Constipation


Infrequent bowel movements in neonates do not necessarily mean that the infant is constipated. Infants occasionally may go without a bowel movement for 5 to 7 days and then pass a normal stool. However, if the infant has never passed stools, especially if there has not been a stool in the first 48 hours of life, the possibility of intestinal stenosis, Hirschsprung disease, or meconium ileus associated with cystic fibrosis should be considered.
Constipation occurring after birth but within the first month of life suggests Hirschsprung disease, hypothyroidism, anal stenosis, or an anteriorly displaced anus.

Infants and children with constipation should have a careful evaluation of the lumbosacral spine for evidence of occult dysraphism, which may be associated with neurogenic bowel or bladder.
 
Questions to Ask about Constipation
The frequency and texture of the stools
The presence of blood on the stool
The association of pain with defecation
A history of waxing and waning of hard stools and watery diarrhea suggesting overflow incontinence

 
Management
  • Watch, +/- Prune juice
  • The acute treatment of constipation in the ED is
    • Disimpaction with a glycerin suppository in infants
    • Bisacodyl suppository in adolescents.
    • Sodium phosphate (e.g., Fleet Enema®) or soap suds enemas are also highly effective, especially if stool is present on rectal examination
Treatment of Constipation in Children >1 year of age
Osmotic laxatives: polyethylene glycol (1–2 packs/d with 8 oz of water or juice)
Lubricants: mineral oil (1–3 cc/kg/d) (should be used with caution in young children and those at risk for aspiration)
Stool softeners: docusate sodium
Stimulant laxatives
  Senna (for 2–6 y olds: sennosides: 3.75 mg/d; maximum of 15 mg/d; for 6–12 y olds: sennosides: 8.6 mg once a day, maximum of 50 mg/d)
  Bisacodyl ( if >6 years old): 5–10 mg at bedtime or breakfast


 
Differential Diagnosis:
2 days old Anatomic Intestinal Stnosis
Atresia
Cystic Fibrosis
Meconium ileus
Hirschsprungs Disease The diagnosis of Hirschsprung disease is supported by absence of feces on rectal examination, a tonic or tight sphincter tone, and an abrupt change in bowel luminal size on barium enema, and is confirmed by a rectal biopsy demonstrating absence of ganglion cells.
1 Mo Old Hirschsprungs Disease
Anal stenosis
Hypothyroidism Infants with hypothyroidism present with constipation, feeding problems, a weak or hoarse cry, a large anterior fontanelle, hypothermia, hypotonia, and peripheral edema.
The child should be admitted for further evaluation and treatment.
Hypothyroidism is part of the routine newborn metabolic screening but varies from state to state.
Anterior anus Correct anatomic positioning of the anus is determined by measuring the distance between the gluteal cleft and the posterior fourchette in girls or the median raphe in boys.
The anus should be no more anterior than two thirds of this distance

 
Functional Constipation Hirschsprungs Disease
> 2 yo < 2 yo (at birth)
Voluntary Holding, Usually secondary to pain Inability to pass meconium > 48 hr of life
Palpable stool - NO palpable stool
Dx Dx
- Palpable stool - ABD XR
- Barium
- Biopsy
Tx Tx
 Stool Softeners, Laxative, Enema Surgery