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Key Features

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  • Most constipation in childhood is a result of voluntary or involuntary retentive behavior (chronic retentive constipation)

  • About 2% of healthy primary school children have chronic retentive constipation

  • Ratio of males to females may be as high as 4:1

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Clinical Findings

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  • Chronic constipation in childhood is defined as two or more of the following characteristics for 2 months:

    • Fewer than three bowel movements per week

    • More than one episode of encopresis per week

    • Impaction of the rectum with stool

    • Passage of stool so large it obstructs the toilet

    • Retentive posturing and fecal withholding

    • Pain with defecation

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Diagnosis

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  • Infants younger than 3 months often grunt, strain, and turn red in the face while passing normal stools

  • Failure to appreciate this normal developmental pattern may lead to the unwise use of laxatives or rectal stimulation

  • Infants and children may, however, develop the ability to ignore the sensation of rectal fullness and retain stool.

  • The dilated rectum gradually becomes less sensitive to fullness, thus perpetuating the problem

  • Retention of feces in the rectum can result in overflow incontinence (encopresis) in 60% of children with constipation

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Treatment

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  • For mild constipation, increased intake of water and such foods as bran, whole wheat, fruits and vegetables, may be sufficient

  • Medications may be required when dietary modification is not enough; following are safe stool softeners for infants and children

    • Polyethylene glycol solution (MiraLax), 0.8–1 g/kg/d

    • Lactulose, 1–2 g/kg/d

    • Milk of magnesia

      • For 2–5 years old, 400–1200 mg/d

      • For 6–11 years old, 1200–2400 mg/d

  • Stimulant laxatives such as Senna or Bisacodyl can be considered as an additional or second-line treatment

  • A recent study showed lubiprostone (Amitiza) was efficacious and well tolerated in children and adolescents with functional constipation. Lubiprostone is a prostone that, acting locally as a specific activator of chloride channel protein-2 in the GI epithelium, promotes intestinal secretion of chloride ions and fluid, enhancing GI motility.

  • Encopresis

    • If present, first, relieve fecal impaction

    • Disimpaction can be achieved in several ways, including

      • Saline enemas

      • Polyethylene glycol (MiraLax), 1 g/kg/d

      • Milk of magnesia, 1–2 mL/kg/d

    • Recurrence is common; should be treated promptly with a short course of stimulant laxatives or an enema

  • Effective stool softeners should thereafter be given regularly in doses sufficient to induce very soft daily bowel movements

  • After several weeks to months of regular soft stools, stool softeners can be tapered and stopped

  • Mineral oil

    • Should not be given to nonambulatory infants, physically handicapped or bedbound children, or any child with gastroesophageal reflux

    • Aspiration may cause lipid pneumonia

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