-mail: stephen.freedman@albertahealthservices.ca).
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text, and links to the digital files are
provided in the HTML text of this article on the journal’s Web site
(www.jpgn.org).
This study was funded in part by The Hospital for Sick Children, Division of
Paediatric Emergency Medicine, Research Fund. The writing or prep-
aration of this article was funded in part by the University of Calgary and
Alberta Health Services. The study sponsors played no role in study
design, data collection, analysis, and interpretation or the writing of the
report or the decision to submit the manuscript for publication.
S.B.F. received funding from The Hospital for Sick Children, Division of
Paediatric Emergency Medicine, Research Fund, and the University of
Calgary, of which he is an employee. The other authors report no
conflicts of interest.
Copyright # 2014 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000000402
JPGN  Volume 59, Number 3, September 2014
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Conclusions: Enema administration and diagnostic imaging are associated
with revisits in children diagnosed with constipation. Their role in the ED
management of pediatric constipation requires further evaluation.
Key Words: abdominal pain, constipation, emergencies, enema, laxatives
(JPGN 2014;59: 327–333)
C onstipation is a common condition with frequent treatment
failures and persistent abdominal pain (1). Children with
constipation require emergency department (ED) care significantly
more often than those without constipation (2). Most children
seeking ED care because of symptoms secondary to constipation
have moderate degrees of fecal loading and are believed to require
disimpaction and maintenance therapy (3,4). Disimpaction, which
is usually performed with the aid of either oral or rectal medications,
or a combination of the 2, has been shown to be effective in small,
uncontrolled studies (4). Although the oral approach is less invasive
and more empowering for the child, adherence can be problematic.
Although the rectal approach may be faster, it is more invasive (5).
Although polyethylene glycol (PEG)–based laxatives can be
effectively and safely used to treat chronic constipation in children
presenting for outpatient care (eg, clinics, primary care) (6), data
regarding their use in children presenting for ED care are limited
(5). The largest prior pediatric ED study, which included 121
children, found that only one-third of this population received an
enema (7). Although the authors found no association between
clinical response, as reported 4 to 6 weeks later, and ED treatment
(7), a subsequent trial involving 79 children concluded that enema
disimpaction provides superior, immediate symptom relief com-
pared with PEG (5). Enema administration, however, is not an
entirely benign treatment. In addition to causing children to become
‘‘upset’’ (5), sodium phosphate enemas have the potential to result
in electrolyte abnormalities (eg, hyperphosphatemia, hypo-
calcemia, hypernatremia, hypokalemia, metabolic acidosis) (8).
Although infrequent, such events have resulted in severe neurologic
deficits and death (9). Thus, given the limited knowledge surround-
ing the pharmacologic management of pediatric constipation in the
ED setting and the success of selected interventions, we conducted a
large, retrospective cohort study to determine whether enema
administration is associated with 7-day ED revisits for persistent
symptoms of constipation. We also sought to identify other diag-
nostic investigations and therapeutic interventions associated with
ED revisits in children with constipation to guide clinical care and
identify future research targets.
METHODS
Study Design and Setting
This secondary analysis used a database created to conduct
a retrospective cohort study related to diagnostic error in
327
 Freedman et al JPGN  Volume 59, Number 3, September 2014

children with constipation (10). The dataset includes a consecutive
series of children <18 years old who presented to the ED of The
Hospital for Sick Children, a tertiary care hospital in Toronto,
Canada, between November 2008 and October 2010, and were
assigned a diagnosis consistent with constipation by the treating
physician.
Key Objectives
The primary objective was to determine whether ED enema
administration (vs no enema) is associated with success as
measured by 7-day ED revisits for persistent symptoms related
to constipation. The latter was deemed to have occurred if the
discharge diagnosis assigned at the revisit was in keeping with
symptoms attributable to constipation (ie, abdominal pain, consti-
pation). Secondary outcomes included assessing associations
between discharge laxative medications (any medication vs no
medication) and revisits and identifying other predictors of
ED revisits.
Selection of Participants
Research ethics board approval was obtained for the conduct
of a record review of children assigned, in the ED, an International
Classification of Diseases–10th Revision discharge code consist-
ent with constipation (F98.1, nonorganic encopresis; K59.0,
constipation). Although not required, 84% of participants had
previously been diagnosed as having constipation (Table 1)
(11). Patients who left before medical evaluation, those hospital-
ized at the index visit or with a significant (ie, surgical) alternative
diagnosis within 7 days (ie, at revisit), were excluded. Data were
abstracted from electronic patient charts. All of the visits during the
subsequent 7 days were reviewed.
Study Protocol
Data abstractors were trained by the principal investigator. To
minimize bias associated with data abstraction, we used specific,
restrictive key words for subjective data fields. Unavailable data
were coded as missing except for particular presenting symptoms
(eg, fever, vomiting, abdominal pain), medical history, and the
performance of diagnostic imaging, laboratory testing, and medical/
surgical consultations, for which the absence of a specific descrip-
tion, was interpreted as ‘‘not present’’ or ‘‘not done.’’ When
multiple documentation sources were present, that of the most
senior physician was used. If physician documentation was una-
vailable, nursing documentation was reviewed and abstracted.
Historical variables were documented before reviewing the out-
come, investigations, and laboratory results.
We also abstracted data related to laxative/enema adminis-
tration and the performance of abdominal x-rays (AXRs). The
amount of stool on AXR was categorized, as we have previously
reported, according to key words in the final radiology report, as

TABLE 1. Baseline description of eligible children including pertinent clinical and laboratory investigations

Data Total cohort, 7-Day ED revisit, No 7-day ED revisit,

available N ¼ 3592 n ¼ 225 n ¼ 3367 P

Demographics
Age, y, mean  SD 3592 6.7  4.4 6.6  4.4 6.7  4.5 0.77
Sex, male (%) 3592 1815 (51) 113 (50) 1702 (51) 0.92
History
Vomit in last 24 h, (%) 3592 703 (20) 63 (28) 640 (19) 0.001
Abdominal pain in last 24 h, (%) 2975 2589 (87) 173 (91) 2416 (87) 0.09
Days since last stool, median (IQR) 2510 1 (0–3) 1 (0–3) 1 (0–3) 0.76
History of constipation, (%) 1730 1447 (84) 94 (83) 1353 (84) 0.72
Significant medical history, N (%)z 3592 375 (10) 37 (16) 338 (10) 0.002
Examination
Pain score (0–10), mean  SD§ 1338 4.7  3.6 5.7  3.6 4.6  3.6 0.01
Unwell appearance, N (%) 3586 546 (15) 40 (18) 506 (15) 0.54
Temperature, 8C, mean  SDjj 3583 36.9  0.5 36.8  0.5 36.9  0.5 0.04
Heart rate, mean  SD, beats/min, 3577 102  22 102  22 102  22 0.92
Respiratory rate, mean  SD, breaths/min 3504 23  6 23  6 23  6 0.89
Abdominal distension, N (%) 3509 277 (8) 22 (10) 255 (8) 0.22
Abdominal tenderness, N (%) 3514 1115 (32) 71 (32) 1044 (32) 0.86
DRE documented, N (%) 3564 224 (6) 14 (6) 285 (9) 0.23
DRE consistent with constipation, N (%) 299 168 (56) 7 (50) 161 (57) 0.78
Investigations
Hemoglobin, mean  SD, g/L 453 129  17 134  18 129  17 0.04
White blood cell, mean  SD, 109/L 453 9.4  3.8 8.3  2.9 9.5  3.9 0.05
Creatinine, mean  SD, mg/dL 409 0.5  0.2 0.5  0.2 0.5  0.2 0.89
Blood urea nitrogen, mean  SD, mg/dL 409 11.5  3.6 12.3  3.9 11.8  3.6 0.36
Urine dipstick, leukocyte trace, (%) 1332 250 (19) 14 (15) 236 (19) 0.37

P value of significance for this table is set at 0.002. DRE ¼ digital rectal examination; ED ¼ emergency department; IQR ¼ interquartile range;
SD ¼ standard deviation.


Compares children with a 7-day ED revisit with those who did not have an eligible revisit.
y
Includes only children who had documentation of abdominal pain and duration.
z
Compares those with a chronic illness potentially associated with abdominal disease to all others.
§
As assigned by the triage nurse using a pain scale because such scoring is not routinely performed and documented by physicians.
jj
Recorded temperatures were adjusted for location of measurement, with 1.18C and 0.68C added to axillary and oral temperatures, respectively (11).

328 www.jpgn.org

Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
 JPGN  Volume 59, Number 3, September 2014
‘‘normal,’’ ‘‘small,’’ ‘‘moderate,’’ and ‘‘large’’ (10). The reports
from other imaging modalities (ie, ultrasound and computed tom-
ography) were not analyzed owing to the small numbers performed,
the challenges with conflicting reports, and an inability to use
standardized terminology. Rectal examination documentation, if
performed, was classified as consistent (‘‘firm,’’ ‘‘hard,’’ ‘‘full,’’
‘‘loading,’’ ‘‘impacted,’’ and ‘‘large’’) or inconsistent (‘‘soft,’’
‘‘none,’’ ‘‘empty,’’ ‘‘small,’’ and ‘‘liquid’’) with constipation. A
random number generator (Microsoft Office Excel 2007, Redmond,
WA) identified 10% of charts for an independent blinded review to
enable interobserver reliability assessment. Agreement was eval-
uated for the following variables: history of abdominal pain,
significant medical history (categorized as none or chronic illness
but unlikely to cause abdominal disease vs chronic illness poten-
tially associated with abdominal disease) (10), general appearance,
abdominal tenderness, and AXR performed.
Data Analysis
A sample size of 2795 patients was estimated to achieve 90%
power to detect a 5% difference between groups (ie, those admi-
nistered an enema vs those not administered an enema) in the
primary outcome (ie, 7-day ED revisit), assuming the baseline
proportions to be 15% in the no-enema group and that 25% of
children would receive an enema. Calculations were performed
using a 2-sided test, with significance set at 0.05. Sample size
calculations were conducted with the use of PASS 2008 (NCSS,
Kaysville, UT).
Frequency counts and percentages are given for discrete
variables; means, medians, standard deviations (SDs), and inter-
quartile ranges are provided for continuous variables. Between-
group differences in continuous variables were analyzed using the
2-sample t-test and the Mann-Whitney U test for normally and non-
normally distributed data, respectively. The association between ED
treatment provided (ie, enema vs no enema) and home medications
and the dichotomous outcome of 7-day ED revisits for constipation
were assessed using the x2 test. When the number of observations in
any given cell of the contingency table was <10, the Fisher exact
test was used. Further analysis of the association of enema admin-
istration in the ED with 7-day ED revisit was conducted using
multiple logistic regression, with the presence or absence of a 7-day
ED revisit as the dependent variable and enema administration as
the independent variable. Variables considered for inclusion in the
model were identified based on clinical plausibility and prior work
and included age, sex, vomiting and abdominal pain in the past
24 hours, significant medical history, days since last stool, prior
episodes of constipation, pain score, blood test and diagnostic
imaging performance, enema administration, and discharge medi-
cations. General appearance was included and children were cate-
gorized as well or unwell as has been previously performed (12).
The chosen variables were assessed for interaction. The model was
the refined using backward stepwise elimination. Variables in the
initial model with P > 0.05 were removed sequentially. The remain-
ing variables were inspected to ensure that confounding bias was not
reintroduced. A variable was considered confounded if the b
coefficient changed by >20%.
Interobserver agreement was evaluated with the Cohen kappa
(k) statistic. Agreement was considered moderate if k values were
between 0.41 and 0.6, strong if between 0.61 and 0.8, and those
>0.8 were deemed to represent near-complete agreement (13). All
of the tests were conducted using SPSS 19.0 (IBM SPSS Statistics,
Armonk, NY). Owing to the conduct of multiple analyses within
each table, a Bonferroni correction was applied (see individual
tables) (14).
www.jpgn.org
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
Constipation: Diagnostic Approach and Treatment
RESULTS
A total of 112,381 ED visits occurred during the study period.
Coding identified 4109 potentially eligible visits. After exclusion of
children admitted, those with alternative diagnoses on chart review,
those who left before medical evaluation, and those assigned a
significant alternative surgical diagnosis, 3894 eligible visits
remained (Fig. 1; the supplemental table shows diagnoses that
resulted in subject exclusion, http://links.lww.com/MPG/A324).
Three hundred two represented revisits within 7 days; therefore,
3592 visits formed the final cohort (Table 1).
Children meeting our definition of a revisit for constipation
(n ¼ 225, 6%) more frequently presented with vomiting, had a
significant medical history, and reported having more pain when
assessed at triage (Table 1). These returning children also under-
went more investigations, including blood tests (19% [42/225] vs
11% [367/3367], 95% confidence interval [CI] of the difference
3%–14%, P < 0.001) and diagnostic imaging (62% [140/225] vs
47% [1580/3367], 95% CI of the difference 9%–22%, P < 0.001)
(Table 2). Surgical and/or medical consultations were also more
common among those who had a revisit (13/225 [6%] vs 93/3367
[3%], P ¼ 0.01). The most frequently consulted specialties were
pediatric surgery (67), neurosurgery (7), urology (6), hematology/
oncology (5), cardiology (4), gynecology (4), and others (13).
ED Enema Administration
The most common treatment administered in the ED was a
rectal enema. Twenty-five percent (877/3592) of the children
received at least 1 enema while in the ED. Children administered
an enema (any type and number) were 1.54 times more likely to
revisit the ED within 7 days than those who did not receive an
enema (8.6% vs 5.5%, 95% CI of the difference 1.1%–5.2%,
P ¼ 0.001).
Those who had an AXR performed were more likely to be
administered an enema (513/1628 [32%] vs 364/1964 [19%],
P < 0.001). Among those who underwent AXR, children with a
moderate-to-large amount of stool were even more likely to receive
an enema (318/923 [35%] vs 195/705 [28%], P ¼ 0.005); however,
among these children, enema administration did not reduce the
likelihood of a revisit (27/318 [9%] vs 47/558 [8%], P ¼ 0.70).
Forty-six children received a second enema (1.3%).
Pediatric Fleet phosphate enemas (65 mL) represented the
most common initial enema administered (602/877, 69%) followed
by 130 mL adult Fleet phosphate enemas (235/877, 27%). Normal
saline enemas were the least common enema administered (40/877,
5%) and they were the most likely to be followed by a second
enema; 35% (14/40) of those initially administered saline enemas
received a second compared with 4% of those administered a Fleet
enema initially (34/837, P < 0.001).
Discharge Medications
Laxative medications were recommended at discharge to
2736 children overall (76%; Table 3) and to 75% (659/877) of those
who were administered an enema in the ED. Seven hundred ninety-
eight children (22%) were instructed to take 2 medications (any
combination) and such children were less likely to have a revisit
compared with children receiving 1 medication (4.6% vs 6.7%,
95% CI of the difference 0.2%–3.7%, P ¼ 0.03). Children who
received a combination of the most common laxative discharge
recommendation, PEG and Pico-Salax (sodium picosulfate, mag-
nesium oxide, and citric acid; Ferring Pharmaceuticals, Toronto,
Canada), however, had a 7.7% revisit rate (19/246).
329
 Freedman et al JPGN  Volume 59, Number 3, September 2014

ED, emergency department Exclusions

• 77 Alternative diagnosis on chart review

4109 Potentially eligible
(index visit; see eTable 1)
visits (ICD codes)
• 73 Admitted to hospital

• 45 Left prior to medical evaluation

• 20 Significant alternative diagnosis within

7 days

3894 Eligible study visits 302 Revisits within 7 days

225 Revisits consistent with 77 Other revisits

3592 Eligible index visits
primary outcome • 25 Viral illness

• 139 Constipation • 13 Urinary tract infection

• 94 Abdominal pain • 7 Gastroenteritis

• 5 Pneumonia

• 5 Otitis media

• 3 Gastritis

• 2 Gastroesophageal reflux

disease

• 2 Henoch–Schonlein

purpura

• 15 Others

FIGURE 1. Overall description of subjects included in the study cohort. ED ¼ emergency department. ICD ¼ International Classification of
Diseases.

Regression Analysis Interobserver agreement was good (N ¼ 360), ranging from

Four variables were determined to be independent predictors
of revisits: the administration of an enema in the ED (odds ratio
[OR] 1.40, 95% CI 1.05–1.88), vomiting in the last 24 hours (OR
1.45, 95% CI 1.07–1.98), the administration of an enema in the ED
(OR 1.40, 95% CI 1.05–1.88), and a significant medical history
(OR 1.26, 95% CI 1.04–1.53) (Table 4).
0.70 (95% CI 0.61–0.74) for unwell appearance to 0.93 for AXR
performance (95% CI 0.91–0.95).
DISCUSSION
Independent predictors of ED revisits for ongoing symptoms
of constipation include the performance of a diagnostic imaging

TABLE 2. Diagnostic testing performed

Total cohort 7-Day ED revisit No 7-day ED revisit

N ¼ 3592 n ¼ 225 n ¼ 3367 P

Urinalysis done, N (%) 1332 (37) 92 (41) 1240 (37) 0.22

Blood test done, N (%) 409 (11) 42 (19) 367 (11) <0.001
AXR 1628 (46) 130 (58) 1498 (45) <0.001
None-to-small stool 700 (43) 55 (43) 645 (43) 0.91
Moderate-to-large stool 923 (57) 74 (57) 849 (57) 0.91
Abdominal/pelvic ultrasound, N (%) 320 (9) 29 (13) 291 (9) 0.03
Abdominal/pelvic computer tomographic scan, N (%) 12 (0.3) 2 (0.9) 10 (0.3) 0.17
Any diagnostic imaging performed, N (%) 1720 (48) 140 (62) 1580 (47) <0.001

AXR ¼ abdominal x-ray; ED ¼ emergency department.

P value of significance for this table set at 0.006.

330 www.jpgn.org

Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
 JPGN  Volume 59, Number 3, September 2014 Constipation: Diagnostic Approach and Treatment

TABLE 3. Discharge medications

Total cohort 7-Day ED revisit No 7-day ED revisit

N ¼ 3592 n ¼ 225 n ¼ 3387 P

PEG, N (%) 1178 (33) 74 (33) 1104 (33) 0.98

PicoSalax, N (%)y 1083 (30) 77 (34) 1006 (30) 0.17
Lactulose, N (%) 992 (28) 51 (23) 941 (28) 0.09
Mineral oil, N (%) 127 (4) 5 (2) 122 (4) 0.35
Glycerin, N (%) 93 (3) 2 (0.9) 91 (3) 0.13
Senokot, N (%) 58 (2) 6 (3) 52 (2) 0.18
Docusate, N (%) 28 (0.8) 2 (0.9) 26 (0.8) 0.69
Pediatric Fleet enema, N (%) 23 (0.6) 3 (1) 20 (0.6) 0.17
Adult Fleet enema, N (%) 13 (0.4) 0 (0) 13 (0.4) 1.0
Bisacodyl, N (%) 13 (0.4) 1 (0.4) 12 (0.4) 0.57

ED ¼ emergency department; PEG ¼ polyethylene glycol. P value of significance for this table is set at 0.005.


Children may have been prescribed >1 discharge medication.
y
PicoSalax is a combination of picosulfate sodium, magnesium oxide, and citric acid, which is a stimulant cathartic that is active locally in the colon.

test, the presence of vomiting at the index visit, enema adminis-
tration, and the presence of a significant medical history. A large
proportion of children received 1 or more enemas in the ED, and a
variety of medications were recommended at discharge. Although
certain medication combinations were associated with ED revisits,
our findings highlight the fact that the optimal ED treatment
regimen remains unknown.
The benefit obtained from enema administration, as com-
pared with oral laxative administration, remains a topic of active
research. Recently, the 2 approaches were found to be equally
effective in treating rectal fecal impaction in children (6). In our
cohort, enema administration was a significant predictor of ED
revisits. A recent clinical trial reported that disimpaction by enema
may be superior to PEG administration in terms of providing
immediate symptomatic relief, but the benefit was not sustained
beyond 24 hours (5). The lack of sustained benefit may be because
enema administration only relieves pressure locally, in the rectum,
but has little impact on stool impaction throughout the rest of the
gastrointestinal tract. A further downside of enema administration is
discomfort, which was reported by 54% compared with 0% admi-
nistered PEG (5).
The practice variation seen in our study is not unique (7,15);
however, the choice of enema is not a trivial matter because
significant complications have been reported following enema
administration to children with constipation (8,16,17). A systematic
review identified 28 pediatric cases with severe hyperphosphatemia
and hypocalcemia following sodium phosphate–containing enema
administration (9). Such events result from pooling of liquid in the
bowel, which attracts large amounts of water, causing dehydration.
TABLE 4. Predictors from multivariate logistic regression model com-
paring children with and without an ED revisit
Variable OR SE 95% CI
Any diagnostic imaging test 1.54 0.15 1.15–2.06
performed, yes
Vomiting past 24 hours, yes 1.45 0.16 1.07–1.98
Blood test done, yes 1.41 0.19 0.97–2.03
Any enema administered in 1.40 0.15 1.05–1.88
the ED, yes
Significant medical history, yes 1.26 0.10 1.04–1.53
CI ¼ confidence interval; ED ¼ emergency department; OR ¼ odds ratio;
SE ¼ standard error.
The retained phosphate is absorbed, leading to severe hypernatre-
mia and hyperphosphatemia (18). These occurrences have led to
recommendations against the use of phosphate-containing enemas
in children of age <2 years (19,20).
Our study design did not permit us to determine follow-up
recommendations at discharge owing to inconsistent charting.
Although we have a single-payer system and in our population
>90% of patients have a primary care provider, we cannot rule out
that access to primary care may have influenced future care seeking
behavior (11). We do not know how many children were seen
during follow-up by their primary care provider or at an alternate
institution. The latter, however, is unlikely because there are no
other pediatric EDs in the city, and we have previously reported that
caregivers rarely seek care elsewhere (21).
Although we have documentation indicating the 84% of
participants had a history of constipation, we are unaware of prior
ED visits and gastroenterology evaluations. These limitations may
have introduced bias into our study. It should also be noted that
follow-up with or the ED consultation of a pediatric gastroenter-
ologist is not routinely performed at the study institution. Most
children with refractory symptoms are studied by a pediatrician; in
Canada, the latter serve as consultants and manage a large pro-
portion of children with constipation, referring them for further
evaluation (eg, pediatric gastroenterology) when they have been
refractory to conventional management or when concerns arise
regarding an organic etiology.
Although a convenient, symptom-based, diagnostic tool with
clinical applicability (the Rome III criteria) has been designed to
assist with assessing children with functional gastrointestinal dis-
orders (22,23), its use by emergency medicine physicians at our
institution is unknown. Consequently, we used a pragmatic dis-
charge diagnosis–based approach; thus, not all of the participants
who were assigned a diagnosis of constipation would meet diag-
nostic criteria (eg, Rome III). The correlation between International
Classification of Diseases–10th Revision diagnostic coding and
Rome III diagnostic criteria (24) is unknown.
Abdominal pain is the most common presenting complaint in
children ultimately diagnosed as having constipation (25,26), and it
is a frequently used outcome measure in studies evaluating the
treatment of constipation. It has been shown to improve in >50% of
children in the ED following enema administration (6,7). Thus,
given the absence of a criterion standard diagnostic test for con-
stipation, it was deemed appropriate to include ‘‘abdominal pain’’
as a discharge diagnosis in keeping with failure of treatment related
to the index visit diagnosis of ‘‘constipation.’’ Other measures such

www.jpgn.org 331

Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
 Freedman et al
as symptomatic relief following enema administration were not
selected because of potential placebo effect bias and the fact that
early improvements in children with constipation do not necessarily
translate into long-term benefits (5).
Given the retrospective design of this study, the outcome
measure had to be objective and available on all of the subjects;
thus, ED revisits were selected because they are an accepted
measure of quality of care across a range of conditions (27) and
are an objective indicator of significant ongoing symptoms leading
to ED care. Consequently, our cohort and analyses include a
heterogeneous group of children who may be at increased risk of
revisits because some of the included participants may have a
combination of irritable bowel with constipation. Because we
did find that children with revisits had more severe pain at pres-
entation, it is possible that our grouping of children with predo-
minantly abdominal pain with those with predominantly
constipation may be affecting our findings. Children presenting
primarily with abdominal pain may not improve significantly
following enema administration, particularly if there is an alternate
explanation for their abdominal pain. This issue has been high-
lighted by experts who have stated that although abdominal pain is
common in children with functional constipation, the role that
constipation plays in children who present with significant abdomi-
nal pain is unknown (28).
Although education and behavior modification aimed at
ensuring that regular toilet habits are important initial steps in
treating constipation (4), we could not capture those elements
owing to the design of our study. Because the addition of medi-
cations to behavioral management is beneficial (29), we focused on
the former because they are recorded in our electronic discharge
database. We, however, do not have data related to compliance or
the doses used. In keeping with the North American Society for
Pediatric Gastroenterology, Hepatology, and Nutrition guidelines,
which endorse many oral pharmacotherapeutic options (4), we
identified the use of a multitude of medications in varying com-
binations. We found that laxative medications were recommended
at discharge to only three-fourths of our cohort, yet their use was
not more frequent among children administered an enema, the
group most likely to require home laxative medications (7). In
support of the North American Society for Pediatric Gastroenter-
ology, Hepatology, and Nutrition recommendations, we found that
children instructed to take multiple medications following dis-
charge were less likely to have a revisit, whereas children who
received a combination of magnesium citrate and PEG had an
increased revisit rate. Although these children may simply have
had more severe constipation, this could not be identified in our
retrospective study and future research should focus on identifying
the optimal maintenance regimen.
Although some aspects of data abstraction were limited by
incomplete records, and it was challenging to determine the severity
of illness at the time of the initial ED visit, we did assess inter-
observer reliability and found it to be good. Because the decision
regarding enema administration was made by the treating physician
(ie, there is no institutional protocol), we cannot determine what
factors were responsible for the decisions at an individual patient
level. In addition, we were unable to evaluate enema response
because of a lack of consistent documentation. Because this was a
single-center study, caution must be exercised when generalizing
our findings to other sites where evaluation and treatment regimens
may differ.
CONCLUSIONS
Enema administration, vomiting, a significant medical
history, and the performance of diagnostic imaging are associated
332
Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
JPGN  Volume 59, Number 3, September 2014
with revisits in children diagnosed with constipation. Although a
large number of medications are recommended at discharge, the
choice of medication does not significantly affect outcomes.
Clinicians, however, should be aware that children instructed to
take 2 medications had fewer ED revisits. Further research is
needed to clarify the role of enemas, the optimal laxative regimen,
and to facilitate primary care provider follow-up for children at risk
for ED revisits, to improve outcomes in children with constipation.
REFERENCES
1. Loening-Baucke V. Factors determining outcome in children with
chronic constipation and faecal soiling. Gut 1989;30:999–1006.
2. Liem O, Harman J, Benninga M, et al. Health utilization and cost impact
of childhood constipation in the United States. J Pediatr 2009;154:258–
62.
3. Pirie J. Management of constipation in the emergency department. Clin
Ped Emerg Med 2010;11:182–8.
4. Constipation Guideline Committee of the North American Society for
Pediatric Gastroenterology, Hepatology, and Nutrition. Evaluation and
treatment of constipation in infants and children: recommendations of
the North American Society for Pediatric Gastroenterology, Hepatology
and Nutrition. J Pediatr Gastroenterol Nutr 2006;43:e1–3.
5. Miller MK, Dowd MD, Friesen CA, et al. A randomized trial of enema
versus polyethylene glycol 3350 for fecal disimpaction in children
presenting to an emergency department. Pediatr Emerg Care 2012;
28:115–9.
6. Bekkali NL, van den Berg MM, Dijkgraaf MG, et al. Rectal fecal
impaction treatment in childhood constipation: enemas versus high
doses oral PEG. Pediatrics 2009;124:e1108–15.
7. Miller MK, Dowd MD, Fraker M. Emergency department management
and short-term outcome of children with constipation. Pediatr Emerg
Care 2007;23:1–4.
8. Mendoza J, Legido J, Rubio S, et al. Systematic review: the adverse
effects of sodium phosphate enema. Aliment Pharmacol Ther 2007;
26:9–20.
9. Ladenhauf HN, Stundner O, Spreitzhofer F, et al. Severe hyperpho-
sphatemia after administration of sodium-phosphate containing laxa-
tives in children: case series and systematic review of literature. Pediatr
Surg Int 2012;28:805–14.
10. Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal
radiograph use, constipation, and significant misdiagnoses. J Pediatr
2014;164:83.e2–8.e2.
11. Freedman SB, Degroot JM, Parkin PC. Successful discharge of children
with gastroenteritis requiring intravenous rehydration. J Emerg Med
2014;46:9–20.
12. Schnadower D, Kuppermann N, Macias CG, et al. Febrile infants with
urinary tract infections at very low risk for adverse events and bacter-
emia. Pediatrics 2010;126:1074–83.
13. Landis JR, Koch GG. The measurement of observer agreement for
categorical data. Biometrics 1977;33:159–74.
14. Sankoh AJ, Huque MF, Dubey SD. Some comments on frequently used
multiple endpoint adjustment methods in clinical trials. Stat Med
1997;16:2529–42.
15. Patel H, Law A, Gouin S. Predictive factors for short-term symptom
persistence in children after emergency department evaluation for
constipation. Arch Pediatr Adolesc Med 2000;154:1204–8.
16. Walker M, Warner BW, Brilli RJ, et al. Cardiopulmonary compromise
associated with milk and molasses enema use in children. J Pediatr
Gastroenterol Nutr 2003;36:144–8.
17. McCabe M, Sibert JR, Routledge PA. Phosphate enemas in childhood:
cause for concern. BMJ 1991;302:1074.
18. Bowers B. Evaluating the evidence for administering phosphate enemas.
Br J Nurs 2006;15:378–81.
19. Fleet enema, a saline laxative. http://www.pdr.net/MedMerck-full-
prescribing-information/fleet-enema?druglabelid=149. Accessed July
24, 2013.
20. Rowan-Legg A. Canadian Paediatric Society-Community Paediatrics
Committee. Managing functional constipation in children. Paediatr
Child Health 2011;16:661–70.
www.jpgn.org
 JPGN  Volume 59, Number 3, September 2014 Constipation: Diagnostic Approach and Treatment

21. Freedman SB, Thakkar VA. Easing the strain on a pediatric tertiary care
center: use of a redistribution system. Arch Pediatr Adolesc Med
2007;161:870–6.
22. Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional
gastrointestinal disorders: child/adolescent. Gastroenterology 2006;
130:1527–37.
23. Burgers R, Levin AD, Di Lorenzo C, et al. Functional defecation
disorders in children: comparing the Rome II with the Rome III criteria.
J Pediatr 2012;161:615.e1–20.e1.
24. Hyman PE, Milla PJ, Benninga MA, et al. Childhood functional
gastrointestinal disorders: neonate/toddler. Gastroenterology 2006;130:
1519–26.
25. Loening-Baucke V, Swidsinski A. Constipation as cause of acute
abdominal pain in children. J Pediatr 2007;151:666–9.
26. Caperell K, Pitetti R, Cross KP. Race and acute abdominal pain in a
pediatric emergency department. Pediatrics 2013;131:1098–106.
27. Bardach NS, Vittinghoff E, Asteria-Penaloza R, et al. Measuring
hospital quality using pediatric readmission and revisit rates. Pediatrics
2013;132:429–36.
28. Tabbers MM, Di Lorenzo C, Berger MY, et al. Evaluation and treatment
of functional constipation in infants and children: evidence-based
recommendations from ESPGHAN and NASPGHAN. J Pediatr Gas-
troenterol Nutr 2014;58:265–81.
29. Nolan T, Debelle G, Oberklaid F, et al. Randomised trial of laxatives in
treatment of childhood encopresis. Lancet 1991;338:523–7.

18th Century Donum Dei for Children

Early American 18th century physiks used opiates (the Donum Dei of Sydenham) for just about any pediatric ailments, most
commonly teething, worms and diarrhea. However, by the mid-century evidence of opiate toxicity in children became common wisdom
among those who cared for them.1 Nevertheless, wet-nurses, nannies and mothers could freely purchase proprietary goods such
as Godfrey’s Cordial (an infusion of sassafras, treacle and 1/2 grain of opium) and Dalby’s Carminative (aromatic peppermint oil with 1/8
grain of opium per oz).
Both of these products were advertized as good for colic, fluxes, fevers, colds and other ailments. Sadly, the most common use
was by nurses to soporify infants and a mid-century legal report described a 14 month old who was ‘‘haggard and aged who appeared no
larger than an infant of one or two months . . .and [who had been] kept on paregoric . . .’’
J.B. Beck, Essay on Infant Therapeutics, 1849

Wrote John Cooke in A Plain Account of the Diseases Incident to Children (1769): ‘‘Opiates with infants ought to be used with the
utmost caution. I lost a son above a year old, who was killed instantly, only with eight drops of liquid laudanum, when two drops are
sufficient for a babe.’’
A.R. Colón, Nurturing Children: A History of Pediatrics, 1999

—Submitted by Angel R. Colón, MD

www.jpgn.org 333

Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.