FUNCTIONAL CONSTIPATION

BACKGROUND

Functional constipation is a common problem in children of all ages. A child with constipation may have bowel movements less frequently than normal, hard bowel movements, or large, difficult, and painful bowel movements.

Most children with constipation do not have an identifiable underlying medical problem causing their symptoms. Constipation generally resolves with changes in diet, behavior, or sometimes with medicine.

DISEASE OCCURRENCE IN POPULATION:

Constipation affects up to 30 percent of children and accounting for an estimated 3 to 5 percent of all visits to pediatricians. Functional constipation is responsible for more than 95 percent of cases of constipation in healthy children one year and older, and is particularly common among preschool-age children.

RISK FACTORS:

Constipation in children is more likely for children who:

• Are sedentary
• Don't eat enough fiber
• Don't drink enough fluids
• Take certain medications, including some antidepressants
• Have a medical condition affecting the anus or rectum
• Have a family history of constipation
• Have allergy to cow's milk or consuming too many dairy products (cheese and cow's milk)

SIGN AND SYMPTOMS:

People who experience functional constipation report some or all of the following symptoms:

• Three or fewer bowel movements per week
• Bowel movements that are hard, dry and difficult to pass
• Feeling of incomplete evacuation
• Pain while having a bowel movement
• Sensation of blockage or obstruction in the anus and / or rectum
• Traces of liquid or clay-like stool in your child's underwear — a sign that stool is backed up in the rectum
• Abdominal pain
• Blood on the surface of hard stool

Symptoms also need to be present at least two days a week, for at least three months over the past six months, in order for a diagnosis of functional constipation to be made.

DIAGNOSTIC TEST:

Your child's doctor will:

• Gather a complete medical history: Your child's doctor will ask you about your child's past illnesses. He or she will also likely ask you about your child's diet and physical activity patterns.
• Conduct a physical exam: Your child's physical exam will likely include placing a gloved finger into your child's anus to check for abnormalities or the presence of impacted stool. Stool found in the rectum may be tested for blood.

More-extensive testing is usually reserved for only the most severe cases of constipation. If necessary, these tests may include:

• Abdominal X-ray: This standard X-ray test allows your child's doctor to see if there are any blockages in your child's abdomen.
• Anorectal manometry or motility test: In this test, a thin tube called a catheter is placed in the rectum to measure the coordination of the muscles your child uses to pass stool.
• Barium enema X-ray: In this test, the lining of the bowel is coated with a contrast dye (barium) so that the rectum, colon and sometimes part of the small intestine can be clearly seen on an X-ray.
• Rectal biopsy: In this test, a small sample of tissue is taken from the lining of the rectum to see if nerve cells are normal.
• Transit study or marker study: In this test, your child will swallow a capsule containing markers that show up on X-rays taken over several days. Your child's doctor will analyze the way the markers move through your child's digestive tract.
• Blood tests: Occasionally, blood tests are performed, such as a thyroid panel.

TREATMENT OPTIONS:

FIBER:

Fiber is a component of plants, and it passes through the intestine undigested. Fiber also absorbs a lot of water, which results in softer, bulkier stools.

Fiber can help decrease the time that it takes food to pass through colon (24 to 48 hours). When stools are soft and bulky, they can move more easily through the colon. When stools are hard and dry, they have trouble moving through–that's when patient is experiencing straining.

For all of these reasons, eating high-fiber foods may help with constipation. There are many high-fiber foods.

• Beans - whole grains and bran cereals
• Fresh fruits and dried fruits
• Vegetables like asparagus, brussels sprouts, cabbage, and carrots,
• Greens like spinach, kale and collard

LAXATIVES:

There are different kinds of laxatives. And they work in different ways.

Bulk-forming laxatives: These are fiber supplements to be taken with water and work similar to food fiber.

OSMOTIC LAXATIVES: Three types include saline, lactulose and polyethylene glycol. They are effective in increasing stool frequency and stool consistency.

• Saline laxatives: Examples include Milk of Magnesia.
• Lactulose laxatives: Lactulose is a nonabsorbable carbohydrate. These can be used for chronic constipation.
• Polyethylene glycol: This is approved to treat occasional constipation for up to two weeks.

STIMULANT LAXATIVES: These can cause rhythmic muscle contractions in the intestines and help move stool through the colon.

STOOL SOFTENERS: These provide moisture to the stool and prevent dehydration and allow the stool to pass through the colon. Stool softeners do not promote bowel movements but instead allow patient to have bowel movements without straining.

LUBRICANTS: They lubricate the bowel and stool so it can move through the intestine more easily. Mineral oil is the most common example.

PRECAUTIONS:

• Offer your child high-fiber foods: Serve your child more high-fiber foods, such as fruits, vegetables, beans, and whole-grain cereals and breads. If your child isn't used to a high-fiber diet, start by adding just several grams of fiber a day to prevent gas and bloating.
• Encourage your child to drink plenty of fluids: Water is often the best.
• Promote physical activity: Regular physical activity helps stimulate normal bowel function.
• Create a toilet routine: Regularly set aside time after meals for your child to use the toilet. If necessary, provide a footstool so that your child is comfortable sitting on the toilet and has enough leverage to release a stool.
• Remind your child to heed nature's call: Some children get so wrapped up in in play that they ignore the urge to have a bowel movement. If such delays occur often, they can contribute to constipation.

REFERENCES:

• Van den Berg MM, Benninga MA, Di Lorenzo C. Epidemiology of childhood constipation: a systematic review. Am J Gastroenterol 2006; 101:2401.
• Loening-Baucke V. Prevalence, symptoms and outcome of constipation in infants and toddlers. J Pediatr 2005; 146:359.
• http://www.letstalkconstipation.com/treatment_options/
• http://www.mayoclinic.org/diseases-conditions/constipation-in-children/manage/ptc-20236058