Functional gastrointestinal disturbances in the early age children

Functional gastrointestinal disturbances in the early age children

 

The Rome criteria is a system developed to classify the functional gastrointestinal disorders (FGIDs), disorders of the digestive system in which symptoms cannot be explained by the presence of structural or tissue abnormality, based on clinical symptoms. Some examples of FGIDs include irritable bowel syndrome, functional dyspepsia, functional constipation, and functional heartburn. The most recent revision of the criteria, the Rome III criteria, were published in 2006 in book form, and in a shorter journal supplement in Gastroenterology.

 

The reliable diagnosis of functional gastrointestinal disorders (FGIDs) has been shown to be based on researches utilizing the Rome criteria by means of self-reported questionnaires. Rome classification system is essentially based on the symptom clusters that remain consistent across clinical and population groups. The Rome criteria have been modified periodically as new scientific data emerges. Rome foundation has undergone many revisions since its first presentation.

Patients with FGIDs report a wide variety of symptoms affecting different regions of the gastrointestinal (GI) tracts. These symptoms in the GI tact are similar in terms of CNS processing of visceral and somatic signals. However, the FGIDs have accompanied distinct peripheral symptoms that require more specific treatment. The psychiatric agents alone in patients with irritable bowel syndrome (IBS) caot control the diarrhea or constipation.

There are no definitive biomarkers to explain FGIDs and the symptoms that bring patients to physicians. Therefore, symptom-based criteria are used for clinical care and research Symptom-based criteria are used in psychiatry (eg, the Diagnostic and Statistical Manual of Mental Disorders IV) and rheumatology. A critical value of the use of symptom-based diagnostic criteria is related to the ability to define patients’ subsets to respond to the clinical trial. The new classification system of Rome III criteria could have important effects on both clinical practice and research. According to the new classification, functional dyspepsia is sub-classified into epigastric pain syndrome and postprandial distress syndrome, based on the presence of meal-related symptoms. IBS is sub-grouped into four categories with the Bristol Stool Scale (BSS). These changes could affect the estimate of prevalence of each subtype and the selection of patients for clinical trials.

The bowel habits in IBS patients show considerable inter- and intra-individual variability, and it has been common to use the supporting symptom criteria to divide IBS patients into different subgroups based on their predominant bowel pattern. This has been important especially in drug trials, where a positive effect could be expected in one subgroup of patients, whereas side effects in the other subgroups. The study was conducted prospectively in female IBS patients by Rome II criteria to determine the level of agreement between Rome II and Rome III subtypes, and it was quite high (86.5%, kappa 0.79). The behaviors of Rome II and Rome III subtypes over time were also similar in terms of subtype prevalence and stability. However, in this study, the author analyzed the subtypes of unspecified IBS and mixed IBS into 1 category. In another study with similar setting, the agreement of Rome II and Rome III of IBS subtype was poor and the main disagreement occurred between the alternating IBS in Rome II criteria and mixed IBS with unspecified IBS subtypes in Rome III criteria. In Rome III questionnaires from the website of Rome foundation, the classification of subtypes of IBS was based on the patients’ response to the direct questions in terms of stool form, instead of BSS. In the study conducted from Park et al, the agreement between subtype defined by the self-reporting stool consistency and subtype categorized by the BSS was poor (kappa 0.08).

A. Functional Esophageal Disorders

A1. Functional Heartburn

Diagnostic criteria* Must include all of the following:

. Burning retrosternal discomfort or pain

·        . Absence of evidence that gastroesophageal acid reflux is the cause of the

·        symptom

·        . Absence of histopathology-based esophageal motility disorders

* Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

A2. Functional Chest Pain of Presumed Esophageal Origin

Diagnostic criteria* Must include all of the following:

§        . Midline chest pain or discomfort that is not of burning quality

§        . Absence of evidence that gastroesophageal reflux is the cause of the symptom

§        . Absence of histopathology-based esophageal motility disorders

* Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

A3. Functional Dysphagia

Diagnostic criteria* Must include all of the following:

§        . Sense of solid and/or liquid foods sticking, lodging, or passing abnormally

§        through the esophagus

§        . Absence of evidence that gastroesophageal reflux is the cause of the symptom

§        . Absence of histopathology-based esophageal motility disorders

·        Criteria fulfilled for the last

months with symptom onset at least months prior to diagnosis

A4. Globus

Diagnostic criteria* Must include all of the following:

§        . Persistent or intermittent, nonpainful sensation of a lump or foreign body

§        in the throat

§        . Occurrence of the sensation between meals

§        . Absence of dysphagia or odynophagia

§        . Absence of evidence that gastroesophageal reflux is the cause of the symptom

§        . Absence of histopathology-based esophageal motility disorders

* Criteria fulfilled for the last months with symptom onset at least

months prior to diagnosis

 

B. Functional Gastroduodenal Disorders

B1. FUNCTIONAL DYSPEPSIA

Diagnostic criteria* Must include:

One or more of the following:

a. Bothersome postprandial fullness

b. Early satiation

c. Epigastric pain

d. Epigastric burning

AND

. No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms

* Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

B1a. Postprandial Distress Syndrome

Diagnostic criteria* Must include one or both of the following:

·        . Bothersome postprandial fullness, occurring after ordinary-sized meals,

·        at least several times per week

·        . Early satiation that prevents finishing a regular meal, at least several times per week

* Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

Supportive criteria

·        . Upper abdominal bloating or postprandial nausea or excessive belching

·        can be present

·        . Epigastric pain syndrome may coexist

B1b. Epigastric Pain Syndrome

Diagnostic criteria* Must include all

of the following:

. Pain or burning localized to the epigastrium of at least moderate severity, at least once per week

·        . The pain is intermittent

·        . Not generalized or localized to other abdominal or chest regions

·        . Not relieved by defecation or passage of flatus

·        . Not fulfilling criteria for gallbladder and sphincter of Oddi disorders

* Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

Supportive criteria

·        . The pain may be of a burning quality, but without a retrosternal component

·        . The pain is commonly induced or relieved by ingestion of a meal, but may occur while fasting

·        . Postprandial distress syndrome may coexist

B2. BELCHING DISORDERS

·        B2a. Aerophagia

Diagnostic criteria* Must include all of the following:

·        . Troublesome repetitive belching at least several times a week

·        . Air swallowing that is objectively observed or measured

* Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

B2b. Unspecified Excessive Belching

·        Diagnostic criteria* Must include all of the following:

·        . Troublesome repetitive belching at least several times a week

·        . No evidence that excessive air swallowing underlies the symptom

* Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

B3. NAUSEA AND VOMITING DISORDERS

B3a. Chronic Idiopathic Nausea

Diagnostic criteria* Must include all of the following:

·        . Bothersome nausea occurring at least several times per week

·        . Not usually associated with vomiting

·        . Absence of abnormalities at upper endoscopy or metabolic disease that explains the nausea * Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

B3b. Functional Vomiting

Diagnostic criteria* Must include all of the following:

·        . On average one or more episodes of vomiting per week

·        . Absence of criteria for an eating disorder, rumination, or major

·        psychiatric disease according to DSM-IV

·        . Absence of self-induced vomiting and chronic cannabinoid use and absence of abnormalities in the central nervous system or metabolic diseases to explain the recurrent vomiting

·        * Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

 

B3c. Cyclic Vomiting Syndrome

Diagnostic criteria Must include all of the following:

·        . Stereotypical episodes of vomiting regarding onset (acute) and duration (less than one week)

·        . Three or nausea and vomiting between episodes

Supportive criterion

History or family history of migraine headaches

B4. Rumination Syndrome in Adults

Diagnostic criteria Must include both of the following:

·        . Persistent or recurrent regurgitation of recently ingested food into the mouth

·        with subsequent spitting or remastication and swallowing

·        . Regurgitation is not preceded by retching

Supportive criteria

·        . Regurgitation events are usually not preceded by nausea

·        . Cessation of the process when the regurgitated material becomes acidic

·        . Regurgitant contains recognizable food with a pleasant taste

C. Functional Bowel Disorders

C1. Irritable Bowel Syndrome

Diagnostic criterion*

Recurrent abdominal pain or discomfort** at least days/month in the last months associated with two or more of the following:

·        . Improvement with defecation

·        . Onset associated with a change in frequency of stool

·        . Onset associated with a change in form (appearance) of stool

* Criterion fulfilled for the last months with symptom onset at least months prior to diagnosis

** “Discomfort” means an uncomfortable sensatioot described as pain.

In pathophysiology research and clinical trials, a pain/discomfort frequency of at least

days a week during screening evaluation is recommended for subject eligibility.

C2. Functional Bloating

Diagnostic criteria* Must include both of the following:

. Recurrent feeling of bloating or visible distension at least

days/month in the last months

. Insufficient criteria for a diagnosis of functional dyspepsia, irritable bowel syndrome, or other functional GI disorder

Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

C3. Functional Constipation

Diagnostic criteria*. Must include two or more of the following:

a. Straining during at least 25 % of defecations

b. Lumpy or hard stools in at least 25 % of defecations

c. Sensation of incomplete evacuation for at least  25 % of defecations

d. Sensation of anorectal obstruction/blockage for at least 25 % of defecations

e. Manual maneuvers to facilitate at least 25 % of defecations (e.g., digital evacuation, support of the pelvic floor)

f. Fewer than three defecations per week . Loose stools are rarely present without the use of laxatives.

 Insufficient criteria for irritable bowel syndrome

* Criteria fulfilled for the last months with symptom onset at least months prior to diagnosis

C4. Functional Diarrhea

Diagnostic criterion*

·        Loose (mushy) or watery stools without pain occurring in at least 75% of stools

* Criterion fulfilled for the last months with symptom onset at least  months prior to diagnosis

C5. Unspecified Functional Bowel Disorder

Diagnostic criterion*

·        Bowel symptoms not attributable to an organic etiology that do not meet criteria

for the previously defined categories

* Criterion fulfilled for the last months with symptom onset at least months prior to diagnosis

D. Functional Abdominal Pain Syndrome

D. Functional Abdominal Pain Syndrome

Diagnostic criteria* Must include all of the following:

·        . Continuous or nearly continuous abdominal pain

·        . No or only occasional relationship of pain with physiological events (e.g., eating, defecation, or menses)

·        . Some loss of daily functioning

·        . The pain is not feigned (e.g., malingering)

·        . Insufficient symptoms to meet criteria for another functional gastrointestinal disorder that would explain the pain

* Criteria fulfilled for the last months with symptom onset at least

months prior to diagnosis

 

Dyspepsia is a common term used to characterize abdominal pain centered in the epigastrium, sometimes combined with other gastrointestinal complaints. Historically the word ‘dyspepsia’ was used for a heterogeneous group of abdominal symptoms. Functional (previously nonulcer) dyspepsia (FD) is the focus of this review, and usually indicates abdominal discomfort or pain with no obvious organic cause that could be identified by endoscopy.

Stomach pain and discomfort have been reported since ancient times. The term ‘dyspepsia’ originates from the Greek ‘δυς-’ (dys-) and ‘πέψη’ (pepse), popularly known as indigestion. It was first recorded in the mid 18th century and since then it has been widely used [Baron et al. 2006]. In the 18th century dyspepsia was thought to be one of the ‘nervous disorders’ along with hypochondria and hysteria [Hare, 1991].

In addition to the term ‘functional dyspepsia’, several other descriptions of dyspepsia are in use, each of which reflects various amounts of investigation into upper gastrointestinal symptoms of the patient. Uninvestigated dyspepsia refers to patients with either new or possibly recurrent dyspeptic symptoms in whom no investigations have previously been undertaken. After those investigations dyspeptic complaints may be called investigated dyspepsia and should be differentiated into organic dyspepsia and FD. Organic dyspepsia means that there is a clear anatomic or pathophysiologic reason for the dyspeptic complaints, such as an ulcer disease or mass. In contrast, when a diagnosis of FD has been made, it means that a number of investigations were performed including upper gastrointestinal endoscopy, and were found to be normal.

Dysmotility is a main focus of research in the pathophysiology of dyspepsia. Numerous studies have documented abnormal gastroduodenal motility in FD patients [Tack et al. 1998]. The abnormalities range from delayed to accelerated gastric emptying, abnormal antral and fundic contractions, and accommodation issues in the fundus and antrum. The symptoms of FD may be explained by disturbed motility both during and after a meal.

 

Accommodation is the ability of the stomach to distend appropriately to the size and timing of a meal, allowing an increase in gastric volume without an increase in pressure. Accommodation problems may be expressed as pain during meal ingestion or early satiation. In the study of Bredenoord et al. [2003], 47% of FD patients were found to have impaired accommodation by single photon emission computed tomography (SPECT). In a study with a fundic barostat, impaired accommodation was shown in 40% of patients with FD, and it was associated with the symptom of early satiety [Tack et al. 1998].

 

SPECT has also been used for assessment of gastric volumes and accommodation. This application is based on the unique capability of both parietal (oxyntic) and nonparietal (mucous) cells to take up and excrete 99mTc-pertechnetate from the circulating blood pool. The use of SPECT to quantify the gastric accommodation response was first proposed and further validated by the Mayo group [De Schepper et al. 2004; Bouras et al. 2002]. Decreased meal size and postmeal symptoms in dyspeptic symptoms were shown to be associated with low fasting gastric volumes and faster gastric emptying [Delgado-Aros et al. 2004a].

 

Delayed gastric emptying was documented in FD patients in a number of studies [Haag et al. 2004]. One study found delayed emptying of solids and liquids in 23 and 35% of patients, respectively. Delayed gastric emptying of solids was associated with postprandial fullness and vomiting. Delayed emptying of liquids was also associated with postprandial fullness and severe early satiety [Sarnelli et al. 2003a]. Interestingly, another study showed abnormal accelerated gastric outflow in patients measured using a c13 breath test. Around 27% of patients with PDS had accelerated gastric emptying in the early postcibal period associated with PDS-related dyspepsia [Zai and Kusano, 2009].

 

More than two-thirds of patients with FD show abnormalities with electrogastrography (EGG) and antral/duodenal manometry [Sha et al. 2009]. A subgroup of FD patients with postprandial symptoms show abnormal intragastric distribution of food, independent of the gastric emptying rate [Troncon et al. 1994]. However, this condition cannot be described as dysmotility only; indeed, promotility agents seem to be only partially helpful in FD

Constipation is a common childhood complaint. Despite its prevalence, it remains a challenging affliction for paediatric patients, their families and health care providers. The etiology of paediatric constipation is likely multifactorial, and is very seldom due to organic pathology. It has been shown that childhood constipation is undertreated. If constipation is unrecognized or inadequately treated, its effects can be far reaching – in children, it can lead to significant abdominal pain, appetite suppression, fecal incontinence with lowered self-esteem, social isolation and family disruption. Children with constipation benefit from prompt and thorough treatment intervention.

Definition

Constipation is defined variably, but involves infrequent, difficult, painful or incomplete evacuation of hard stools. The term ‘functional constipation’ describes all children in whom constipation does not have an organic etiology. Functional constipation is commonly the result of withholding of feces in a child who wants to avoid painful defecation. Frequently, children with constipation will also experience recurrent episodes of fecal incontinence due to overflow caused by fecal impaction (known as encopresis).

The Rome II paediatric criteria for functional gastrointestinal disorders were established in 1999, and were to be used as a diagnostic aid and to provide categorization for research purposes . The updated Rome III criteria for functional constipation were published in 2006

Rome III diagnostic criteria for functional constipation (criteria fulfilled at least once per week for at least two months before diagnosis):

Must include two or more of the following in a child with a developmental age of at least four years, with insufficient criteria for the diagnosis of irritable bowel syndrome:

1.     Two or fewer defecations in the toilet per week.

2.     At least one 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.

Objective

The current practice point focuses on the management of functional constipation in children, rather than its differentiation from organic pathology. The reader is referred to other resources for a diagnostic discussion.

Management

The goals in treating constipation are to produce soft, painless stools and to prevent the reaccumulation of feces. These outcomes are achieved through a combination of education, behavioural modification, daily maintenance stool softeners and dietary modification. Fecal disimpaction may be necessary at the outset of treatment.

Initial laboratory and radiographical investigations are not necessary unless history and examination suggest organic disease.

Education

Parents and older children will benefit from a brief description of the mechanism of functional constipation. This should be the first step in treatment.

When stool enters the normal rectum, the involuntary smooth muscle of the internal anal sphincter is relaxed. The urge to defecate is signaled when the stool reaches the external anal sphincter. If the child voluntarily relaxes the external sphincter appropriately, the rectum is evacuated. If, however, the child tightens the external sphincter and the gluteal muscles, the fecal mass is pushed back in the rectal vault and the urge to defecate subsides. Parents will likely recognize examples of these characteristic withholding behaviours: squatting, rocking, stiff walking on tiptoes, crossing the legs or sitting with heels pressed against the perineum. Withholding leads to stretching of the rectum and lower colon, and retention of stool. The longer the stool remains in the rectum, the more water is removed and the harder the stool becomes, to the point of impaction. Involuntary overflow soiling then occurs around this mass of impacted stool.

Loss of control over defecation confuses the child and angers the parents, who may believe that the child is intentionally soiling his/her underwear. It is very important to remove these negative attributions, and to have parents understand that soiling is not a willful or defiant behaviour.

Two transition periods in which the developing child is particularly prone to functional constipation are at the time of toilet learning, and during the start of school. Toilet learning should not be a struggle, and the clinician may have a role in aiding parents to determine the child’s readiness.

By the time a child is referred to a clinician, constipation may have been a problem for a long period. Thus, it is very important to instill hope and positivity in the frustrated child and her/his parents. Positive messaging is aided by education and a clear management plan to foster a sense of control. In addition, it is crucial to acknowledge that proper management of constipation is a long-term partnership, necessitating patience and realistic goals for improvement.

Parents often worry (but may not ask) about the potential for medications to render the bowel ‘lazy’ or ‘addicted to laxatives’. Misconceptions must be anticipated and dispelled through education about stool softeners, which do not make the bowel contract or spasm, are absorbed minimally (if at all) from the gut, and are safe for long-term use.

Fecal disimpaction

Fecal impaction is identified by the presence of a large and hard mass in the abdomen or dilated vault filled with stool on rectal examination, and often substantiated by a history of overflow incontinence. (An abdominal radiograph is not needed to diagnose fecal impaction.) It is important to recognize the presence of fecal impaction because maintenance stool softeners can worsen overflow incontinence if the impaction is left untreated.

Disimpaction can be achieved by either oral or rectal medication. In a double-blind uncontrolled study, Youssef et al  showed that the three-day administration of polyethylene glycol (PEG) 3350 at a dose of 1 g/kg/day to 1.5 g/kg/day (maximum dose 100 g/day) successfully disimpacted 95% of children, and was well tolerated. Another study showed that a regimen of daily enemas for six days was equally as effective as PEG 3350 (1.5 g/kg/day) in relieving disimpaction, but may be less well tolerated. High-dose mineral oil has also been shown to be effective.

Children with severe impaction may need to be admitted to hospital or an outpatient medical unit for nasogastric lavage with PEG solution if the volume required is intolerable orally. This is usually continued until the rectal effluent is clear.

Digital disimpaction cannot be recommended based on available information, and may have harmful effects

Maintenance therapy

Once the impacted stool has been removed, the focus of the treatment should be on preventing recurrence with use of laxatives. Refer to Table 1 for a list of medications used to treat constipation. Medications have been shown to be more effective than behavioural change alone in the treatment of constipation . A systematic review of laxative treatments for childhood constipation has been recently published, and acknowledges the relative paucity of well-designed trials for laxatives in children and the resultant difficulty in establishing first-line therapy.

TABLE 1 Medications for the treatment of paediatric constipation
Laxative	Dosage	Side effects
Lactulose	1 mL/kg/day – 3 mL/kg/day in divided doses	Flatulence, abdominal cramps
Milk of magnesia (Magnesium hydroxide)	1 mL/kg/day – 3 mL/kg/day of 400 mg/5 mL available as liquid	Magnesium poisoning (infants). In overdose, hypermagnesemia, hypophosphatemia and secondary hypocalcemia
Polyethylene glycol 3350	Disimpaction: 1 g/kg/day – 1.5 g/kg/day for 3 days Maintenance: Starting dose at 0.4 g/kg/day – 1 g/kg/day	Limited. Occasional abdominal pain, bloating, loose stools
Polyethylene glycol-electrolyte solution (lavage)	Disimpaction: 25 mL/kg/h (to 1000 mL/h) by nasogastric tube until clear effluent Maintenance: 5 mL/kg/day – 10 mL/kg/day (older children)	Nausea, bloating, abdominal cramps, vomiting and anal irritation
Mineral oil	Disimpaction: 15 mL/year – 30 mL/year of age (up to 240 mL daily) Maintenance: 1 mL/kg/day – 3 mL/kg/day <1 year of age: Not recommended	Lipid pneumonia if aspirated. Theoretical interference with absorption of fat-soluble substances, but no evidence
Senna	2–6 years: 2.5 mL/day – 7.5 mL/day 6–12 years: 5 mL/day – 15 mL/day	Idiosyncratic hepatitis, melanosis coli, hypertrophic osteoarthropathy, analgesic nephropathy
Bisacodyl	Oral: 3–12 years: 5 mg – 20 mg Rectal: <2 years: 5 mg/day 2–11 years: 5 mg/day – 10 mg/day	Abdominal cramping, nausea, diarrhea, proctitis (rare)
Docusate sodium	5 mg/kg/day divided three times a day or as a single dose	Abdominal pain, cramping, diarrhea
Glycerin suppositories	–	None
Phosphate enemas	<2 years old: Not recommended >2 years: 6 mL/kg (up to 135 mL)	Risk of mechanical trauma to rectal wall Abdominal distention or vomiting Hyperphosphatemia, hypocalcemia

There is growing evidence to support the efficacy and safety of PEG 3350 in the maintenance treatment of children with constipation. PEG 3350 without electrolytes (Lax-A-Day [Pendopharm, Canada] or RestoraLAX [Merck Canada Inc]) is a tasteless, odourless, osmotic laxative. It is available in powder form, and dissolves well when mixed in juice or water. It is absorbed only in trace amounts from the gastrointestinal tract and, unlike other colonic lavage solutions, carries no risk of electrolyte imbalance. The effects of PEG 3350 start within the first week of treatment.

Compared with placebo, PEG 3350 was more effective in increasing defecation frequency. PEG 3350 has been shown to be more effective (with increase in bowel movement frequency and decrease in fecal incontinence) than lactulose, and equally as effective as milk of magnesia, although better tolerated. A recent study showed no additional effect of regular enemas compared with PEG 3350 alone in children with severe constipation.

Dose-finding studies for PEG 3350 used starting doses of 0.4 g/kg/day to 0.8 g/kg/day as either a single or twice-daily dose and, when tailored to effect, a range of doses from 0.27 g/kg/day to 1.4 g/kg/day and 0.3 g/kg/day to 1.8 g/kg/day was reported. Maintenance doses of 0.4 g/kg/day to 1.0 g/kg/day have been shown to be effective and well tolerated. A common reason for the lack of response to stool softening therapy is inadequate dosing; physicians should not hesitate to start PEG therapy at a higher dose of 1.0 g/kg and then decrease as necessary.

The safety profile for PEG 3350 has been favourable. Clinical adverse effects are minor and can include bloating, flatulence, abdominal pain and loose stools. Ione of the aforementioned trials was PEG 3350 discontinued due to side effects related to the medication.

There is no evidence that docusate is effective in paediatric constipation. There is no evidence to recommend mineral oil in jelly form (Lansoyl [Aurium Pharma Inc, Canada]) over standard mineral oil, other than the issue of palatability. Sennosides have been shown to be inferior to lactulose, with respect to symptom control, relapse rate and side effects in two trials.

With any stool softener, parents should be advised to adjust the dose according to the response, increasing the dose every two days until the child has one to two soft stools per day, or decreasing the dose if the child has loose stools. Parents should be warned that some leaking or soiling might persist at the start of treatment. Physicians should also discuss an ‘emergency plan’ with the parents, to be used if there is indication that impaction is recurring (eg, increasing the dose of stool softener or using a suppository).

Behavioural modification

A toileting regimen that dedicates time for defecation is valuable. Most people who have normal stooling habits tend to defecate at the same time each day. This conditioned reflex tends to occur within 1 h of eating, and usually in the morning. A constipated child should have a routine scheduled toilet sitting for 3 min to 10 min (age dependent), once or twice a day. Ensure that the child has a footstool on which they can support their legs to effectively increase intra-abdominal pressure (valsalva). There should be no punishment for not stooling during the toileting time; praise and reward for stooling and the behaviour of toilet sitting can be offered.

It is helpful to have children and their caregivers keep a diary of stool frequency to review at the next appointment. A copy of the Bristol chart can be helpful for standardizing stool descriptions.

Regular physical activity can be recommended, although its role in treating constipation remains unclear.

Dietary modification

A balanced diet that includes whole grains, fruits and vegetables is recommended as part of the treatment of constipation in children.

Carbohydrates (especially sorbitol) found in prune, pear and apple juices can cause increased frequency and water content in stools .

Fibre intake below the minimum recommended value has been shown to be a risk factor for chronic constipation in children. The American Academy of Pediatrics recommends a fibre intake of 0.5 g/kg/day (to a maximum of 35 g/day) for all children. There is little evidence supporting fibre supplementation (above the recommended daily intake) in children with constipation. There are no published studies regarding the use of wheat dextrin (Benefiber [Novartis Consumer Health Inc, USA]) or psyllium fibre (Metamucil [Procter & Gamble, USA]) supplements for treating childhood constipation. Adequate fluid intake must be ensured with a bulking agent such as fibre.

Although excessive milk intake can exacerbate constipation, there is insufficient evidence that eliminating it from the diet improves refractory constipation. For children unresponsive to adequate medical and behavioural management, consideration could be given to a time-limited trial of a cow’s milk-free diet. Intolerance to cow’s milk, particularly in children with atopy, has been associated with chronic constipation.

Two studies have addressed the use of probiotics in treating constipation in children. In the first study, the addition of Lactobacillus rhamnosus GG was not an effective adjunct to lactulose in treating constipation. The second study’s sample size was too small to draw any meaningful conclusion.

Constipation in infants

In infancy, constipation is mostly functional, but a heightened vigilance for identifying red flags suggestive of an organic disorder in this age group is necessary. It is known that breastfed infants can have greater variability than formula-fed infants in stool frequency. (Some normal breastfed newborns may stool with each feeding or may not have a bowel movement any more often than every seven to 10 days.). Mineral oil is contraindicated in infants because of uncoordinated swallowing and the risk of aspiration and subsequent pneumonitis. Increased intake of fluids and reducing excess cow’s milk intake may be helpful for constipation in older infants. Recommendations to add brown sugar to formula or water for infant constipation are anecdotal and not evidence based, as well as pose a risk of caries development. Lactulose and glycerin suppositories may be used. Two retrospective chart reviews examining the safety of PEG 3350 in infants have been reported. Both showed that at doses of 0.8 g/kg/day, PEG was well tolerated, effective and safe in the management of constipation in infants younger than 18 months of age.

Follow-Up

Regular follow-ups with ongoing support and encouragement to the child and caregivers at scheduled office visits or through phone conversations are essential. In many cases, stool softeners need to be taken for months or years to promote soft daily stools. Children with constipation should be treated for at least six months, and should have regular bowel movements without difficulty before considering a trial of weaning maintenance therapy. The relapse rate for constipation can be quite high, and problems with stooling may persist into adulthood.

Referral to a gastroenterologist

Consultation with a gastroenterologist should be sought when adequate therapeutic measures fail or there is a concern that organic disease exists. Further investigations may be warranted at this time.

Summary of recommendations

A thorough history and physical examination are required to rule out organic causes of constipation.

Investigations (laboratory and radiography) are seldom required.

Education is critical at the initial visit and should be regularly reinforced at subsequent visits.

Disimpaction can be achieved with either oral or rectal medication.

A balanced and varied diet with requisite fibre intake is recommended.

Behavioural management should be used in conjunction with medication therapy.

PEG 3350 is a safe, effective and well-tolerated long-term treatment for constipation.

Regular follow-up is very important.

Referral to a gastroenterologist should be made in refractory cases or when there is a suspicion of organic disease.

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8. www.bookfinder.com/author/american–academy–of–pediatrics
9. www.emedicine.medscape.com
10. http://www.nlm.nih.gov/medlineplus/medlineplus.html