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Approach to Constipation
- Alarm signs or symptoms
- MNEMONIC – MMM BB DD PSW
- Mucus in stool
- Meconium (within 48 hours of birth)
- MEN (family history)
- Bleeding
- Birth (symptoms since birth?)
- Diabetes (GDM)
- Distention
- Pencil like stools
- Systemic symptoms (fever, nausea, diarrhea)
- Weight loss, difficulty gaining weight
- If yes, investigate further in keeping with the pertinent positive alarm sign
- Is the infant exclusively breast fed AND > 2 weeks old?
- If yes, then constipation is probably normal, and reassess in clinic in 2-4 weeks
- If no, then this is likely functional constipation (99 % of cases of constipation)
- ROME criteria for functional constipation (at least 2 criteria)
- < 2 defecations per week
- > 1 episode of fecal incontinence
- Stool large enough that there is concern that it will obstruct the toilet
- Pain with defecation
- Presence of large fecal mass in rectum
- History of retentive posturing or volitional retention
- Initial management involves
- Education regarding constipation
- If on solid foods, balanced diet and unprocessed food is best
- 1 hour of moderate intensity exercise if of appropriate age
- If pre-towel trained delay toilet training 3-5 months until constipation resolves
- If already toilet trained, have child sit on toilet 20-30 minutes after each meal
- Foot stools can be used to increase abdominal pressure and help with defecation
- If on lactose free formula, switching to standard formula (lactose free has less sugar which worsens constipation)
- Try Biogaia (probiotic) and/or Ovol drops (for gas pains)
- Constipation diary
- If effective, then continue to monitor
- If not effective, then it is time to start PEG (see CHEO handout on constipation)
- Start with bowel disimpaction with PEG which using weight based dosing – this runs for 3 days
- After the first 3 days, you provide maintenance dose of PEG for 2-3 months, after which you can gradually wean down on PEG if the patient has had at least 1 month constipation free while on PEG
- This maintenance dose is required to “retrain the bowels” after the bowels have been chronically constipated and dilated
- If PEG treatment is not effective and child is still on formula, consider switching to hypo-allergenic (hydrolyzed or partially hydrolyzed formula for a trial of 2 weeks and assess for improvement)
- If PEG treatment is not effective and child is over 6 months / not on formula, consider
- Other investigations
- Celiac screening (presents within 6-24 months with anorexia, abdominal pain, diarrhea, poor weight gain, abdominal distention, vomiting)
- TSH, T4
- Colonic manometry (rule out colonic neuromuscular disorders)
- Cow’s milk allergy (trial of avoiding dairy products and soy milk)
- If at this point nothing has worked then consider referral to a pediatric gastroenterologist / reevalute other organic diseases if not already done