1. Constipation in Pediatrics
St. David’s North Austin Medical Center Grand Rounds
June 2019
Dyer Heintz, MD
Dell Children’s Medical Group

2. Disclosures
Speakers bureau for Abbott Nutrition

3. Objectives -Define constipation in infants and children
-Differentiate functional constipation from organic constipation
-Be able to evaluate for organic causes of constipation
-Understand the treatment options for constipation in infants and children

4. How Big of a Problem Is It?
-Accounts for 3% of pediatrician visits
-Accounts for up to 25% of pediatric gastroenterology visits
-Occurs in 30% of kids (likely more)
-Costs for functional constipation in US- $3.9 billion per year (from 2009)
-$4.6 billion per year in 2019 when adjusted for inflation
-Three fold increase in mean total unadjusted annual healthcare expenditure for children with constipation vs those without ($3430/yr versus $1099/yr)
Baker SS, Liptak GS, Colletti RB, Croffie JM, Di Lorenzo C, Ector W, et al. Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 1999;29:612–626.
Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C. Health utilization and cost impact of childhood constipation in the United States. J Pediatr. 2009;154:258–262.

7. Normal Defecation Pattern
Infants
-0 – 7 stools per day
-Breastfed infants may go up to 2 weeks between bowel movements
-Frequency usually decreases between 2 and 3 months of age
Toddlers
-1 – 2 per day
>4 yo
-3/day – 3/week
Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2004

8. Definition in Infants and Toddlers (<4 yo)
1. 2 or less defecations per week
2. At least 1 episode of incontinence per week after the acquisition of toileting skills
3. History of excessive stool retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large-diameter stools that may obstruct the toilet
Accompanying symptoms may include irritability, decreased appetite, and/or early satiety, which may disappear immediately following passage of a large stool
-Symptoms present for at least a month with 2 or more criteria
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

9. Infant Dyschezia
-At least 10 minutes of straining and crying before successful passage of
soft stools, in the absence of other health problems.
-Can include screaming, crying, and turning red or purple in the face with
effort.
-Stools are usually evacuated daily.
-Symptoms begin in the first months of life and generally resolve spontaneously
after a few weeks.
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

10. Definition in Kids (>4 yo)
1. 2 or less defecations in the toilet per week
2. At least 1 episode of fecal incontinence per week
3. History of retentive posturing or excessive volitional stool retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large-diameter stools that may obstruct the toilet
-Symptoms at least once per week for at least 2 months with at least 2 of the criteria
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

11. When Does It Start? -Six months of age -Introduction of solids
-Change in motility patterns
-Three years of age
-Initiation of toilet training
-Five years of age
-Start school
-Anytime

12. What Does It Look Like In Clinic? Signs/Symptoms
Pain (classically periumbilical)
Distention
Nausea
Vomiting
Reflux
Flatulence
Anorexia
Diarrhea (encopresis)
Extended toilet time
Large stools
Hematochezia
Anal fissures/skin tags
Rectal prolapse
Stool withholding
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

13. What Do You Look For? Physical Exam
External anal exam: location, fissures, skin tags, trauma, soiling, asymmetry
Back: sacral dimple, hair tuft
Abdomen: tone, fullness, discomfort
Legs: weakness
Neuro: developmental status, reflexes
Psych: hyperactivity
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

14. Rectal?

15. Who Needs Evaluation? -Failure to pass meconium in 48 hours
-Symptoms within the first month of life
-Abdominal distention in the context of constipation
-Abnormal weight loss
-Hematochezia
-Abnormal rectal exam
-Neurological findings in lower extremities
-Failure to respond to standard interventions
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

16. Why Might It Occur? Organic causes
Celiac disease
Hypothyroidism
Dietary protein allergy
Drugs
Heavy metal ingestion (lead)
Vitamin D intoxication
Botulism
Cystic fibrosis
Hirschsprung disease
Anal achalasia
Colonic inertia
Anorectal malformations/Imperforate anus
Mass (sacral teratoma, Ewing sarcoma)
Spinal cord anomalies/tethered cord
Abnormal abdominal musculature (prune belly, Down syndrome)
Pseudoobstruction
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

17. Causes - Reality Functional constipation (95% of cases)
-Stool withholding
-Inattentive (ADD/ADHD)
Allergy (infants)
Slow transit constipation
Dyssynergic defecation
Other causes
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

18. NASPGHAN Guidelines

19. NASPGHAN Guidelines

20. NASPGHAN Guidelines

21. NASPGHAN Guidelines

22. NASPGHAN Guidelines

23. NASPGHAN Guidelines

24. What Do You Do? Evaluation
History and exam are the mainstay in diagnosis
Basic imaging not needed for most cases
-Can be helpful to differentiate retentive from non-retentive encopresis or if the diagnosis is unclear
-Look at the image
Algorithm does not suggest any evaluation prior to GI referral
-I usually recommend basic labs in kids with encopresis or non-responsive to therapy (thyroid studies, Celiac screen)
-Cost analysis studies finds no benefit, as the prevalence of these conditions is close to standard population
Chogle A, Saps M. Yield and cost of performing screening tests for constipation in children. Can J Gastroenterol Dec;27(12):e35-8. Epub 2013 Nov 13.
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

25. What Does GI Do? Specialty Evaluation
Labs
Barium enema
Sitz marker study
MRI lumbosacral spine
Anorectal manometry
Colonic manometry

26. How Do You Treat It? Infants
-Juice (apple, prune, pear): ½ to 2 oz daily
-MOA: Poor absorption of sorbitol leads to an osmotic effect to soften and bulk stools
-SE: diarrhea, acidic stools, diaper rash
-Lactulose: 1 – 2 g/kg once to twice daily
-MOA: Non-absorbable sugar leads to an osmotic effect to soften and bulk stools
-SE: diarrhea, acidic stools, diaper rash, gassiness and abdominal distention
-Glycerin suppositories
-MOA: Stimulates rectal contractions, soften and lubricates stool
-SE: none
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

27. How Do You Treat It? Children
Osmotic Laxatives
-Polyethylene Glycol 3350: 0.2 – 0.8 g/kg/day
-MOA: Minimally absorbed inert molecule to soften and bulk stools
-SE: Diarrhea, flatulence
-Magnesium:
-2–5 years: 0.4–1.2 g/day 6–11 years: 1.2–2.4 g/day 12–18 years: 2.4–4.8 g/day
-MOA: Minimally absorbed element to soften and bulk stools
-SE: Diarrhea, cramping, magnesium toxicity
-Lactulose: max dose 60 g/day or 90 mL/day
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

28. How Do You Treat It? Children
Stimulant Laxatives
-Bisacodyl:
-3–10 years: 5 mg/day
->10 years: 5–10 mg/day
-Senna:
-2–6 years: 2.5–5 mg once or twice/day
-6–12 years: 7.5–10 mg/day
->12 years: 15–20 mg/day
-Sodium picosulfate:
-1 mo–4 years: 2.5–10 mg/day
-4–18 years: 2.5–20 mg/day
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

29. How Do You Treat It? Children
Enemas -Sodium phosphate (Pediatric for kids <11yrs) -Bisacodyl -Glycerin -Normal saline (10 mL/kg up to 300 mL)

30. How Do You Treat It? Adjunct Treatments in Children
-Abdominal massage (hypertonia)
-Mineral oil (>2yrs): 1 – 3 mL/kg/day up to 90 mL
-MOA: lubricating agent
-SE: malabsorption, fecal incontinence, aspiration pneumonitis
-Foot stool (positioning)
-Scheduled toilet time
-Pelvic floor therapy
-Rectal stim (infants)
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

31. How Do You Treat It? Children
-Extra water
-Extra fiber
-Probiotics
-Behavioral therapy
-Dietary eliminations
NO supporting evidence
Others I don’t use
-Docusate po
-Low dose magnesium products
-Fiber gummies
-Enema protocols
Tabbers MM. Nonpharmacologic treatments for childhood constipation: systematic review. Pediatrics Oct;128(4):

32. What Else Can GI Do? -Linactolide/Lubiprostone- not approved in kids
-Rectal botulinum toxin (withholders and anal fissures)
-Cecostomy
-Surgery

33. What Do I Do? PEG 3350: ½ to 1 capful daily to twice daily
-Titrate dose to effect with a goal of 1-2 soft stools daily
Magnesium: 400 mg to 1600 mg once to twice daily
Fiber (Soluble fiber or wheat dextrin): 1-2 tablespoons daily
-Adjust magnesium dosage up to max dosing
Add stimulant if not effective (>2yrs)

34. What About for Encopresis?
Clean out
-PEG 3350: wt in kg X 1.5 gm / 17 = total caps per day up to 14 caps in one day for 3-6 days
(ex. 30kg X 1.5 / 17 = 2.6 caps or 3 caps per day)
-Mix in flavored, non-carbonated beverage
-Magnesium citrate: age in yrs X 1 oz = total dose up to 10 oz in one day
(ex. 7yrs X 1 = 7 oz per day or 13 yrs X 1 = 10 oz per day)
-Follow by lots of liquids
-Enema first for fecal impaction
-May need to do for 3 – 6 days in a row
-Equally as effective as PEG 3350
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274

35. What About for Encopresis?
Maintenance
-Osmotic laxative with the addition of a stimulant
-Senna: use chewable tablets (15mg) and cut in half, if needed
-Liquid preparation has 2 separate concentrations: 8.8 mg/5 mL and 175 mg/5 mL
-Bisacodyl: older children
-Consider pelvic floor therapy in children >7yrs

36. What About Polyethylene Glycol 3350?
Medication is minimally absorbed (excreted in urine unprocessed)
Present in foods as a coating and binding agent and in cosmetics
Despite the media/blog hype, there is no evidence of significant side effects related to its usage in over 250 available studies
Contamination seen in 2008 with small amounts of toxic compounds (ethylene glycol and diethylene glycol), which have not been found since
Effective and achieves the highest compliance rate of any therapeutic regimen
No evidence of any lab abnormalities after a year of daily treatment in kids
I give it to my kids, but there are alternatives for leery families
NASPGHAN Position Statement on PEG 3350, July 2015
Alper A, Pashankar DS. Polyethylene glycol: a game-changer laxative for children. J Pediatr Gastroenterol Nutr Aug;57(2):

37. How Good Are We At Treating?
-60% of children are symptom free in 6 to 12 months
-50% are off of therapy
-25% of children will have continued symptoms into adulthood
-Only ~5% require daily treatment 10 years out
-Prognostic factors for symptom recurrence in adulthood
-Delayed intervention
-Older age of onset
-Fewer bowel movements at symptom onset
-60% improve with primary care management
-75% improve with specialty management
Pijpers MA. Functional constipation in children: a systematic review on prognosis and predictive factors. Pediatr Gastroenterol Nutr Mar;50(3):
Bongers ME, et al. Long-term prognosis for childhood constipation: clinical outcomes in adulthood. Pediatrics Jul;126(1):e

38. Special Populations Spina bifida Anorectal malformations
Down syndrome/hypotonia/neuropathy
Hypertonia/spasticity
Muscular dystrophy/weakness/myopathy

39. Summary -Constipation is a common and costly problem
-Well defined criteria for a diagnosis of constipation in kids
-Algorithm available for management and referral
-A variety of safe and effective medications available
-Despite treatment, 25% of kids will have issues as adults as well

40. Resources

41. Resources NASPGHAN -Website: naspghan.org -App: NASPGHAN Toolbox
-Treatment algorithms: constipation, ingestion
-Nutrition: Formula composition, fortification instructions, caloric needs
Online: ucanpooptoo.com, aap.org
Your friendly local pediatric gastroenterologists

42. References
Baker SS, et al. Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. JPGN. 1999;29:612–626.
Liem O, et al. Health utilization and cost impact of childhood constipation in the United States. J Pediatr. 2009;154:258– 262.
Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2004
Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274.
NASPGHAN Position Statement on PEG 3350, July 2015.
Alper A, Pashankar DS. Polyethylene glycol: a game-changer laxative for children. J Pediatr Gastroenterol Nutr Aug;57(2):
Pijpers MA. Functional constipation in children: a systematic review on prognosis and predictive factors. Pediatr Gastroenterol Nutr Mar;50(3):
Bongers ME, et al. Long-term prognosis for childhood constipation: clinical outcomes in adulthood. Pediatrics Jul;126(1):e

43. The Children’s Book of Lies