Join us as Dr. Lu puts the “Func” in Functional Constipation. Dr. Peter Lu, pediatric gastroenterologist and motility specialist at Nationwide Children’s Hospital teaches us what is required for diagnosing constipation, tips for management, diagnostic and therapeutic snags to avoid, and the true impact of this common diagnosis. So sit back, re(mira)lax, and enjoy the show!
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Functional constipation is defined as decreased bowel movements/changes in bowel patterns and the absence of “organic causes” aka other disease processes. First, let’s tackle bowl patterns using the Rome IV criteria.
NASPGHAN defines functional constipation with the Rome IV criteria. There is one set of criteria for infants and children 0-4 years of age and a second set for ages 4-17 years. Taken directly from the guideline paper, the criteria are two or more of the following:
For children less than 4 years old:
For children greater than 4 years old*:
*The NASPGHAN paper states developmental age of 4 years old, which can come down to clinical judgement.
Bristol stool chart: Great for research and can be helpful in clinic, however Dr. Lu and others use lots of descriptors or describes consistency in relation to food instead, as kids and parents alike may find this easier to understand (hot cocoa, mashed potatoes, banana, raisins/pebbles).
Below you will find a (nearly) exhaustive list of diseases that could mimic functional constipation. A well-gathered history and physical exam may be enough to adequately rule out organic causes, obtain a working diagnosis of functional constipation, and begin treatment. Put another way, testing can be reserved for strange stories or when conservative management fails.
Some of the more common tests obtained are:
Diet should be well-rounded, including fruits and veggies.
While we do not have much evidence on constipation prevalence by race, we do know that these disparities exist again and again in medicine. Food deserts, increased prevalence of ACE’s, and decreased access to medical care all have the potential to exacerbate functional constipation for our patients in minority communities. Be on the lookout for these issues!
Neurodivergence, especially ASD is correlated with functional constipation.
If functional constipation is suspected or diagnosed, start with an osmotic laxative. In toddlers and school aged children, stimulant laxatives can be used. Below you will find specific tips for age groups.
Osmotics draw fluid into the stool content thereby softening stool. All osmotics have similar efficacy, however PEG-3350 is generally the best tolerated. 3350 refers to the average molecular weight.
Verify formula mixing, then consider eliminating milk protein, soy. Consider a diagnosis of Hirschsprung’s at this time as well.
Consider stool softeners like lactulose, milk of magnesia, or PEG-3350.
If osmotic laxatives are not working, stimulants can be added for adjunctive therapy. Senna and bisacodyl have similar effects, but senna can be crushed and is therefore more readily tolerated. According to Dr. Lu, there is very little evidence of “making the colon lazy” or dependent on laxatives. Withholding and chronic distension of the colon is much more likely to make the colon less effective.
Nonpharmacologic techniques and behavioral therapies help significantly, like tracking stools, using reward systems, or partnering with psychologists or behavior therapists.
Cleanouts may be needed for children with fecal incontinence/encopresis or a large stool ball in the rectum. Cleanouts consist of higher doses of PEG-3350 and a stimulant laxative before and after. Mineral oil or bisacodyl enemas can be used as well for known rectal stool-balls.
Some children require admission to hospital for intractable constipation, prior failed at-home cleanouts, or manual disimpaction in the OR.
A number of medications used in the adult world are making their way to pediatrics. Including secretagogues like linaclotide and libuprostone, as well as promotility agents like prucalopride. All of these three have had positive cohort studies, but RCTs in children that were negative. Dr. Lu’s expert opinion is that constipation can be varied in children and therefore targeted IBS treatments like those used in adults may seem less efficacious in children when studied in aggregate.
Biofeedback/physiotherapy can also be used for patients with previously diagnosed pelvic floor dysfunction.
The vast majority of kids with functional constipation will improve with basic treatment, behavioral strategies, osmotic laxative, and one stimulant. Intractable constipation after adequate first line therapies, concern for organic causes, or a story that just doesn’t fit are all appropriate referrals.
Pediatric gut motility specialists can perform specialized testing like anorectal manometry or full thickness biopsies (diagnostic for Hirschsprung’s), and more!
Listeners will explain the basic diagnosis and management of pediatric functional constipation.
After listening to this episode listeners will be able to…
Dr. Lu reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Ward B., Lu P., Cruz M, Masur S, Chiu C, Berk J. “#66: Constipation (Let It Flow!) – We’ve Been Waiting So Long For This Episode To Come Out!”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ October 12, 2020.
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