Menu Close

Understanding Pediatrics: Approach to Constipation in Pediatrics

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