Functional Constipation

4 y/o pt with no h/o irritable bowel disease presents with acute on chronic abdominal pain and constipation. Parents report voluntary stool retention, two or fewer BMs per week, hard/painful BMs, stools that obstruct toilet, and at least one episode of stool incontinence per week. Deny bloody stools, delayed meconium passage at birth. Large fecal mass in recutm, normal cremasteric/anal wink/patellar reflexes on exam.

• Consider obtaining TSH, lead level, fecal occult blood testing

• Consider abdominal x-ray

• Treatment

  • Perform fecal disimpaction in office

  • Trial of dietary fiber, fruit juices (e.g. prune, pear)

    • < 4 months: 2 ounces diluted fruit juice

    • > 4 months: 4 ounces diluted fruit juice

  • Polyethylene glycol (Miralax)

    • < 18 months: 1 tsp qd

    • 18 months to 3 years: 2 tsp qd

    • Weight-based: 0.8 g/kg/day in 8 ounces fluid; maximum 34 g qd

  • 2+ y/o: Dulcolax 10 mg qd

  • Glycerin suppository daily

• Counseling

  • Parents counseled about recognizing withholding behavior; regular toileting/incentive systems encouraged

  • Parents counseled to expect prolonged course with frequent relapses

• Consider GI referral for persistent symptoms

Notes

• Most common cause of abdominal pain in children

• Diagnosed using Rome III criteria; vary based on developmental age

• Treatment options for children

  • Osmotic/lubricant laxatives

    • Polyethylene glycol 3350 powder (MiraLax)

    • Lactulose (70 percent solution)

    • Sorbitol (70 percent solution)

    • Magnesium hydroxide (milk of magnesia)

    • Mineral oil

  • Stimulant laxatives

    • Senna

    • Bisacodyl (Ducolax)

    • Glycerin suppositories

  • Stool softener: Docusate

• Enemas do not improve outcomes in children with severe constipation