2018-19 TOW #28: Constipation/Encopresis

Next week we are reviewing constipation/encopresis. Talking about poop may be uncomfortable for our patients, yet we know how important it is for us to be comfortable addressing this issue.

Materials for this week:

Review on constipation in pediatrics:

  1. Epidemiology: Constipation accounts for 3–10% of visits to general pediatric clinics and up to 25% of referrals to pediatric gastroenterologists worldwide. Genetics plays a role, and social/ environment risk factors include low consumption of fiber, low levels of physical activity, living in a highly-densely-populated community, and low parental education. In >90% of children with symptoms, no obvious organic cause is found.
  2. Clinical definition: Pediatric functional constipation is defined as at least 2 of the following (frequencies in parentheses): Two or fewer defecations per week (75%), At least one episode of fecal incontinence per week (75-90%), Stool retentive posturing (35-45%), Painful or hard bowel movements (50-80%), Large diameter stools that could obstruct the toilet (75%), Presence of a large fecal mass in the abdomen or rectum (30-75%).
  3. Physical exam: Many have normal exams. 30-50% have a palpable abdominal mass. 5-25% have anal fissures or hemorrhoids. 3% have anal prolapse. >40% have fecal impaction.
  4. Work-up: Diagnosis can be made with history and exam and rarely requires additional work-up, except for more severe persistent cases. Concerning history would include passage of meconium >48 h after birth, bloody diarrhea, fatigue, fever, bilious vomiting, and eczema.
  5. Management: a 4-step approach is recommended with 1) education, 2) disimpaction, 3) preventing stool reaccumulation, and 4) behavioral therapy. Oral laxatives with Polyethylene glycol (PEG) (1-1.5g/kg/day) or rectal enema are considered equivalent first-line therapy for disimpaction. Maintenance laxatives are needed for most children for months to years. In my experience, there also may be a role for increasing fiber through supplements, such as products like Benefiber, especially for more minor constipation, or when laxatives lead to incontinence. Protocols and education are provided through our GI department including their constipation protocol.

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