1

-
( Tabbers MM, et al. Evaluation and Treatment of Functional Constipation in
Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN.

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J Pediatr Gastroenterol Nutr 2014; 58:258-74)

..
.

1. (Functional constipation)
ROME III criteria 1

10

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infant dyschezia

2. 2

3. functional constipation

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3.1

- ROME III criteria 1 criteria

- alarm signs and symptoms

3.2 routine

Pt

fecal impaction ( )
3.3 colonic transit studies

3.4 rectal ultrasound

4. Hirschsprung disease

4.1 alarm
symptoms
4.2 2-4 intractable
constipation

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4.3 routine hypothyroidism, celiac

disease, hypercalcemia alarm symptoms

4.4 Anorectal manometry intractable constipation

rectoanal inhibitory reflex Hirschsprung disease

4.5 rectal biopsy gold standard Hirschsprung disease

4.6 barium enema

(barium enema Hirschsprung disease)
5. intractable constipation

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5.1 Colonic manometry intractable constipation

5.2 MRI spine

5.3 full-thickness colonic biopsy

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5.4 colonic scintigraphy rouine

6. nonpharmacologic treatment
6.1

Pt

6.2

6.3 physical activity

6.4 prebiotics routine

6.5 probiotics routine

6.6 intensive behavioral protocalized therapy

6.7 multidisciplinary treatment (Pediatirc GI, pediatrician, dietician,

psychotherapist, physical therapist) routine
6.8 biofeedback ()

4
7.
7.1 Disimpaction

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6.9

Polyethelene glycol (PEG) with /without electrolytes

PEG (rectal enema)
7.2 Maintenance therapy

- PEG with without electrolytes 0.4 /.

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- lactulose PEG
- MOM, mineral oil stimulant laxative

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7.3 maintenance 2
1
7.4 (toilet training)

8. (intractable constipation)

Pt

8.1 lubiprostone, linaclotide prucalopride

8.2 antegrade enema

8.3 Transcutaneous nerve stimulation routiine

9.

9.1 6-12 50
pediatric gastroenterologist

Pt

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1 ROME III

Pt

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(Maintenanec Rx)

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Pt

ga
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2 4

Functional constipation

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2-4

1 6

Functional constipation

Fecal impaction

Disimpction
-
-

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No fecal impaction

(Maintenanec Rx)

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(Adherence)

/
fecal impaction Rx

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TSH2 T4
Celiac screening

Pt
Colonic transit

Intractable
constipation

2 6

Intractable constipation

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rule out
- Hirschsprung disease (ARM, rectal biopsy
- (bariom enema)
- (MRI)

Colonic manometry

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Biofeedback
ACE
Botox
SNS
TENS

SNS
Botox
TENS
Pseudo-obstruction

2 6 ()

ARM, anorectal manometry; ACE, antegrade continence enema; SNS. sacral nerve

Pt

stimulation; TENS, transcutaneous electric nerve stimulation