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1. Assessment and management of pediatric constipation in primary care..................................................... 1
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Assessment and management of pediatric constipation in primary care
Author: Coughlin, Elizabeth C
Publication info: Pediatric Nursing 29. 4 (Jul/Aug 2003): 296-301.
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Abstract: Assessment and management of pediatric constipation is a challenging problem frequently faced by
primary care practitioners. The purpose of this article is to offer a review of the literature including the definition
of pediatric constipation and the presentation, etiology, and management of this common childhood disorder.
Education and anticipatory guidance with children and their families should be included in the treatment regimen
to prevent recurrences and promote health maintenance. [PUBLICATION ABSTRACT]
Full text: Headnote Assessment and management of pediatric constipation is a challenging problem frequently
faced by primary care practitioners. The purpose of this article is to offer a review of the literature including the
definition of pediatric constipation and the presentation, etiology, and management of this common childhood
disorder. Education and anticipatory guidance with children and their families should be included in the
treatment regimen to prevent recurrences and promote health maintenance. Constipation is a frequent
complaint encountered by those in pediatric primary care, accounting for roughly 3% of outpatient visits and one
quarter of all pediatric gastroenterology referrals (Baker et al., 1999). Assessment and management of pediatric
constipation poses many challenges for the practitioner including deciphering whether the problem is organic or
non-organic in nature; determining appropriate pharmacological, dietary, and behavioral treatment; and
educating parents as to what constitutes and may precipitate constipation. By offering education and
anticipatory guidance as well as interventions tailored to the needs of the family, nurse practitioners in pediatric
primary care settings are in a position to make significant contributions to the prevention and successful
management of constipation in children. Definition A review of the literature indicates there is disagreement over
the definition of constipation. Rogers (1997) outlines constipation as "the difficulty or delay in the passage of
stools, without necessarily implying that the stools are hard" (p. 40). Lewis and Muir (1996) add that this
difficulty or delay causes distress to the child. Castiglia (2001) states that constipation refers to the lack of full
evacuation of the lower bowel, while Abel (2001) defines it as "an alteration in the frequency and consistency of
the individual's usual pattern of defecation" (p. 211). Still others delineate the definition by time, such as "fewer
than three stools per week" (Young, 1996, p. 88), or "delay in defecation, present for two or more weeks" (Baker
et al., 1999, p. 2). Thus, it comes as no surprise that parents are often unclear as to what constipation actually
is and when they should begin to be concerned about the lack of passage of stool in their children.
Compounding the confusion is the differences in stooling patterns among breastfed versus bottle-fed infants.
Breastfed infants can have bowel movements as frequently as with every feeding or as rarely as one every
several days. Bottle-fed infants may be more prone to hard stools because of the differences in fat digestion
and absorption between breast milk and formula (Thompson, 2001). In general, infants have roughly four stools
per day during the first 7 days, decreasing to one to two stools per day by 2 years of age and then to one stool
per day on average by 4 years of age (Baker et al., 1999). Educating parents on the breadth of normal stooling
patterns, therefore, is an important first step in preventing complaints of constipation in the primary care setting.
Assessment and Presentation History. As with all pediatric complaints, assessment of constipation begins with
taking a careful and detailed history. Parents should be asked about any medications the child is taking; the
onset of symptoms; frequency, size, and consistency of the child's stool; presence of blood in the stool; and
previously attempted treatments. Time after birth of passage of meconium, age of and techniques employed in
toilet training (if applicable), and the presence of daytime or nighttime soiling or defecation in inappropriate
places should also be ascertained. The child's dietary history, exercise patterns, behavioral history, and family
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history of bowel problems should be included as well as the parental definition of constipation and parental
response to the current problem (Pyles &Gray, 1997). This latter information is particularly useful in assessing
the parents' knowledge base and in formulating appropriate interventions. Signs and symptoms. The signs and
symptoms of constipation may vary depending on the age of the child. Infants may present with "grunting baby
syndrome" in which straining, turning red in the face, grimacing, and even crying are manifestations (Rogers,
1997). This display of effort is generally rewarded by a stool of normal volume and consistency. In toddlers,
passage of stool, particularly hard stool, may be painful or result in small tears in the anal canal resulting in
pain, thus causing the child to withhold the stool out of fear or avoidance of pain. This then results in a vicious
cycle of pain, withholding stool, and even impaction as the longer the child resists having a bowel movement,
the harder and more painful it becomes for him or her to do so (Castiglia, 2001). Parents may report the child
actively resisting the urge to defecate by rocking back and forth on his or her toes, squeezing buttocks together,
clenching fists, and fidgeting (Baker et al., 1999). Stool withholding can lead to retentive fecal soiling, also
known as encopresis. Encopresis occurs when watery stool passes by hard fecal content in the lower rectum
resulting in recurrent soiling and is often confused with diarrhea. Other commonly reported symptoms include a
change in normal bowel routine; passage of hard, dry, rock-like stools; blood in the stool; abdominal pain;
distention or cramping, a feeling of fullness leading to decreased appetite and nausea; and a sense of
incomplete emptying of the colon (Abel, 2001). Physical examination findings. On examination, hyperactive
bowel sounds may be auscultated (Creason &Sparks, 2000) and a sausage-shaped abdominal mass may be
palpated in the descending colon or even as far back as the transverse or ascending colon. The anus may show
evidence of tearing or scarring. The presence or absence of the anal wink reflex should also be assessed, as
this will evaluate the ability of the anal sphincter to contract. A digital rectal exam offers the practitioner
information regarding anal tone, length of the anal canal, dilatation of the rectum, and the presence and
consistency of fecal matter that might indicate impaction (Loening- Baucke, 1997). A test for occult blood may
be done on feces obtained at this time (Baker et al., 1999). Etiology and Differential Diagnoses Organic causes
of constipation. The causes of pediatric constipation can be divided into two categories: organic or functional,
also known as idiopathic. Organic causes account for only 5% of the cases of constipation in children and
include anatomic, neuromuscular, metabolic, or endocrine causes of constipation (Castiglia, 2001). Perhaps the
most well-documented and common etiology resulting in constipation in infants is Hirschsprung's disease
(aganglionic megacolon). Hirschsprung's is an anatomic and neuromuscular abnormality that results in a
segment of anus or rectosigmoid colon lacking ganglia in the myenteric and submucosal plexuses. This results
in a lack of parasympathetic innervation, causing an inhibition of relaxation of that portion of the colon (Castiglia,
2001). Dilatation of the proximal segment to the affected colon ensues. Constipation, vomiting, diarrhea,
abdominal distention, failure to thrive, failure to pass meconium, absence of encopresis, and an empty anal
canal upon examination are common manifestations of the condition (Castiglia, 2001). Other anatomic and
neuromuscular organic causes of constipation that must be included in differential diagnosis are anal stenosis,
anal atresia, anal fissures, presence of a pelvic mass, bowel obstruction, rectal prolapse, spinal cord disorders
(including meningomyelocele), cerebral palsy, and muscular dystrophy (Abel, 2001; Kuhn, Marcus, &Pitner,
1999; Loening-Baucke, 1997; Pyles &Gray, 1997). Possible metabolic and endocrine abnormalities include
hypothyroidism, hypokalemia, hypercalcemia, and lead intoxication (Abel, 2001; Kuhn et al., 1999). Irritable
bowel syndrome (IBS), another common cause of constipation, is generally diagnosed by exclusion. Heitkemper
and Jarrett (2001) state that 65% of children diagnosed with recurrent abdominal pain qualify under the adult
criteria for IBS, yet fail to be diagnosed with this condition. Malnutrition, restricted dietary regimens, and
dehydration can also result in constipation and must be planned for in the overall management plan for these
children. Non-organic causes of constipation. Non-organic or functional constipation, which accounts for a
majority (95%) of cases of constipation in children (Loening-Baucke, 1997), has varied etiology. Common
causes are linked to food, lack of exercise, and behavioral or psychological problems. Changes in diet habits or
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routines may precipitate constipation. For example, many parents report that a switch from breast milk to
formula or a switch between formulas can precipitate bouts of constipation. Iron-fortified formula is often thought
by caretakers to cause constipation in infants, however, this has not been shown by controlled research studies
to be a cause of constipation (Castiglia, 2001). While Castiglia cites that "insufficient data exist to support
routine screening for cow's milk allergy as a cause of constipation" (p. 201), a double- blind, crossover study by
lacono et al. (1998) comparing the use of soy milk versus cow's milk in children with chronic constipation found
that 68% of the-children studied had improved bowel habits with soy milk. Roughly two thirds of those studied
showed constipation to be a symptom of intolerance to cow's milk (Iacono et al., 1998). Lack of dietary fiber has
long been associated with constipation. The American Health Foundation recommends the daily fiber intake for
children to be equal to the age of the child in grams plus five additional grams (i.e., a 5-year-old child should eat
10 grams of fiber each day). A study by Hampl, Betts, and Benes (1998) found, however, that only 45% of 4- to
6-year-olds and 32% of 7- to 10-year-olds consumed this amount of fiber on a regular basis. An additional
concerning trend affecting constipation among today's young people is lack of exercise. Children's daily routines
are becoming increasingly sedentary with television viewing and "screen time" on computers or video games
taking the place of outdoor activity. Lack of regular exercise at home is compounded by decreasing physical
activity time in schools. Sedentary behavior, such as watching television, in addition to decreasing
gastrointestinal motility and weakening abdominal muscles used in defecation decreases the time in a child's
day for physical activity and is often accompanied by consumption of high fat, low fiber foods (MacKenzie,
2000). The combination of poor diet and lack of exercise then sets the stage for constipation to occur.
Psychosocial and behavioral factors are often the source of constipation in children. Inappropriate toilet training
practices involving children too young neurologically or cognitively to understand and act on the request to
defecate in a toilet, or overly demanding parents who do not have appropriate expectations of their child's ability
to be toilet trained, can lead to constipation (Kuhn et al., 1999). Caretakers can be impatient and intolerant of
accidental soiling resulting in the child becoming fearful, anxious, and insecure (Young, 1996). Lack of
education on normal bowel patterns and unrealistic expectations of the child's ability to be toilet trained may
lead parents to be inappropriately harsh, occasionally even abusive, with their children regarding stooling.
Patterns of withholding stool, which may lead to impaction or encopresis, may emerge if children are afraid of
being punished for defecating. Fear of pain, as mentioned earlier, or embarassment or fear about using toilets
outside of home, such as at school or in a store, may lead to withholding and suppressing the urge to defecate.
Some children may fear plugging the toilet with a large stool, especially if this has previously happened and
resulted in embarrassment or punishment. Magical thinking in toddlers can also lead to fearful reactions;
children may see advertisements on television with germs and monsters climbing out of the toilet or personify
their stool and be afraid of drowning the stool (Rogers, 1997). The disappearance of stool and the loud sound
and rush of water can frighten children who may be afraid that they may be hurt by the toilet. Young children,
too, may simply be too busy exploring their world to recognize the urge to defecate and go to the bathroom to
have a bowel movement.
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Management Because of the multi-dimensional etiology of constipation, a multi-faceted approach to treatment
seems most appropriate and effective. Since the vast majority of cases of constipation are functional in origin,
treatment discussed will assume a non-organic etiology. The intervention plan for functional constipation
includes medication, behavioral modification, bowel retraining, and education. The North American Society for
Pediatric Gastroenterology and Nutrition position statement on constipation in infants and children (Baker et al.,
1999) recommends an intervention algorithm that begins with treating fecal impaction if present (see Figure 1),
followed by education, diet modification, medications, and follow-up. Levy (2001) suggests a similar stepwise
approach beginning with disimpaction followed by maintenance of a clean colon, establishment of more
effective toileting patterns, and improvement in family and social interactions. The goal of treatment is complete
evacuation of the lower bowel on a daily, or near-daily, basis by the easy passage of soft stools. Treatment to
regain muscle tone of the anal canal may be required for 2-6 months (Castiglia, 2001), and maintenance
therapy may be needed for up to 2 years (Thompson, 2001). Offering support to parents throughout this time
period is essential, as there is no easy or definitive cure, and frustrating relapses can occur (Pyles &Gray,
1997).
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Medication. In the event that fecal impaction is present, initial treatment is aimed at evacuation of bowel
contents either by oral or rectal medications. High doses of mineral oil and polyethylene glycol (PEG, MiraLax)
electrolyte solutions are commonly used oral means, while phosphate soda, saline, or mineral oil enemas can
be used rectally (Baker et al., 1999). The use of enemas, however, should be avoided if possible (Rogers,
1997) since they are likely to cause more discomfort than oral means. In extreme cases, large volumes of bowel
cleansing agents such as GoLytely(R) can be administered in the hospital, but treatment at home with milder
substances is preferred. Once disimpaction has been accomplished, maintenance therapy can begin. A wide
variety of laxatives are used, generally in incrementally decreasing dosages (see Table 1). Asking parents to
keep a diary of bowel movement frequency, consistency, and amount can assist the practitioner in adjusting
dosages of medications (Lewis &Muir, 1996). Effective medications available include lubricants such as mineral
oil; osmotic laxatives such as lactulose, sorbitol, or PEG; and magnesium hydroxide. Stimulant laxatives such
as senna (Senokot(R), Ex-lax(R), Fletcher's Castoria(R)) and bisacodyl (Ducolax(R)) may be needed
intermittently as rescue therapy to prevent recurrence of impaction but should be avoided for long-term, daily
use (Baker et al., 1999). Use of mineral oil carries with it some danger of aspiration and should be avoided in
children who resist taking it or who have dysphagia or vomiting. It has not been documented to interfere with
absorption of fat-soluble vitamins (Levy, 2001). Several studies have been done comparing the effectiveness of
different types of laxatives in the management of chronic constipation in children. Gremse, Hixon, and
Crutchfield (2002) performed an unblinded, randomized study comparing PEG to lactulose. They found that
there were no significant differences in stool frequency, form, and ease of passage between the two
medications but that PEG significantly decreased the total colonic transit time compared to lactulose. Parents
and caregivers cited PEG as effective in 84% of the children and lactulose as effective in only 46%. PEG overall
was the laxative of choice not only for effectiveness but also for ease of administration and tolerability. In
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another study, Pashankar and Bishop (2001) also examined the efficacy of PEG as well as the optimal dosing in
children. They found that all 20 participants in the study had improved bowel habits with PEG on a mean dose
of 0.84 g/kg/d. Beginning on high doses and adjusting accordingly to achieve desired number and consistency
of bowel movements was recommended. Side effects were limited to transient diarrhea and flatulence as
dosages were adjusted, unlike lactulose, PEG was found not to cause persistent gas, abdominal pain, or
perianal irritation. Cisapride (Propulsid(R)), a prokinetic agent that increases colonie propulsion, has also been
tested as a treatment for constipation in children. Nurko, Garcia-Aranda, Worona, and Zlochisky (2000)
performed a double-blind, placebo controlled study over a 2-year period in Mexico. Cisapride was found to
improve the number of soft bowel movements achieved by the study participants, but the response was not
immediate. This led the investigators to suggest that it not be used as first-line treatment for constipation in
children but rather as an option when other laxatives and interventions have failed. Diet. To supplement the
effects of treatment with laxatives, changes in diet are recommended. Because a decrease in appetite is
sometimes associated with constipation, though, this can prove to be a challenge to parents. It has long been
thought that increasing fluids and fiber in the diet aid passage of stool, however the literature is mixed on this
issue. Thompson (2001) suggests that fiber does not play a beneficial role in the management of constipation,
citing that its role in alleviating constipation has been "overemphasized" (p. 29). Baker et al. (1999) found "no
randomized controlled studies that demonstrated a proven effect on stools of increasing intake of fluids, non-
absorbable carbohydrates or dietary fiber in children" (p. 7). Nonetheless, many authors continue to recommend
diets that include increased fluids and soluble fiber and that are low in sugar, fat, starch, and insoluble fiber
(Abel, 2001; Levy, 2001; Pyles &Gray, 1997; Young, 1996). Including carbohydrates, particularly sorbitol found
in some fruit juices, is reported to be helpful (Baker, 1999) though high osmolarity liquids such as Karo(R) syrup
have not been proven effective (Young, 1996). Behavioral modification. Another controversial area is the
effectiveness of biofeedback as a treatment option for constipation. Biofeedback operates by making the child
more aware of bodily functions, such as rectal sensitivity to distention, that then "helps alter physiological
responses through behavioral modification techniques" (Pyles &Gray, 1997, p. 73). Loening- Bauke (1997) says
this type of training can be attempted but the effectiveness of it "has not been well established" (p. 2234). It
appears that for severe cases of constipation and those leading to encopresis, biofeedback may be an effective
management technique (Baker et al.; Pyles &Gray; Vitito, 1999). In addition to the use of medications and
changes in diet, behavioral modification and parental education are effective interventions in establishing
toileting patterns. Encouraging regular toilet use to normalize the behavior and facilitate positive associations
with toileting is effective. Colonic stimulation is greatest 10-15 minutes after eating, thus this can be an
opportune time to encourage sitting on the toilet for intervals of 10 minutes or so. The child should be
comfortable and relaxed; a footstool can help facilitate proper positioning for a bowel movement (Loening-
Bauke, 1997; Vitito, 1999). Systems of positive reinforcement can be employed for successful use of the toilet
such as stickers on calendars or charts, special activities, and praise (Kuhn et al., 1999; Loening-Bauke, 1997;
Pyles &Gray, 1997; Vitito, 1999). Since the process of constipation management can be lengthy, the focus
should remain on continuing improvement, not on complete resolution (Vitito, 1999). Successful treatment is
contingent on patience and time-consuming interventions on the part of the family. Continual support through
close follow- up is, therefore, essential (Baker et al., 1999). Education. Pediatric nurses and pediatric nurse
practitioners can perhaps be most effective at intervening through education. Educating parents about normal
stooling patterns, appropriate toilet training practices, and supportive management if problems do arise can
prevent or minimize the number and extent of episodes of constipation a child may have. If anticipatory
guidance is offered, which enables parents to recognize the early signs of constipation, potentially more
deleterious conditions such as impaction and encopresis may be avoided. During well-child visits, continual
review of feeding and stooling patterns; dietary habits, including transitions between breast-milk, formulas, and
solid foods; and exercise/activity patterns can prevent problems that might lead to constipation. Kuhn, Marcus,
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and Pitner (1999) suggest using the 15- or 18- month well-child visit to discuss plans for toilet training and make
sure that parents understand the importance of developmental readiness of the child. If constipation does occur,
continual validation of parental concern, reinforcement of efforts being made, and a review of symptom
management and the treatment plan can contribute to a successful outcome for the child (Abel, 2001). If
encopresis is involved, teaching parents that soiling is outside the child's control can help alleviate some of the
anger and frustration that may ensue. Scheduling follow-up visits every 3-4 weeks, as well as making periodic
telephone calls provides excellent opportunities to ascertain management success and provide additional
information and support to families. Conclusion Constipation in the pediatric population is a commonly
encountered problem in primary care settings. Because resolution of the problem can be lengthy and taxing for
families, careful assessment of the situation must be made. Treatment plans must be tailored to meet the
family's particular environmental and psychosocial situation, and continual support and follow-up are essential.
Pediatric nurses can provide anticipatory guidance and education that may lead to better prevention of the
problem and overall health promotion. Sidebar The Primary Care Approaches section focuses on physical and
developmental assessment and other topics specific to children and their families. If you are interested in author
guidelines and/or assistance, contact Patricia L. Jackson Allen at Pat.Jackson@nursing.ucsf.edu References
References Abel, E. (2001). Managing constipation in a pediatric patient: It is more than a simple problem.
Clinical Excellence for Nurse Practitioners, 5(4), 211-217. Baker, S.S., Liptak, G.S., Colletti, R.B., Croffie, J.M.,
DiLorenzo, C., Ector, W., et al. (1999). Constipation in infants and children: Evaluation and treatment. Medical
position statement of the North American Society for Pediatric Gastroenterology and Nutrition. Retrieved
November 19, 2002, from www.naspgn.org Castiglia, P. (2001). Constipation in children. Journal of Pediatric
Health Care, 15(4), 200-202. Creason, N., &Sparks, D. (2000). Fecal impaction: A review. Nursing Diagnosis,
11(1), 17-22. Gremse, D., Hixon, J., &Crutchfield, A. (2002). Comparison of polyethlene glycol 3350 and
lactulose for treatment of chronic constipation in children. Clinical Pediatrics, 41(4), 225-229. Hampl, J., Betts,
N., &Benes, B. (1998). The "Age +5" rule: Comparisons of dietary fiber intake among 4- to 10- year-old children.
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all in your head: Irritable bowel syndrome. American Journal of Nursing, 101(1), 26-32. Iacono, G., Cavataio, F.,
Montalto, G., Florena, A., Tumminello, M., Soresi, M., et al. (1998). Intolerance of cow's milk and chronic
constipation in children. The New England Journal of Medicine, 339(16), 1100-1104. Kuhn, B., Marcus, B.,
&Pitner, S. (1999). Treatment guidelines for primary nonretentive encopresis and stool toileting refusal.
American Family Physician, 59(8), 2171-2177. Levy, J. (2001). Fecal soiling (Encopresis). Retrieved November
19, 2002, from www.naspgn.org/sub/Encopresis.htm Lewis, C., &Muir, J. (1996). A collaborative approach in
the management of childhood constipation. Health Visitor, 69(10), 424-426. Loening-Baucke, V. (1997). Fecal
incontinence in children. American Family Physician, 55(6), 2229-2235. MacKenzie, N.R. (2000). Childhood
obesity: Strategies for prevention. Pediatric Nursing, 26(5), 527-530. Nurko, S., Garcia-Aranda, J., Worona, L.,
&Zlochisky, O. (2000). Cisapride for the treatment of constipation in children: A double-blind study. The Journal
of Pediatrics, 136(1), 35-40. Pashankar, D.S., &Bishop, W.P. (2001). Efficacy and optimal dose of daily
polyethylene glycol 3350 for treatment of constipation and encopresis in children. The Journal of Pediatrics,
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56, 58, 60-62, 67-68, 70-74. Rogers, J. (1997). Childhood constipation and the incidence of hospitalisation.
Nursing Standard, 12(8), 40-42. Thompson, J. (2001). The management of chronic constipation in children.
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Nursing, 19(3), 88-93. AuthorAffiliation Elizabeth C. Coughlin, RN, MSN, is a Student, Boston College, Connell
School of Nursing, Brighton, MA.
Subject: Pediatrics; Children & youth; Digestive system; Excretory system; Primary care
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MeSH: Algorithms, Constipation -- etiology, Diagnosis, Differential, Humans, Constipation -- diagnosis (major),
Constipation -- therapy (major), Pediatrics (major), Primary Health Care (major)
Publication title: Pediatric Nursing
Volume: 29
Issue: 4
Pages: 296-301
Publication year: 2003
Publication date: Jul/Aug 2003
Year: 2003
Section: Primary care approaches
Publisher: Anthony J. Jannetti, Inc.
Place of publication: Pitman
Country of publication: United States
Publication subject: Medical Sciences, Medical Sciences--Nurses And Nursing
ISSN: 00979805
Source type: Scholarly Journals
Language of publication: English
Document type: Journal Article
Accession number: 12956550
ProQuest document ID: 199423453
Document URL: http://search.proquest.com/docview/199423453?accountid=33171
Copyright: Copyright Anthony J. Jannetti, Inc. Jul/Aug 2003
Last updated: 2013-02-06
Database: ProQuest Medical Library
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