Functional Constipation PPSNCM

Functional
Constipation
John Paul Oliveros, MD
Pediatric Gastroenterologist
“Constipation is a
symptom,
not a disease”
Constipation: a global perspective.
World Gastroenterology
Organization. 2010
Hamid, R and Banday, SS.
Management of pediatrich
constipation. IntechOpen. 2019
Definition
• Constipation is a condition in which bowel movements are less frequent
than usual or consists of hard, dry stools that are painful or difficult to
pass
• Acute or Chronic
• Functional vs Organic The NASPGHAN Fellows Concise
Review of Pediatric Gastroenterology,
Hepatology and Nutrition. 2nd edition.
2017
Stool frequency
Age Frequency
Newborn 2-4 stools per day
Infants (breastfed) 1-2x a week
Toddlers 1 per day
Above 5 years old 3-5 per week
The NASPGHAN Fellows Concise

Review of Pediatric Gastroenterology,
Hepatology and Nutrition. 2nd edition.
2017
Pathophysiology
Lixin Z, et al. Physiol Genomics 2014; 46
Organic Constipation
Tran, DC and Sintusek, P. Functional constipation in children:

what physicians should know. World J Gastroenterol 2023
Febraury 28; 29 (8): 1261-1288
Danger Signs

Febraury 28; 29 (8): 1261-1288
Functional Constipation (Rome IV criteria)
• For infants and children up to 4 years of age
Must include one month of at least two of In toilet trained children the following additional
the following : criteria may be used :
1. Two or fewer defecations per week
2. History of excessive stool retention 6. At least 1 episode/week of
3. History of painful or hard bowel incontinence after the acquisition
movements of toileting skills
4. History of large diameter stools 7. History of large diameter stools
5. Presence of a large fecal mass in the which may obstruct the toilet
rectum
* Symptoms cannot be fully explained by
another medical condition
Functional Constipation (Rome IV criteria)
• For children with developmental age of > 4 years
At least two of the following present at least once per week for at least
one month:
1. Two or fewer defecations in the toilet per week
2. At least one episode of fecal incontinence per week
3. History of retentive posturing or excessive volitional stool retention
4. History of painful or hard bowel movements
5. Presence of large fecal mass in the rectum
6. History of large diameter stools that may obstruct the toilet
* The symptoms can not be fully explained by another medical condition
Onset
Infant
• Introduction of complementary feeding
• Diaper rash
Toddler
• Toilet training
• Inconsistent care-giver, diaper rash
School Age Walker’s Textbook of

• Avoid school toilets Pediatric Gastrointestinal
Disease. 6th edition. 2018
• Diet, low physical activity, obesity
Medical History
• Timing of 1st bowel movement after birth
• Age of onset of constipation
• Stool frequency, consistency, and size
• Painful defecation
Walker’s Textbook of Pediatric Gastrointestinal

Medical History
• Presence of blood on stool/toilet paper
• Retentive posturing
• Soiling
• Social and emotional factors

Retentive posturing/withholding behavior
• Going stiff
• Clenching buttocks
• Walking on tip toes
• Crossing leg
• Bracing against the furniture
• Curling up in a ball
• Sitting with legs straight up https://www1.racgp.org.au/AJGP/2018/May/
Paediatric-constipation#.W8jjZjfZQwY.twitter
Physical Examination
• To rule out organic constipation
• General physical examination
• Abdominal exam: distention, fecal mass (30-75%), tenderness and
bowel sounds
• Back examination: spine defects, sacral dimple, tufts of hair
Physical Examination
• Rectal exam: soiling, position of anus, fissures and fistulas, peri-anal sensation,
sphincter tone, size of rectum, polyps, hemorrhoids
• May not be necessary if history suggest FC
• Indications:
• Delayed passage of meconium
• Intractable constipation
• Uncertain diagnosis according to ROME IV criteria
• Suspicion of anatomic defect
Febraury 28; 29 (8): 1261-1288
Diagnostics
• Functional constipation is a clinical diagnosis
• History and Physical examination as basis for diagnosis
• Diagnostics may be needed to rule out organic constipation
• Intractable cases
• Uncertain diagnosis
• Red flag signs
Di Lorenzo, C. and Nurko, S. Pediatric Functional
Gastrointestinal Disorders. 2016
Diagnostics
Laboratory: for patients with intractable constipation
• Thyroid studies: hypothyroidism
• Serum calcium: hypercalcemia
• Serum IgE: cows milk protein allergy

Diagnostics
• Abdominal radiograph
• In patients with uncertain diagnosis
and limited physical examination
• Sensitivity: 60-80%
• Specificity:
• Inconsistent relationship of
constipation symptoms with fecal
loading in x-rays
Febraury 28; 29 (8): 1261-1288
Diagnostics
• Abdominal ultrasound
• Requested for abdominal pain
• Assess stool retention
• Estimate rectal and colon size
• Mesenteric adenitis (?)

Febraury 28; 29 (8): 1261-1288
Diagnostics
• Colonic Transit Time (CTT)
• Prolonged in constipation
• Constipation ruled out if < 62 hrs
• Routine use is not recommended
• May differentiate between
Functional constipation and
Functional Non-retentive fecal
Tabbers, M.M., et al. Evaluation and Treatment of functional
incontinence Constipation in Infants and Children: Evidence Based
recommendations form ESPGHAN and NASPGHAN. JPGN 2014. Vol
58, No. 2, 258-274
Diagnostics
• Tests for Intractable constipation
• Colonic manometry
Tran, DC and Sintusek, P. Functional
• MRI constipation in children: what
physicians should know. World J
• Colonic full thickness biopsies Gastroenterol 2023 Febraury 28; 29
(8): 1261-1288
• Colonic scintigraphy Tabbers, M.M., et al. Evaluation and

Treatment of functional Constipation in
• Wireless motility capsule Infants and Children: Evidence Based
recommendations form ESPGHAN and
NASPGHAN. JPGN 2014. Vol 58, No. 2,
258-274
Diagnostics
• Tests to rule out Hirschsprung Disease

• Rectal suction biopsy: Gold Standard
• Anorectal manometry: not available
• Barium enema: preop assessment of aganglionic segment
Tabbers, M.M., et al. Evaluation and Treatment of functional
Constipation in Infants and Children: Evidence Based
recommendations form ESPGHAN and NASPGHAN. JPGN 2014.
Vol 58, No. 2, 258-274
Diagnostics
Treatment
• Goals:
• Establishing regular defecation
• Daily stools
• Soft stools
• Easy defecation
• Preventing relapse Tran, DC and Sintusek, P. Functional
constipation in children: what
Gastroenterol 2023 Febraury 28; 29
(8): 1261-1288
Treatment
• Tools:
• Oral laxatives
• Structured toilet training
• Phases:
• Education
• Fecal disimpaction
• Preventing fecal reaccumulation constipation in children: what
• Follow-up Gastroenterol 2023 Febraury 28; 29
(8): 1261-1288
Treatment
• Education
• Important for adherence to treatment and success
• Explain to parents
• physiology of defecation
• Associated factors
• Sequalae Tran, DC and Sintusek, P. Functional
• No quick fix constipation in children: what
(8): 1261-1288
Treatment
• Education
• Toilet training
• 5-10minutes
• After meals
• 3-4x a day initially
• Reward system
• Positive and supportive trainer Hamid, R and Banday, SS.
• Potty trainer (<8yo) constipation. IntechOpen. 2019
Treatment
• Education
• Diet
• Normal Fiber intake
• Normal Fluid intake
*Tabbers, M.M., et al. Evaluation and Treatment of functional

Constipation in Infants and Children: Evidence Based
recommendations form ESPGHAN and NASPGHAN. JPGN
2014. Vol 58, No. 2, 258-274
*Philippine Dietary Reference Intake. FNRI. 2015
Treatment
AGE ENERGY NEEDED AMOUNT TEXTURE FREQUENCY
PER DAY IN
ADDITION TO
BREAST MILK
6-8 months 200 kcal/day Start with 2-3 tbsp. Start with thick 2-3 meals per day
per feed, porridge, well
increasing mashed foods Depending on
gradually to ½ of a child’s appetite, 1-2
250 ml cup Continue with snacks may be
mashed family foods offered
9-11 300 kcal/day ½ of a 250 ml cup Finely chopped or 3-4 meals per day
months mashed foods, and
foods that baby can Depending on
pick up child’s appetite, 1-2
snacks may be
offered
12-23 ¾ to full 250 ml cup 550 kcal/day Family foods, 3-4 meals per day
months chopped or mashed if
needed Depending on
child’s appetite, 1-2
snacks may be
offered
Treatment
• Pharmacologic
• Oral
• Osmotic laxatives (1st line)
• Stimulatory laxatives
• Rectal
• Enema
• suppository
• Lubricants constipation in children: what
(8): 1261-1288
Treatment
• Disimpaction phase
• Crucial to maximize success of treatment
• 5-6days
• Medications:
• Polyethylene glycol with or without electrolytes (1-1.5gm/kg/day)
• Sodium phosphate enemas (2.5mg/kg/day)
(8): 1261-1288
Treatment
• Maintenance Phase
• Until treatment goals are achieved
• regular bowel habit
• soft painless stools
• Decrease laxative gradually before stopping
• Regular follow-ups
Treatment
• Maintenance phase
• Medications:
• Polyethylene glycol (0.4gm-0.8gm/kg/day)
• Lactulose 70% (1ml/kg/day)
Tabbers, M.M., et al. Evaluation and

Treatment of functional Constipation in
Infants and Children: Evidence Based
recommendations form ESPGHAN and
NASPGHAN. JPGN 2014. Vol 58, No. 2,
258-274
Treatment (adjuncts)
• Prebiotics
• Probiotics
• Limited evidence

(8): 1261-1288
Prognosis
• Post treatment (6-12months)
• 50% will recover without laxatives
• 10% will be symptom free but still on laxatives
• 40% will still have symptoms even on laxatives

Prognosis
• Quality of life:
• without treatment: adverse psychosocial effects
• With treatment: increase scores in all life quality and total scores
(KINDL)
Erdur, B. and Ayar, M. Treatment of functional

constipation significantly increased quality of life in
children 4-17years old. Turk J Gastroenterol. 2020.
Nov; 31(11): 814-818
Summary
• Functional constipation is a common childhood condition
• Affects both patient and family, decreasing quality of life
• Functional constipation is more common than organic causes
• It can be diagnosed clinically using the ROME IV criteria
Summary
• Treatment goals include a regular bowel habit with soft and painless stools
for the patient
• Treatment phases are education, disimpaction, maintenance and follow-up
• Essential to treatment is toilet training and use of oral laxatives
• Treatment is long and success is dependent on compliance of medications,
healthy balanced diet, proper potty training, and regular follow-up
Thank you

Functional Constipation PPSNCM

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Functional

The NASPGHAN Fellows Concise

Tran, DC and Sintusek, P. Functional constipation in children:

Tran, DC and Sintusek, P. Functional constipation in children:

School Age Walker’s Textbook of

Walker’s Textbook of Pediatric Gastrointestinal

Walker’s Textbook of Pediatric Gastrointestinal

Walker’s Textbook of Pediatric Gastrointestinal

Tran, DC and Sintusek, P. Functional constipation in children:

• Colonic scintigraphy Tabbers, M.M., et al. Evaluation and

• Tests to rule out Hirschsprung Disease

*Tabbers, M.M., et al. Evaluation and Treatment of functional

Tabbers, M.M., et al. Evaluation and

Tran, DC and Sintusek, P. Functional

Hamid, R and Banday, SS.

Erdur, B. and Ayar, M. Treatment of functional

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