Constipation

Question 1

What is constipation?

Answer 1

Decrease in the frequency of bowel movements, characterized by the passing of hardened stools that may be large and associated with straining and pain

Question 2

How often do newborn babies poo?

Answer 2

4-5 times a day

• decreases to 2x a day by 1 year, and after another year, they poo daily or every other day

Question 3

What is soiling?

Answer 3

Involuntary/voluntary passage of stool outside of the toilet in children ≥ 4 YO after excluding any organic causes

MCC of soiling = chronic constipation (involuntary overflow incontinence)

Question 4

Diagnosis of constipation

Answer 4

2 or more of the following:

1. Stool patterns:

→ < 3 Complete type 3/4 stools per week
→ Rabbit droppings (type 1)
→ Large, infrequent stools blocking the toilet
→ Overflow soiling

2. Sx a/w defecation

→ Anal pain/straining
→ Retentive posturing
→ Abdominal pain/poor appetite that improves after defecation

3. Past hx of constipation/anal fissures/bleeding with hard stools

Question 5

What are 5 red flags in constipation cases?

Answer 5

1. Failure to pass meconium within 24H of life
2. Faltering growth
3. GROSS abdominal distention
4. Abnormal LL neurology/deformity
5. Sacral dimple - spina bifida occulta

Question 6

What are the signs suggestive of IDIOPATHIC constipation?

Answer 6

1. Not present from birth (passed meconium within 48H)
2. Precipitation factors
3. Normal growth
4. Mild abdominal distention

6 precipitating factors:

1. Change of diet
2. Infection
3. New medications
4. Potty training
5. Starting school
6. Major change

Question 7

What is faecal impaction, and when is it suspected?

Answer 7

Faecal impaction → accumulation of hard, dry stool in the rectum/colon

Suspected when:
1. Hx of severe sx of constipation
2. Overflow soiling
3. Faecal mass palpable on abdominal examination

Question 8

Mx of idiopathic constipation

Answer 8

1. Reassurance
2. Disimpaction if any identified faecal impaction
3. Maintenance therapy - PEG/sodium picosulfate/lactulose/docusate for months to years
4. Counsel, educate, and signpost (ERIC) - scheduled toileting, use of a bowel habit diary, and reward systems

Question 9

What is the disimpaction regimen?

Answer 9

1. Escalating dose of PEG (macrogol)
2. Add stimulant lx - sodium picosulfate (if PEG alone is insufficient)

OR

Osmotic laxative - lactulose (less preferred for rapid disimpaction and usually used for maintenance therapy after PEG)

FOR 1-2 WEEKS

PEG = Polyethylene glycol

Question 10

What are the 3 types of laxatives?

Answer 10

1. Stimulant laxatives - stimulate bowel peristalsis via enteric nerves (faster bowel movement)
2. Osmotic laxatives - draw water into the bowels + soften the stools
3. Bulk-forming laxatives - increase stool bulk to stimulate peristalsis

SL:
1. Senna
2. Sodium picosulfate

OL:
1. PEG - Polyethylene glycol
2. Lactulose

BFL:
1. Ispagjula (psyllium)
- rarely used in very young children and more common in older children with mild constipation as maintenance therapy

Question 11

3 common SE of PEG

Answer 11

1. Abdominal pain
2. Diarrhoea
3. N+V

Question 12

2 contraindications for osmotic laxatives

Answer 12

1. Severe dehydration
2. Intestinal obstruction/ileus - DO NOT USE UNTIL OBSTRUCTION EXCLUDED