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''This page is for '''pediatric''' patients; for adult patients see [[Special:MyLanguage/constipation|constipation]].''

==Background==

*Functional constipation is the most common, but must evaluate for concerning/organic causes (see DDX)
*There is a wide range of normal frequency of stools and no widely-accepted definition of pediatric constipation.
**In general, stool frequency decreases with age, ranging from 3 per day in neonates/infants to 1.5 per day in young children, reaching adult frequency by roughly 3 yo.<ref>Baaleman DF, Wegh CAM, de Leeuw TJM, van Etten-Jamaludin FS, Vaughan EE, Schoterman MHC, Belzer C, Smidt H, Tabbers MM, Benninga MA, Koppen IJN. What are Normal Defecation Patterns in Healthy Children up to Four Years of Age? A Systematic Review and Meta-Analysis. J Pediatr. 2023 Oct;261:113559. doi: 10.1016/j.jpeds.2023.113559. Epub 2023 Jun 16. PMID: 37331467.</ref>
*Prevalence ranges from 1-30%<ref>Van den Berg, et al. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol. 2006. Oct. 101(10):2401-9.</ref> and comprises a significant proportion of pediatric ED visits.

==Clinical Features==

[[File:BristolStoolChart.png|thumb|Bristol Stool Chart.]]
*Most patients note some combination of withholding/infrequent defecation, painful defecation, or crampy abdominal pain
**This can include stools that are too large, too hard, and/or painful to pass
*May be associated with [[Special:MyLanguage/abdominal pain (peds)|abdominal cramping]], rectal discomfort, withholding behavior, encopresis
*May be complicated by [[Special:MyLanguage/rectal bleeding|rectal bleeding]], [[Special:MyLanguage/anal fissures|anal fissures]], [[Special:MyLanguage/fecal impaction|fecal impaction]]
*'''Should have a benign "soft" abdominal exam (vs. more concerning abdominal pathologies)'''

===Red flags===

*Significant or constant/unrelenting [[Special:MyLanguage/abdominal pain (peds)|abdominal pain]]
*[[Special:MyLanguage/Failure to thrive|Failure to thrive]]
**Delayed meconium passage
**Bilious vomiting
**Melena
**Severe abdominal distention
**[[Special:MyLanguage/Fever|Fever]]

==Differential Diagnosis==

{{Infant Constipation}}

===Children (older than 1 year) Constipation===

*Functional constipation (>95% of cases)
*Organic causes
**[[Special:MyLanguage/Hirschsprung's disease|Hirschsprung's disease]]
**Metabolic causes
***[[Special:MyLanguage/Hypothyroidism|Hypothyroidism]]
***[[Special:MyLanguage/Hypercalcemia|Hypercalcemia]]
***[[Special:MyLanguage/Hypokalemia|Hypokalemia]]
***[[Special:MyLanguage/Diabetes insipidus|Diabetes insipidus]]
***[[Special:MyLanguage/Diabetes Mellitus|Diabetes Mellitus]]
**[[Special:MyLanguage/Cystic fibrosis|Cystic fibrosis]]
**Gluten enteropathy
**Spinal cord trauma or abnormalities
**Neurofibromatosis
**[[Special:MyLanguage/Heavy-metal poisoning|Heavy-metal poisoning]]
**Medication side effects
**Developmental delays
**Sexual abuse

{{Pediatric abdominal pain DDX}}

==Evaluation==

===Workup===

[[File:Constipation(lots).png|thumb|Stool burden that may be consistent with constipation on [[Special:MyLanguage/KUB|KUB]]. '''Use of a KUB to diagnose constipation in pediatric patients is generally NOT indicated,''' as other serious pathology may also result in the imaging findings.]]
;Use of a KUB to diagnose constipation in pediatric patients is generally NOT indicated, as [[Special:MyLanguage/acute appendicitis|acute appendicitis]] and other serious pathology may also result in increased stool burden. If the abdominal exam is concerning, proceed to ultrasound/CT.
*''In many cases, may require no workup and diagnosis can be made clinically''
*Consider digital rectal exam
**Although generally not necessary, this may be done to assess for organic causes or to assess for disimpaction success
*Consider abdominal labs
**CBC
**Chemistry ([[Special:MyLanguage/hypokalemia|hypokalemia]] or [[Special:MyLanguage/hypercalcemia|hypercalcemia]])
**LFTs + lipase
**Coagulation studies (PT, PTT, INR), as a marker of liver function
*Consider [[Special:MyLanguage/TSH|TSH]] if concern for [[Special:MyLanguage/hypothyroid|hypothyroid]] related [[Special:MyLanguage/constipation|constipation]]
*Consider diagnostic imaging
**'''Constipation should not cause abdominal tenderness on exam'''
**Ultrasound if concern for [[Special:MyLanguage/intussception|intussception]], biliary pathology, and/or beginning of [[Special:MyLanguage/appendicitis|appendicitis]] workup
**CT abdomen/pelvis with IV contrast if concern for surgical abdomen
***CT may show stool burden in colon/rectum

===Diagnosis===

*'''Note that the emergency physician's primary role is to rule out organic and life-threatening causes of constipation'''
**[[Special:MyLanguage/Acute appendicitis|Acute appendicitis]] and other causes of surgical abdomen may present as constipation, in which case the primary emergency medicine goal is ruling out these other conditions
*Pediatric constipation is frequently a clinical diagnosis; the ROME IV criteria may be utilized to diagnose pediatric constipation, but this is not necessary to do in ED

==Management==

''While acute disimpaction (oral, rectal, or both) in the ED may be helpful, maintenance therapy (to prevent stool re-impaction) and family education is equally important and may prevent future ED visits.''

===Infants===

*Dietary interventions
**Not yet begun solid foods
***Sorbitol-containing juices (eg, apple, prune, or pear), which help increase stool water content and frequency
***For infants four months and older, starting dose: 2-4 ounces of 100-percent fruit juice per day
***Karo syrup, add 1 tsp to 4 oz cooled, boiled water; give 1 oz of solution to baby just before feeds twice a day until stool softens
**Who have begun solid foods<ref>Baby Care Advice. http://www.babycareadvice.com/babycare/microsites/infant_constipation/infant_constipation.old.htm.</ref>
***Sorbitol-containing fruit purees (e.g. pureed prunes).
***Substitute multigrain or barley cereal for rice cereal
***Recommended fiber intake in grams = child's age in years + 5 <ref>Mulhem E, Khondoker F, Kandiah S. Constipation in Children and Adolescents: Evaluation and Treatment. Am Fam Physician. 2022 May 1;105(5):469-478. PMID: 35559625.</ref>
*Disimpaction
**Rectal: Consider glycerin suppositories or lubricated rectal thermometer as forms of rectal disimpaction; however, this may create tolerance if used frequently
**PO: Consider [[Special:MyLanguage/Polyethylene glycol 3350|Polyethylene glycol 3350]] 0.4 g/kg/day PO as a first-line agent, followed by [[Special:MyLanguage/Lactulose|Lactulose]] 1 mL/kg PO as a second-line agent
**Note that enemas are often not recommended for infants < 2 years due to increased risk of iatrogenic electrolyte derangements or rectal perforation.<ref>Soumoy MP, Bachy A. Danger des lavements phosphatés chez le nourrisson [Risk of phosphate enemas in the infant]. Arch Pediatr. 1998 Nov;5(11):1221-3. French. doi: 10.1016/s0929-693x(98)81238-4. PMID: 9853060.</ref>

===Toddlers and children===

*WITHOUT withholding behavior, bleeding, or [[Special:MyLanguage/anal fissure|anal fissure]]
**Fiber: age + (5 to 10) grams daily
**Adequate fluid intake: 32-64 ounces [960-1920 mL] per day
*WITH withholding behavior, pain while defecating, [[Special:MyLanguage/rectal bleeding|rectal bleeding]] or [[Special:MyLanguage/anal fissure|anal fissure]]
**[[Special:MyLanguage/Polyethylene glycol 3350|Polyethylene glycol 3350]](e.g., Miralax) is the first-line treatment 0.4 g/kg/day MAX 6 days or [[Special:MyLanguage/Lactulose|Lactulose]] 1 mL/kg PO
*Enemas
**Saline enema, 5-10 mL/kg
**Mineral oil enema, 15-30 mL/year
**Sodium phosphate (Fleet) enema, approximately 1 oz for 2-4 yo, 2.25 oz for 5-11 yo, 4.5 oz for > 12 yo <ref>Neal S. LeLeiko, Sarah Mayer-Brown, Carolina Cerezo, Wendy Plante; Constipation. Pediatr Rev August 2020; 41 (8): 379–392. https://doi.org/10.1542/pir.2018-0334</ref>
*Stimulants such as [[Special:MyLanguage/Bisacodyl|Bisacodyl]] (Dulcolax) PO/suppository and [[Special:MyLanguage/Senna|Senna]] can be used as short term medications but are less studied in clinical trials compared to polyethylene glycol<ref>Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74. doi: 10.1097/MPG.0000000000000266. PMID: 24345831.</ref>

==Disposition==

*Outpatient pediatrician follow-up
*Consider urgent vs nonurgent referral to a pediatric gastroenterologist if red-flag symptoms are present

==See Also==

*[[Special:MyLanguage/Constipation|Constipation]]
*Tables on neonatal constipation differential and normal stool/urine output<ref>Helman, A. Morgenstern, J. Ivankovic, M. Long, B. Reid, S. Swaminathan, A. EM Quick Hits 25 – Cerebral Venous Thrombosis, Diphenhydramine Alternatives, Abdominal Compartment Syndrome, Neonatal Constipation, Intubating Metabolic Acidosis. Emergency Medicine Cases. January, 2021. https://emergencymedicinecases.com/em-quick-hits-jan2021/ Accessed 1/26/2021</ref>.

==References==

<references/>

[[Category:Pediatrics]]
[[Category:GI]]

Constipation (peds)/en - Revision history

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