Constipation in Children

Question 1

What is the definition of constipation in children?

Answer 1

A child that defecates less than 3 times per week
or
Significant difficulty passing stool.

Question 2

What is chronic constipation associated with in children?

Answer 2

Hard pellet like stool that is difficult to pass.

Question 3

How are most cases of constipation in children described?

Answer 3

Idiopathic or functional constipation

Question 4

What is functional constipation due to?

Answer 4

Lifestyle factors

Question 5

What are possible causes of constipation in children?

Answer 5

• Low fibre diet
• Dislike of using toilet
• Pain on passing stool
• Anal fissure
• Not recognising sensation of needing to pass stool

Question 6

What underlying conditions can constipation be a sign of?

Answer 6

Hirschsprung’s disease (MAIN)
Cystic fibrosis
Hypothyroidism.

Question 7

What are features of constipation?

Answer 7

• Hard stools that are difficult to pass
• Rabbit dropping stools
• Straining and painful passages of stools
• Abdominal pain

Question 8

What is retentive posturing?

Answer 8

Holding an abnormal posture

Question 9

What might you be able to feel on a constipated child?

Answer 9

Hard stools may be palpable in abdomen

Question 10

What do you need to check for in children before treating the constipation?

Answer 10

Faecal impaction

Question 11

What is faecal impaction?

Answer 11

Inability to evacuate large hard inspissated concreted stool or bezoar lodged in the lower GI tract

Question 12

What are symptoms of faecal impaction?

Answer 12

• symptoms of severe constipation
• overflow soiling
• faecal mass palpable in the abdomen

Question 13

What are red flag symptoms of constipation?

Answer 13

• Not passing meconium within 48 hours of birth
• Neurological signs or symptoms, particularly in the lower limbs
• Vomiting
• Ribbon stool
• Abnormal anus
• Abnormal lower back or buttocks
• Failure to thrive

Question 14

What is the first line management if faecal impaction is present?

Answer 14

Polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen

Question 15

What disease causes chronic constipation?

Answer 15

Hirchsprung’s disease

Question 16

What is Hirschsprung’s disease due to?

Answer 16

Absence of ganglion cells from myenteric and submucosal plexuses

Question 17

How does Hirchsprung’s disease occur?

Answer 17

As the baby develops in utero, the distal colon is not innervated correctly.
The resulting aganglionic colon is shrunken and not able to distend properly.

Question 18

What does an aganglionic colon cause?

Answer 18

Back pressure of stool trapped in the more proximal colon.

Question 19

How can Hirschsprung’s disease present at birth?

Answer 19

• a delay in passing meconium (>48 hours)
• a distended abdomen
• forceful evacuation of meconium after digital rectal examination

Question 20

How can Hirschsprung’s disease present later in childhood?

Answer 20

Chronic history of constipation
Poor response to movicol disimpaction regimens
Poor weight gain.

Question 21

How can the diagnosis of Hirschsprung’s disease be confirmed?

Answer 21

Full-thickness rectal biopsy

Question 22

What is the initial management of Hirschsprung’s disease?

Answer 22

Rectal washouts initially

Question 23

What is the definitive management of Hirschsprung’s disease?

Answer 23

Removal of the section of aganglionic colon- Anorectal pull through procedure