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Constipation | Part One

Andi Marmor, MD and Lisa Patel, MD
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23:04

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Lisa and Andi discuss why functional constipation occurs, the evidence behind prevention and treatment, appropriate treatment regimens for the outpatient setting, and when patients should be referred for inpatient cleanout for constipation.

  • Functional constipation is constipation without a known medical cause. This is often a clinical diagnosis without need for any lab work or imaging to confirm the diagnosis. 

    • The definition of constipation requires that the stool itself is hard or difficult to pass, which can come in addition to discomfort, sometimes pain and can include fecal encopresis, which is the leakage of liquid stool around a hard ball of stool. 

    • Constipation is very common with ⅓ of children having constipation at some point. 

    • Common times of onset including introduction of solids, toilet training and school age. 

  • Children can present with the classic symptoms, poor appetite or watery stool.

  • Symptoms that may alert to another diagnosis include: Bilious emesis, persistent distention, severe or bilious emesis, urinary incontinence, bloody diarrhea or thin “pencil like” stools. 

  • Other questions that can help determine another etiology of the constipation are delayed passage of meconium, developmental problems or growth problems. 

  • On exam the major categories of what you are looking for are anatomic abnormalities, neurologic problems, chronic diseases and metabolic disease. 

    • The exam should include looking at the sacrum and anus, lower extremity tone and lower extremity reflexes. A digital rectal exam is not routinely required to make the diagnosis. 

  • While diet changes may be helpful in preventing constipation, treatment is less clear. 

    • Fiber intake has not been shown to be an effective treatment for kids with moderate to severe constipation. Insoluble fiber can increase the size of the stool leading to more difficulty passing stool. 

    • Increasing water has also not been shown to be effective treatment. 

    • Marmor will often recommend reducing constipating foods such as milk, white bread, white pasta, white rice.  

    • Juices can be helpful, the sugar acts as an osmotic force and some juices like apple juice, pear juice, and prune juice contain sorbitol. Marmor will recommend using this like a medication and reserving their use for daily or twice daily dosage.

    • Beyond dietary changes, scheduled toilet sitting 10-15 minutes after meals and giving children a stool to put their feet so the knees are up towards the chest can help. 

  • For infants and young children juice is often sufficient to relieve symptoms

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Peds RAP April 2020 Written Summary 449 KB - PDF

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