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Lack of universally approved definition of constipation is a major concern in the studies of constipation. In children, it is more challenging as it depends on the interpretation of symptoms by parents. Baker et al have defined constipation as “a delay or difficulty in defecation, for two weeks or more and sufficient to cause significant distress to patient”. The Paris Consensus on Childhood Constipation Terminology (PACCT) group defined constipation as “two or more of the following, for 8 weeks:
Studies have shown the prevalence of constipation in the pediatric population to range from 0.7% to 29.6%. 3% of pediatric patients presenting to OPD have constipation. Also, constipation constitutes 10-25 % of patients referred to pediatric gastroenterology clinics. Most studies have reported no significant gender difference. It is also known to be more common in low socioeconomic status and low parental income. Formula-fed infants are known to be more likely to have constipation than breast-fed infants. Diagnosis of Constipation The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) attempted to formulate Uniform Evidence-based guidelines for evaluation and management of functional constipation in 2014. Despite the unreliability and non-specificity of symptom description in infants and young children, history and physical examination is still the main basis of the diagnosis.
The main points to be noted are age of onset of symptoms, frequency of defecation, consistency of stools (expressed in some scale like Bristol scale, Lane’s modified Bristol stool form scale or Amsterdam infant stool scale),status of toilet training, pain during defecation, blood in stools, Constipation associated Fecal Incontinence (CFI), retentive posturing, diet history, weight loss and nausea/vomiting. Children may display retentive posturing or withholding actions in the form of standing on toes, swaying back and forth, tightening of the lower limbs and backward bending of the spine which is often mistaken by the parents as straining. Age of onset prior to one month suggests a strong probability of Hirschprung’s disease. Time of passing first meconium also needs to be enquired as the lag of >48 hours strongly favors the diagnosis of Hirschsprung’s disease. Many times there would be a precipitating factor for constipation such as a painful bowel movement, changeover of feeds from breastfeeding to formula feeding or beginning of toilet training, etc. Similarly, dietary history, treatment history, developmental history, and psychosocial history are also important. The family history of gastrointestinal disorders (Hirschsprung’s disease, inflammatory bowel disease, celiac disease, food allergies, etc) and disorders of other organs like thyroid, parathyroid, kidneys or other conditions like cystic fibrosis should be enquired.
Physical examination should include:
When history and abdominal examination does not accurately identify the diagnosis of constipation, DRE can be used. Beckman et al did a study to determine the accuracy of clinical variables to diagnose radiographically established constipation. Taking colon filled with fecal material to radiographically define constipation, it was found that stool present in the rectal exam was the best variable that differentiates between patients with and without constipation. If there are no palpable abdominal fecoliths and no history of CFI, DRE would be required to detect “fecal mass in the rectum” which is one of the criteria for ROME III definition of constipation. The NASPGHAN and ESPGHAN 2014 guideline recommend DRE for diagnosis of constipation if only 1 out of 6 criteria in Rome III is satisfied and discourages routine use of DRE to diagnose constipation.
Differential Diagnosis Though functional constipation is the most common cause of constipation, another differential diagnosis should be considered and should be ruled out in history and examination. The following alarm signs and symptoms would help to identify the presence of an organic disease causing constipation:
Passage of meconium after 48 hours of birth
Fecal impaction is defined as a hard mass in the lower abdomen identified on physical examination or a dilated rectum loaded with a stool on rectal examination or excessive stool in the distal colon on abdominal radiography. History of CFI also points out the diagnosis of fecal impaction. Although abdominal radiography may give less discomfort to the child compared to rectal examination, it consumes more time, cost and exposes to radiation. It is not routinely recommended for diagnosing fecal impaction. Hence in children suspected to have fecal impaction but without history of CFI or palpable fecal mass per abdomen, DRE becomes necessary. But the 2014 NASPGHAN and ESPGHAN guidelines do not have definite recommendation on using DRE for diagnosing fecal impaction. The NICE guidelines recommend to look for fecal impaction in all cases of idiopathic constipation and to do DRE if indicated. But it is not described what the indications are. In children less than 1 year age it recommends DRE to look for fecal impaction only if it is not responding to treatment in 4 weeks. These recommendations would result in unnecessary delay in the treatment of impaction. Treatment of constipation without prior disimpaction in a child is likely to be ineffective in a child with fecal impaction. Treatment In presence of fecal impaction, the first step is disimpaction. The most preferred agent used for disimpaction is oral Polyethylene glycol with electrolytes. Enemas although equally effective are considered more invasive can also be used if there is the unavailability of polyethylene glycol. The next step is to start maintenance therapy. Among the various agents used polyethylene glycol is again the most effective one but the dose is lower than for disimpaction.
In the absence of fecal impaction, treatment is directly started with maintenance therapy. Maintenance therapy has to be titrated according to response. Meanwhile, parents should be counseled about high fiber diet and toilet training. The gastrocolic reflex is utilized and the child is encouraged to sit in the toilet for defecation after each meal. Positive reinforcement by rewards and maintenance of bowel diary is also advised. Treatment is continued for at least 2 months with a symptom-free period of the at least 1-month following which dose is gradually tapered. Many children require treatment for several months or years. Regular follow up is required to assess for relapse and to reinforce food and toilet habits. Starting maintenance therapy without disimpaction in a child with fecal impaction is unlikely to succeed and causes unnecessary distress to the child and family and increases chances of poor compliance. Utilization of DRE DRE seems to be underutilized in clinical practice. A study by Gold et al showed that 77% of children referred to Pediatric Gastroenterology did not undergo prior rectal examination.
Another study performed by Scholer et al showed DRE was done in only 5% of children presenting with acute abdominal pain in Clinic or emergency. A possible reason for this underutilization could be a physician not being comfortable with the procedure, excess apprehension of the child and the risk of ruining a physician-child relationship. Another possible reason could be an underestimation of fecal retention by the physician as fecal impaction may often have a subtle and nonspecific presentation. Usefulness of DRE Though there have been studies on the utilization of DRE, there are no studies demonstrating the actual usefulness of DRE. Hence it is difficult to comment on what proportion of cases is likely to be missed if DRE is omitted in routine evaluation. In 2014 NASPGHAN and ESPGHAN guidelines, DRE is recommended for diagnosis of constipation if only one of the ROME III criteria is present leading to doubt in the diagnosis. The guideline also recommends DRE to evaluate underlying organic medical condition in the presence of alarm signs and symptoms or in case of intractable constipation. But the guideline does not make any comment on use of DRE for diagnosis of fecal impaction. Hence a study to demonstrate frequency of fecal impaction in DRE would tell us what proportion of DRE shows impaction and would provide a definite evidence to support use of DRE.
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