1. Constipation, Encopresis, Diarrhea
Abbey Rupe, MD
2.7.12

2. Definitions
“Rome III” diagnostic categories of functional disorders of defecation in children:
Functional constipation
In infants and preschool children
In children 4-18 years of age
Infant dyschezia
Nonretentive fecal incontinence

3. Functional constipation--Dx
Infants and toddlers: 2 or more of the following present for at least 1 month:
2 or fewer defecations/week
At least 1 episode of incontinence after being toilet trained
Hx of excessive stool retention
Hx of painful or hard bowel movements
Presence of large fecal mass in the rectum
Hx of large-diameter stools that may obstruct the toilet

4. Functional constipation--Dx
Children w/ developmental age 4-18 yrs; at least 2 of the following present for at least 2 months:
2 or fewer defecations/week
At least 1 episode of fecal incontinence/week
Hx of retentive posturing or excessive volitional stool retention
Hx of painful or hard bowel movements
Presence of a large fecal mass in the rectum
Hx of large-diameter stools that may obstruct the toilet

5. Functional vs Organic constipation
Organic causes: < 5% of cases
Anatomic: anal stenosis, imperforate anus
Metabolic/GI: hypothyroidism, CF, diabetes mellitus, celiac disease
Neuropathic: spinal cord abnormalities, tethered cord
Intestinal nerve/muscle disorders: Hirschsprung disease, neuropathies
Misc: cow’s milk protein intolerance, lead ingestion, vit D intoxication, botulism

6. Functional constipation-etiology
3 periods when kids prone to develop constipation:
Introduction of cereals and solid food to infant’s diet
Toilet training
Starting school

7. Functional constipation--causes
Painful defecation
Can start a vicious cycle
Toilet training
Stool is held for longer periods between BMs
Power struggles can develop
Diet
Highly processed foods consumed at the expense of fruit, veggies, and fiber
Cow’s milk and constipation???? controversial

8. Evaluation History Delayed passage of meconium Painful defecation
Blood on stool
Toilet training issues
Voiding dysfunction and enuresis
Diet
Changes at home/school
Family hx

9. Evaluation Hx: signs suggesting possible organic cause:
Weight loss or poor weight gain
Anorexia
Delayed growth
Delayed passage of meconium (after 48 hours)
Urinary incontinence
Passage of blood (unless due to anal fissure)
Constipation present since birth/early infancy
Acute constipation
Fever, vomiting, diarrhea
Extraintestinalsx

10. Evaluation Physical exam Abdominal distention Mass in suprapubic area
Anal fissure
Soiled underwear
Anal sphincter tone
Size of rectal vault
Impacted stool
Lower back skin defects

11. Evaluation PE findings suggestive of organic cause: FTT
Abdominal distention
Lower spine abnormalities
Anteriorly displaced anus
Tight, empty rectum in presence of palpable fecal mass
Absent anal wink
Absent cremasteric reflex
Decreased lower extremity tone or strength

12. Evaluation Laboratory (if indicated) KUB CBC Thyroid
Celiac disease panel
Barium enema
Anorectalmanometry
Rectal biopsy
Motility studies
Sweat chloride

14. Evaluation Findings supportive of functional etiology:
Onset coincides with dietary changes, toilet training, or painful bowel movements
Stool withholding behavior
Good response to conventional treatment

15. Infants: Constipation vs normal stooling
Breast-fed infants: average 3 stools/day
Range: BM with every feed to BM every 7-10 days
Formula-fed infants:
Average 2/day
Can vary with formula
Soy-based—tend to produce harder stools; hydrolyzed casein formulas tend to produce looser stools

16. Infants
Grunting, apparent straining, turning red in the face, etc does not necessarily mean an infant is constipated
More appropriate measure is consistency of the stool
Efforts >10 minutes to produce soft stool: “infant dyschezia” – failure to relax pelvic floor during defecation effort; resolves spontaneously with time

17. Infants “normal” stools Constipated: Reassure, reassure, reassure
Press on feet, press knees to belly, raise vertical, etc
Constipated:
1 tsp dark Karo syrup bid
Miralax
Glycerin suppository
Juice—pear, apple, prune
If on solids:
increase pear, prune, plums, beans, peas, peaches
Decrease rice cereal, applesauce, bananas

18. Treatment of Children Goal: 1 soft, easily passed stool daily
Education
“cycle” of constipation
Length of treatment
Safety of medication used
3 phases:
Disimpaction
Maintenance
Follow-up

19. Disimpaction
Options: oral or NG medications, rectal medications, or combination
Inpatient vs outpatient
Oral:
Polyethylene glycol (Miralax)
Polyethylene glycol-electrolyte solution
Mineral oil (don’t use if at risk for GER)
Other: magnesium hydroxide, magnesium citrate, lactulose, sorbitol, senna, bisacodyl

20. Disimpaction Rectal Phosphate sodium enema (2 yrs and older)
Mineral oil enema
Bisacodyl suppository (older children)
Glycerin suppository (infants)

21. Maintenance Polyethylene glycol Magnesium hydroxide Lactulose
Mineral oil

22. Medications Polyethylene glycol (PEG 3350, Miralax) Osmotic laxative
OTC
grams/kg/day
Mix in 4-8 ounces liquid
Increase or decrease by ½ to 1 tsp every other day until stools soft and daily

23. Medications Mineral oil Lubricant laxative
? Interfere with absorption of fat soluble vitamins
Administer in mid-afternoon and bedtime
+/- give multivitamin
More palatable if chilled and served with a fat- containing food the child likes (pudding, yogurt, ice cream, chocolate syrup)
Avoid in kids < 1 yr of age and those at risk for GER (aspiration pneumonitis)

24. Medications Other osmotic laxatives: Stimulant laxatives
Milk of magnesia
Lactulose
Stimulant laxatives
Senna, bisacodyl

25. Maintenance Behavior modification: “Poop Journal”
“scheduled sitting” on the toilet for 5-10 minutes at same time each day (preferable within 30 minutes after a meal)
Provide footstool for support if needed
Reward system
“Poop Journal”

27. Maintenance/prevention
Dietary changes
Increase intake of fruit, raw veggies, bran, whole- grain breads, cereals, and fluids other than milk
Cow’s milk
Consider 1-2 week trial of elimination in atopic children whose constipation is unresponsive to other measures
?probiotics

28. Maintenance/prevention
When to discontinue medications?
Depends on child and severity of constipation
Taper gradually, resume if constipation returns

29. Encopresis/fecal incontinence
Constipation with fecal incontinence—80- 95%
Nonretentive fecal incontinence—5-20%
Rome III criteria:
Children with developmental age of >4 yrs, with all the following present for at least 2 months:
Defecation into places inappropriate to the social context at least once/month
No underlying disease process to explain the symptoms
No evidence of constipation

30. Constipation-associated fecal incontinence
Manage as you would for severe constipation

32. Non-retentive fecal incontinence
Causes: unclear
Some association w/ behavioral and attention problems as well as anxiety and depressive symptoms
Soiling episodes often linked to certain persons or situations
Up to 40% have never been fully toilet trained

33. Non-retentive Treatment: Outcome: No widely effect treatments 
Behavior modification
Highly structured toilet training protocol aimed at frequent efforts at defecation
Reward system
Psychosocial diagnosis and support
Outcome:
one study found 29% resolution at 2 yrs, 65% after 5 yrs, and 90% after 10 years

34. Indications for referral
Consider when oral and/or rectal medications are ineffective for disimpaction or when dietary and laxative therapy are ineffective
Complete laboratory data prior to consultation (thyroid, calcium, celiac disease, lead)
Referral options:
Wichita: 2 peds gastroenterologists
Children’s Mercy: peds GI, BRICK clinic

35. Constipation questions?

36. Diarrhea Acute Chronic
Passage of loose or watery stools at least 3x/day in a 24-hour period
Lasts <14 days
Chronic
Stool volume of >10 gm/kg/day (infants/toddlers) or >200gm/day (older children) x14 or more days
Typically means: loose or watery stools occurring at least 3x/day

37. Acute diarrhea Etiology Infectious gastroenteritis
Acute watery diarrhea
Rotavirus (infants/young children)
E. coli (older children)
Invasive (bloody) diarrhea—frank blood in stool + fever
Shigela
Salmonella
Campylobacter
EHEC
EIEC
Other: influenza, HIV, pneumonia, UTI, meningitis, sepsis

38. Acute diarrhea Assessment:
Type of diarrheal illness (watery, invasive, chronic)
Assess hydration
Assess comorbid conditions

39. Assess hydration status (WHO)
Clinical feature
< 5 % dehydrated
5-10 % dehydration
>10% dehydration
Gen. appearance
Well, alert
Restless, irritable
Lethargic or unconscious
Eyes
Normal
Sunken
Thirst
Drinks normally, not thirsty
Thirsty, drinks eagerly
Drinks poorly or unable to drink
Skin pinch
Goes back quickly
Goes back slowly
Goes back very slowly
Estimated fluid deficit
< 50 ml/kg
ml/kg
>100 ml/kg

40. Diagnostic studies Not indicated in most cases
Dehydration requiring IVF
Stool studies:
Viral antigen (rota)
Culture (bloody diarrhea)
O and P (recent travel)
C. diff (recent abx)

41. Treatment—acute watery diarrhea
Fluid and electrolytes
Replacement
Maintenance
< 2 yrs: ml ORS/episode of V/D
> 2 yrs: ml ORS/episode of V/D
Oral Rehydration Solution
Mixture of water, salts, and glucose
Pedialyte, etc
IVF
Rehydrate with NS boluses (20 ml/kg), followed by dextrose-containing IVF

42. Treatment--AGE Refeeding
Feeding can be resumed as soon as rehydration is complete
Feed age-appropriate diet
BRAT is unnecessarily restrictive

43. Treatment--AGE Pharmacotherapy Antibiotics—not indicated
Antidiarrheal—not recommended
Antimotility (i.e. loperamide)—not recommended due to side effects (lethargy, CNS depression, etc)
Antisecretory (i.e. bismuth)—contain salicylates (EVEN Children’s PeptoBismol)
Probiotics
Reduce stool output and diarrhea duration
Antiemetics--controversial

44. Chronic diarrhea Post-enteritis syndrome
Most acute enteric infections resolve within 14 days
Occasionally, acute GE can cause mucosal damage to small intestine and trigger chronic diarrhea
? Secondary to transient lactase deficiency
Probiotics may speed recovery

45. Chronic diarrhea DDx list is HUGE! Functional Enteric infection
Excessive juice/osmotically active carb intake
Idiopathic
Enteric infection
Postentereitis syndrome
Parasites
Bacteria
Viruses
CMV, rota, HIV

46. Chronic diarrhea DDx, cont’d CF Immune deficiency
Abnormal immune response
Celiac disease
Food allergic enteropathy
IBD
Protein losing gastroenteropathy
Factitious diarrhea

47. Chronic diarrhea Lab Celiac serology (anti-tTG)
Stool pH, electrolytes, reducing substances
Occult blood and leukocytes
Stool fat
Concern for IBD: CBC, albumin, ESR
Sweat chloride
Fecal elastase

48. “Toddler’s Diarrhea”
Aka Functional Diarrhea or Chronic nonspecific diarrhea of childhood:
Painless passage of 3 or more large, unformed stools during waking hours for 4 or more weeks
Onset in infancy or preschool years
Without FTT or specific definable cause

49. Toddler’s Diarrhea Early morning stools: large and semi-formed
Stools become progressively looser as day progresses
Nearly all will develop normal bowel patterns by 4 yrs of age

50. Toddler’s Diarrhea Sometimes due to excessive intake of fruit juice
Improves if intake is decreased
No other dietary modification needed

51. Diarrhea—questions?