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Paediatric functional constipation is a growing medical condition in New Zealand and worldwide, with a reported average prevalence of ~12%[[1]] (range 0.5% to 32.2%).[[2]] It accounts for 10% and 25% of admissions in general paediatric and paediatric gastroenterology clinics.[[3]] In the state of Victoria, Australia, paediatric constipation costs $5.5 million annually,[[2]] while in the United States the estimation is $3.9 billion,[[3]] which creates additional financial pressure on burgeoning healthcare systems.

The number of bowel movements varies with chronological age: for instance, 5–40 motions per week are regarded as the normal range for a 3-month-old, and 4–20 and 3–14 motions per week for 12-month- and 3-year-olds, respectively.[[4,5]] According to Yacob et al, constipation onset can occur at three different stages.[[3]] It can occur from (1) the transition from breast-feeding or formula milk to solids, (2) toilet training or (3) the commencement of day care, kindergarten or school. Functional constipation is distinguished by painful bowel movements, irregular defecation, extreme stool retention and large stool calibre.[[3]] It may also include faecal incontinence that is caused by the overflow of soft stools around a hard and large faecal deposit accumulated in the rectum.[[6]]

The aetiology of functional constipation remains unclear, although nutritional, behavioural and psychosocial abnormalities and genetic factors may be contributing factors.[[7]] More than 33% of children develop chronic symptoms where pain is an important aspect in prompting fear and the withholding of defecation. It has been reported that 50% of children with functional constipation have persistent symptoms after 6–12 months of conventional treatment and 25% have symptoms that continue into adulthood.[[8]] Despite these realities, the majority of children with functional constipation do not receive timely treatment.[[9]] Predicting which children will benefit from treatment is difficult due to inconsistent prognostic factors.[[8]]

Care planning

Care planning focuses on patient-centred care that considers the needs, concerns, beliefs and goals of the person rather than the needs of the systems or professionals.[[10]] It is underpinned by shared decision-making and communication to support behaviour change and improve health knowledge. Typically, a care plan includes assessment, diagnosis, prioritised interventions, medical management, key actions and tasks, role responsibility, crisis or contingency planning and times and methods for review and follow-up. There are various paediatric constipation care plans, some of which are complex and others simplistic (Figures 1 and 2).

Figure 1: A New Zealand example of a paediatric constipation care plan.

Figure 2: An international example of a paediatric constipation care plan for infants 6 months of age or older.[[6]]

ACE = antegrade continence enema; MRI= magnetic resonance imaging; SNS = sacral nerve stimulation; TENS = transcutaneous electric nerve stimulation; TSH = thyroid-stimulating hormone.

The benefit of a care plan is to enable and improve communication between the patient and healthcare team in real time. There are various generic hard copy and electronic care plans that are available on the Health Navigator New Zealand website.[[11]] Increasingly, web-based and electronic tools are being used to document care plans and are usually part of an extensive patient system that may include a patient portal.[[11]] The majority of New Zealand district health boards (DHBs) will have a child constipation care plan that will be based on high-quality information and known national and international best practice guidelines. The contributors to these plans work in the clinical setting and have expertise and specialisation in paediatric medicine. Thus DHBs’ care plans may differ slightly depending on the local expertise.

Practitioners can access their local DHB care plan through Community HealthPathways website. The care plan should include the definition of chronic constipation, the age range that the plan is for and criteria to thoroughly assess the patient’s history (ie, onset of constipation, frequency and type of stools, soiling, bleeding, pain with stool, diet, exercise, abdominal pain). The clinical assessment should include height, weight, nutritional status, abdomen, spine and lower limbs (muscle tone, reflexes, gait) and perianal conditions (fissures, fistula, lipoma). An abdomen x-ray is not required. Blood mixed within a stool and vomiting in the setting of faecal impaction requires urgent referral.[[12]] The care plan should include guidelines for disimpaction (prescription), management (medication, diet, behavioural, exercise, toileting) and ongoing management, whether or not the child responds over the defined duration.[[12]] A constipation care plan may also include red flags (eg, when the child is unwell and has any of the following: greater than 48 hours delayed passage of meconium or symptoms within two weeks of birth, passage of toothpaste or ribbon stools, abdominal distension and vomiting, abnormalities of anus, spine or gluteal region, unexplained weakness or deformity of lower extremities, neurological findings and weight loss or faltering growth).[[13]]

Recent international research identified that a paediatric constipation action plan (AP) requires key evidence-based concepts, including imagery, comprehension, quality, readability and suitability using jargon free language.[[14]] The researchers investigated the use a pictogram-based constipation AP to assist clinicians, caregivers and children in the management of functional constipation (Figure 3).[[14]] The AP was designed to optimise knowledge transfer between the health service and caregiver at the time of discharge and empower home management of constipation. The AP adopted a health-informed approach to provide information on evidence-based medication and behavioural interventions, and to reduce disparities in constipation outcomes related to low health literacy.

The AP included four sections:

  1. Cleanout: green (feeling good).
  2. Maintenance: yellow (feeling bad).
  3. Acute: red (feeling worse).
  4. Severely acute.

Each section included the type, amount and frequency of medication, with key behaviours highlighted in the green, yellow and red sections. According to the authors, the twelve images in the pictogram were easily interpreted and facilitated comprehension for patient and caregiver. Using lay language with the images maximised the caregivers’ comprehension, which further empowered caregivers to improve their child’s compliance and clinical outcomes.[[14]]

Figure 3: An international example of an action plan for paediatric functional constipation.

In New Zealand, the Auckland Region Community HealthPathways has compiled a constipation AP[[15]] with the aim for children to pass at least three soft, painless bowel motions per week (type 4 stool). The AP includes a YouTube video link on constipation and conveys to the caregiver key bullet points about providing three servings per week of foods containing seeds (kiwifruit) or segments (mandarins), increasing fibre and water intake, encouraging regular exercise and practising regular and good toilet technique. It also provides a disimpaction plan (similar to the Waitematā DHB schedule[[16]]), regular maintenance medication prescription and a stool dairy for monitoring bowel movements, to assist the caregiver and child with the progress and the medical staff in determining the correct treatment. Finally, a reward star chart is included to motivate and encourage positive behaviour from the child.

Diagnosis

Rome IV17provides a method for diagnosing functional constipation, according to which two or more criteria must occur one or more times per week for a minimum of one month (Table 1). It is important that a thorough and correct assessment is undertaken. This should include a physical examination to assess the abdomen for faecal masses, anal patency, anal fissures and patulous anus, as well as neurological testing for reflexes, lower-limb tone, spine and gait.[[5]] Further examination should identify or discard other underlying pathophysiology, such as perianal disease, Hirschsprungs disease, inflammatory bowel disease, urinary symptoms and systemic symptoms (reduced body mass, decline in growth, lethargy).[[5]] Laboratory testing should only be performed to exclude an underlying condition such as hypothyroidism or hypercalcaemia. Coeliac disease, associated with iron deficiency anaemia, abdominal pain and poor growth, should be considered for assessment if constipation arises early with the introduction of gluten.[[6]]

Table 1: Rome IV constipation criteria.

Due to its poor reliability, abdominal radiography is not recommended for diagnosis.[[1]] However, there are exceptions: for example, when a child’s history is unclear, when confirming faecal impaction or when planning treatment for disimpaction.[[3]] In cases with a history of chronic constipation, anorectal manometry can assess anal sphincter function, pelvic floor function and anorectal reflexes. When the constipation is severe and unresponsive to conventional treatment, colonic manometry is used to assess colon motility.[[3]] Magnetic resonance imaging is not advised in the absence of neurological abnormalities.[[6]] Other diagnostic techniques include colonic transit time, scintigraphy, rectal barostat and wireless motility capsule.[[1]]

Management

The treatment plan should include a holistic team approach involving the paediatric clinician, paediatric continence nurse, parents, whānau, dietician, clinical psychologist, physiotherapist and, when required, Māori and Pacific health specialist staff. The common approach to treating functional constipation is education, behavioural modification and laxatives.[[3]] In New Zealand, when paediatric constipation is more severe and treatment is unresponsive, there may be an underlying condition. The general practitioner will refer the child to a continence service or paediatric department of the local DHB. Under a paediatric continence nurse-led intervention, the nurse works in close co-operation with the consultant paediatrician to determine a treatment plan. The paediatric continence nurse also works closely with the caregiver by providing regular telephone follow-ups. This close communication allows for ongoing medical management, reduces emotional stress and provides reassurance to the caregiver of the long-term plan for their child. The approach of a nurse-led intervention is considered internationally an effective use of services and cost-efficient in providing greater care for paediatric constipation.[[18]]

Depending on the severity and longevity of the constipation, some caregivers become frustrated with the lack of therapeutic diagnostic testing, which can unpropitiously affect the treatment due to misunderstanding and noncompliance. It is imperative that the medical team provide clear and succinct written and verbal communication about the diagnosis to the caregiver. The medical team should focus on all treatment being individualised and long-term. Therefore, it is important that caregivers follow the instructions given to them by the medical team and enact the treatment plan. Central to the plan is the caregiver’s ability to be educated. This requires time and effort to bring a positive change. In addition, caregivers are encouraged to provide healthy, well-balanced meals with adequate fibre to soften the stool consistency. Increasing fibre also requires increasing the child’s water intake. The action plan (Figure 3) is a key document in assisting with monitoring, treatment and ongoing care of the child.

Diary

It is imperative caregivers complete a daily diary on the amount of medication, frequency and type of stool (using Bristol Stool Form Scale), associated behaviours, fluid intake and food intake. The recording of data can be tedious and a burden for the caregiver, but it is an invaluable source of information for the medical team to determine the defecation pattern, quantify therapeutic progress and enhance treatment adherence. Various mobile applications (apps) currently exist (Stool Log—Bowel Movement Journal, GutTracker, Poop Tracker, PoopLog) that allow the user to track and analyse bowel movements. PoopMD+, a mobile app that uses a smartphone’s camera and colour-recognition software to analyse an infant’s stool, can accurately identify images of pale-coloured stools.[[19]] However, a comprehensive, cloud-based diary app that includes the aspects described above should be developed. This would expedite data entry, increase compliance and allow proactive monitoring, diagnosis and treatment, which would benefit both the caregiver, child and medical team.

Toilet training

It is often difficult to undertake toilet training when a child has functional constipation. Out of despair of trying, some caregivers abandon toilet training, which they later regret because their child may not become toilet trained before starting school. This can cause distress for both caregiver and child. For children not toilet trained, it may be appropriate to continue with nappies. Toilet training should be encouraged when laxatives have softened the stool and the child has regained confidence . Caregivers need to create a non-threatening and pleasant environment. This requires patience, consistency, regularity and encouragement. A child may have increased anxiety when using toilets outside their home, which further increases the likelihood of withholding. A study revealed that school toilets were an unpleasant, terrifying place where bullying occurred, which is likely to exacerbate withholding.[[20]] Using the toilet requires comfort, safety and appropriate ambience. Day-care centres, kindergartens and schools may need to address the state and environment of their toilets.

The rectum ampulla stores the stool and expands the rectal walls, which stimulates the stretch receptors. This sends a message to the brain indicating that it’s toilet time. The problem occurs if the child decides to withhold; as the stool sits in the rectum, water continues to be absorbed by the colon and the stools become very hard, and as more food is digested, additional stools fill the rectum and it backfills into the colon. When the child eventually visits the toilet, the stool is very hard and large, which makes it difficult to pass. Therefore, it is beneficial to establish a toilet-training routine. Regularity is important for toilet training. Children should be encouraged to sit on the toilet at frequent periods: for example, it is preferable to schedule using the toilet 20 minutes after a meal,[[21]] and following breakfast and dinner is considered the best time.[[13]] Encouraging and praising the child are important aspects for successful toilet training. Incentives, such as star charts, new underwear or special ‘treats’, may help to reinforce positive behaviour.[[13,21]] It is important that the child performs correct toilet posture. This means knees higher than hips (use a footstool), elbows on knees, leaning forward, pushing the abdomen out and straightening the spine.[[13,21]]

Medication

Many caregivers have concerns about the frequency and amount of prescribed medication. Laxatives are essential for the treatment of constipation as they re-establish regular, painless bowel movements,[[5]] so that the enlarged rectum can return to a normal size. The aim of the medication is to soften the stool. Common laxatives include lactulose, docusate tablets, magnesium hydroxide or macrogol. Magnesium hydroxide (8%) is a mixture that pharmacists need to prepare before being dispensed, and it is not recommended for long-term use unless under medical supervision.[[22]] Macrogol-3350 (Molaxole®, Movicol®, Movicol®-Half, Lax-Sachets®) is a powder that gets mixed with liquid. Each sachet of macrogol contains 13.125 g and electrolytes. Stimulant laxatives, such as bisacodyl, glycerol, poloxamer 188 and sodium picosulfate, are effective in generating propagated colonic contractions. At certain times, these strong and sustained colonic contractions can be interpreted as abdominal cramping. Some children have a negative response to this cramping sensation. They may complain, withhold and misuse the opportunity to have a bowel movement. It is important that caregivers are aware of the cramping, and if the cramping is severe, the dose may need adjusting.[[3]]

For disimpaction, a high dosage and large volume of liquid consumption is required until the bowel is emptied. Initially, macrogol is prescribed for disimpaction. If there is no response to macrogol, sodium picosulphate can be considered.[[13]] An alternative method to delivering the powerful laxative solution is a nasogastric tube, which requires hospitalisation for approximately seven days. The procedure of the nasogastric tube can be a terrifying experience for both child and caregiver. Recently, a 3-year-old diagnosed with faecel impaction rejected the nasogastric tube by vomiting its displacement, causing severe distress and anxiety to both child and caregiver. Oral treatment of macrogol is advised when possible. However, this relies on the child consuming the prescribed liquid, which is sometimes difficult to achieve. International research for disimpaction recommends a dosage 1–1.5 g/kg/day for 3–6 days.[[23]] In New Zealand, Waitematā DHB recommends different dosages for children aged 2–5 years and 6–11 years (Table 2).[[16]] This is based from the Movicol Junior® disimpactment dosage approved by Medsafe.[[24]] Maintenance therapy for macrogol ranges from 0.75 g/kg/day[[25]] to 1 g/kg/day.

Table 2: Recommended dosage for child faecal disimpaction.[[16]]

If faecal impaction is untreated, the overall treatment for constipation will be ineffective. The prescription of laxatives will require ongoing adjustment (higher or lower) depending on the child’s response to the medication. The duration of laxatives often ranges from months to years rather than weeks.[[22]]

Most laxatives have a disclaimer that prolonged use is not usually recommended and may lead to dependence. This heightens a caregiver’s apprehension about their child’s long-term medication use. Although the chronic effects have not been extensively investigated, the bowel does not become ‘dependent’ on the medication.[[26]] The benefits of pharmacologic treatment outweigh its potential adverse effects, and the concern of developing dependence is unfounded.[[3]] Medicating for a soft stool will allow the bowel to return to its normal size, shape and function. This requires medication to be administered regularly for a prolonged time and caregivers should therefore remain attentive to the treatment plan.

Other treatments

Functional constipation may require multidisciplinary treatment, but currently there is a lack of evidence to support this.[[6]] Novel therapies, such as sacral nerve stimulation, have yielded positive results and may be considered in the overall treatment plan. Research reported that six months of transcutaneous electrical stimulation treatment significantly improved defecation frequency, soiling, abdominal pain, urge to defecate and quality of life in 50% of children with chronic constipation.[[27]] Greater research is required to confirm its use. Other therapies of pre- and pro-biotics are considered ineffective in treating paediatric constipation.[[6]] A normal fibre intake is recommended and can be achieved with at least three servings each of fruit and vegetables, selecting wholemeal bread and cereals high in fibre, adding bran to baking and including legumes. There is no evidence to date to support the use of fibre supplements to treat functional constipation, and allergy testing is not recommended for diagnosing suspected cow’s-milk allergy in children with constipation.[[6]]

It is unclear whether physical activity assists with constipation. Physical activity was associated with a reduced risk of functional constipation in pre-school-aged children. [[28]] But, in contrast, a higher level of physical activity was observed in preadolescent children diagnosed with functional constipation.[[29]] Expert opinion recommends a normal level of physical activity for children with constipation.[[6]] In New Zealand, it is recommended that toddlers and pre-schoolers disperse at least three hours of physical activity across each day,[[30]] and that 5–17-year-olds accumulate at least one hour a day of moderate to vigorous physical activity, plus strengthening activities at least three days a week.[[31]]

The use of physiotherapy treatment remains equivocal. Six weeks of physiotherapy treatment involving muscle training of the abdominals, breathing exercises and abdominal massage improved the frequency of bowel movements compared to the medication group.[[32]] Similarly, an eight-week programme focused on pelvic floor muscles reported a significant increase in stool frequency and stool diameter, but no changes were observed in stool withholding, faecal impaction and defecating pain.[[33]] A recent study, however, reported that after eight-months of combining physiotherapy treatment activating abdominal and pelvic floor muscles with conventional treatment (toilet training, nutritional advice, laxatives) was not effective compared to conventional treatment alone.[[34]]

Surgical intervention

Despite aggressive therapy of high-dose laxatives and behavioural modification, some children with chronic, intractable constipation do not progress. Intractable constipation is defined as not responding to optimal conventional treatment for at least three months.[[6]] It can become so severe that it adversely affects the child’s self-esteem and ability to socialise, which impacts the quality of life of the child and family.[[35]] Surgical intervention is considered a treatment of last resort, but it may be advised in difficult intractable cases. The type of surgery will be determined by a comprehensive evaluation of the colonic and anorectal anatomy and physiology, and anorectal and colonic manometry are often used to guide surgical decision-making.[[36]] Surgical strategies vary across New Zealand. They are limited to a number of regions and are not available to the primary care physician. A survey of physicians specialising in paediatric surgery and paediatric gastroenterology reported considerable variation in the diagnosis and treatment of children with intractable constipation. The authors of the survey suggested there is a great need for evidence-based guidelines for children who respond inadequately to pharmacological management.[[36]]

In summary, constipation is a chronic condition and its treatment requires medication to keep the stool soft and behavioural interventions. A thorough history, including questions about the frequency of bowel movements and stool type, is required. If no red flags are found after examining the abdomen, spine, lower limbs and perianal area, the practitioner should have confidence to aggressively manage the constipation[[37]] through a constipation action plan.[[15,37]]

Summary

Abstract

Constipation is common in young children and results in approximately 350 hospitalisations per 100,000 population for 0–4-year-olds. Constipation can become chronic in more than one-third of those affected. The purpose of this article is to provide an awareness and highlight the care planning, diagnosis and management in paediatric functional constipation. It is intended for general practitioners and those in primary healthcare who may be unfamiliar with functional constipation. Paediatric functional constipation affects the child’s physical, psychological and social wellbeing while causing significant stress to the caregiver/whānau. Despite its prevalence, functional constipation is often misdiagnosed and inadequately treated. Functional constipation requires a comprehensive therapeutic plan, including education, behavioural intervention and medication. Pharmacological treatment often causes concern and misapprehension for developing ‘dependence’, which is unfounded. Children with chronic constipation who do not progress, despite aggressive medical therapy and behavioural modification, may benefit from further assessment with colonic transit or anorectal and colonic manometry. In the future, novel medical, exercise and surgical strategies will have a role in advancing improved outcomes in children who are unresponsive to conventional medical and behavioural interventions. However, this will require more evidence-based guidelines. Unresponsive constipation cases should be included in the care planning of district health boards, which may assist in a multidisciplinary approach to assisting the physical and psychosocial aspects of constipation.

Aim

Method

Results

Conclusion

Author Information

Darryl J Cochrane: Associate Professor, School of Sport, Exercise & Nutrition, Massey University, New Zealand.

Acknowledgements

Correspondence

Darryl Cochrane, School of Sport, Exercise & Nutrition, Massey University, Private Bag 11 222, Palmerston North, New Zealand, +64 6 951 7532

Correspondence Email

D.Cochrane@massey.ac.nz

Competing Interests

Nil.

1 Tambucci R, Quitadamo P, Thapar N, et al. Diagnostic tests in pediatric constipation. J Pediatr Gastroenterol Nutr. 2018; 66:89-98.

2 Trajanovska M, Liew A, Gibb S, Goldfeld S, King SK. Retrospective audit of referral and triage pathways of paediatric patients with constipation and soiling. J Paediatr Child Health. 2020; 56:298-303.

3 Yacob D, Di Lorenzo C. Constipation in children: A guide to prompt diagnosis and effective treatment. Curr Treat Options Peds. 2020; 6:101-15.

4 Nurko S, Zimmerman LA. Evaluation and Treatment of Constipation in Children and Adolescents. Am Fam Physician. 2014; 90:82-90.

5 Singh H, Connor F. Paediatric constipation: An approach and evidence-based treatment regimen. Aust J Gen Pract. 2018; 47:273-7.

6 Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014; 58:258-74.

7 Peeters B, Benninga MA, Hennekam RC. Childhood constipation; an overview of genetic studies and associated syndromes. Best Pract Res Cl Ga. 2011; 25:73-88.

8 Pijpers MA, Bongers ME, Benninga MA, Berger MY. Functional constipation in children: a systematic review on prognosis and predictive factors. J Pediatr Gastroenterol Nutr. 2010; 50:256-68.

9 Lindgren H, Nejstgaard MC, Salö M, Stenström P. Evaluation of bowel function in healthy children: untreated constipation is common. Acta Paediatr. 2018; 107:875-85.

10 Michie S, Miles J, Weinman J. Patient-centredness in chronic illness: what is it and does it matter? Patient Educ Couns. 2003; 51:197-206.

11 Health Navigator New Zealand [Internet]. Care planning. Edition. [cited 4 February 2021]. Available from: https://www.healthnavigator.org.nz/clinicians/c/care-planning/

12 MidCentral District Health Board [Internet]. Constipation in children. Edition. [cited 6 May 2020]. Available from: https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Latest%20Updates/HP_Constipation%20in%20children.pdf

13 Auckland Region Community Health Pathways [Internet]. Constipation in children. Edition. [cited 4 February 2021]. Available from: https://aucklandregion.communityhealthpathways.org/14683.htm

14 Reeves PT, Kolasinski NT, Yin HS, et al. Development and assessment of a pictographic pediatric constipation action plan. J Paediatr Child Health. 2021; 229:118-26.

15 Dillon C. Child constipation action plan. Auckland Regional Health Pathways, 2020.

16 Waitematā District Health Board [Internet]. Macrogol 3350 - For constipation and disimpaction in children. Edition. Waitemata District Health Board. [cited 18 May 2020]. Available from: https://www.healthnavigator.org.nz/medicines/m/macrogol/

17 Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology. 2016; 150:1456-68.

18 Tappin D, Nawaz S, McKay C, MacLaren L, Griffiths P, Mohammed TA. Development of an early nurse led intervention to treat children referred to secondary paediatric care with constipation with or without soiling. BMC Pediatr. 2013; 13:1-9.

19 Franciscovich A, Vaidya D, Doyle J, et al. PoopMD, a mobile health application, accurately identifies infant acholic stools. Plos One. 2015; 10:1-9.

20 Vernon S, Lundblad B, Hellstrom AL. Children's experiences of school toilets present a risk to their physical and psychological health. Child Care Hlth Dev. 2003; 29:47-53.

21 MidCentral District Health Board. A guide for parents/whānau and caregivers toilet training your preschool child. MidCentral District Health Board, 2018.

22 KidsHealth. Laxatives. Edition. [cited 22 May 2020]. Available from: https://kidshealth.org.nz/laxatives

23 Youssef NN, Peters JM, Henderson W, Shultz-Peters S, Lockhart DK, Di Lorenzo C. Dose response of PEG 3350 for the treatment of childhood fecal impaction. J Pediatr. 2002; 141:410-4.

24 Medsafe [Internet]. New Zealand Datasheet for MOVICOL® Junior. Edition. MedSafe [cited 18 May 2020]. Available from: https://www.medsafe.govt.nz/Profs/Datasheet/m/MovicolHalfpwdr.pdf

25 Pashankar DS, Bishop WP. Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children. J Pediatr. 2001; 139:428-32.

26 Nurko S, Zimmerman LA. Evaluation and treatment of constipation in children and adolescents. Am Fam Physician. 2014; 90:82-90.

27 Yik YI, Hutson J, Southwell B. Home-based transabdominal interferential electrical stimulation for six months improves paediatric slow transit constipation (STC). Neuromodulation. 2018; 21:676-81.

28 Driessen LM, Kiefte-de Jong JC, Wijtzes A, et al. Preschool physical activity and functional constipation: the Generation R study. J Pediatr Gastroenterol Nutr. 2013; 57:768-74.

29 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fibre, fluids and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009; 13:116-27.

30 Ministry of Health. Sit Less, Move More, Sleep Well: Active Play Guidelines for Under-Five. Wellington: Ministry of Health, 2017.

31 Ministry of Health. Sit Less, Move More, Sleep Well: Physical Activity Guidelines for Children and Young People. Wellington: Ministry of Health, 2017.

32 Silva CAG, Motta M. The use of abdominal muscle training, breathing exercises and abdominal massage to treat paediatric chronic functional constipation. Colorectal Dis. 2013; 15:250-5.

33 Farahmand F, Abedi A, Esmaeili-Dooki MR, Jalilian R, Tabari SM. Pelvic floor muscle exercise for paediatric functional constipation. J Clin Diagn Res. 2015; 9:16-7.

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36 Koppen IJ, Kuizenga-Wessel S, Lu PL, et al. Surgical decision-making in the management of children with intractable functional constipation: What are we doing and are we doing it right? J Pediatr Surg. 2016; 51:1607-12.

37 Hayman R [Internet]. Constipation in children. https://www.goodfellowunit.org/podcast/constipation-children: Goodfellow Unit, 2020.

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Paediatric functional constipation is a growing medical condition in New Zealand and worldwide, with a reported average prevalence of ~12%[[1]] (range 0.5% to 32.2%).[[2]] It accounts for 10% and 25% of admissions in general paediatric and paediatric gastroenterology clinics.[[3]] In the state of Victoria, Australia, paediatric constipation costs $5.5 million annually,[[2]] while in the United States the estimation is $3.9 billion,[[3]] which creates additional financial pressure on burgeoning healthcare systems.

The number of bowel movements varies with chronological age: for instance, 5–40 motions per week are regarded as the normal range for a 3-month-old, and 4–20 and 3–14 motions per week for 12-month- and 3-year-olds, respectively.[[4,5]] According to Yacob et al, constipation onset can occur at three different stages.[[3]] It can occur from (1) the transition from breast-feeding or formula milk to solids, (2) toilet training or (3) the commencement of day care, kindergarten or school. Functional constipation is distinguished by painful bowel movements, irregular defecation, extreme stool retention and large stool calibre.[[3]] It may also include faecal incontinence that is caused by the overflow of soft stools around a hard and large faecal deposit accumulated in the rectum.[[6]]

The aetiology of functional constipation remains unclear, although nutritional, behavioural and psychosocial abnormalities and genetic factors may be contributing factors.[[7]] More than 33% of children develop chronic symptoms where pain is an important aspect in prompting fear and the withholding of defecation. It has been reported that 50% of children with functional constipation have persistent symptoms after 6–12 months of conventional treatment and 25% have symptoms that continue into adulthood.[[8]] Despite these realities, the majority of children with functional constipation do not receive timely treatment.[[9]] Predicting which children will benefit from treatment is difficult due to inconsistent prognostic factors.[[8]]

Care planning

Care planning focuses on patient-centred care that considers the needs, concerns, beliefs and goals of the person rather than the needs of the systems or professionals.[[10]] It is underpinned by shared decision-making and communication to support behaviour change and improve health knowledge. Typically, a care plan includes assessment, diagnosis, prioritised interventions, medical management, key actions and tasks, role responsibility, crisis or contingency planning and times and methods for review and follow-up. There are various paediatric constipation care plans, some of which are complex and others simplistic (Figures 1 and 2).

Figure 1: A New Zealand example of a paediatric constipation care plan.

Figure 2: An international example of a paediatric constipation care plan for infants 6 months of age or older.[[6]]

ACE = antegrade continence enema; MRI= magnetic resonance imaging; SNS = sacral nerve stimulation; TENS = transcutaneous electric nerve stimulation; TSH = thyroid-stimulating hormone.

The benefit of a care plan is to enable and improve communication between the patient and healthcare team in real time. There are various generic hard copy and electronic care plans that are available on the Health Navigator New Zealand website.[[11]] Increasingly, web-based and electronic tools are being used to document care plans and are usually part of an extensive patient system that may include a patient portal.[[11]] The majority of New Zealand district health boards (DHBs) will have a child constipation care plan that will be based on high-quality information and known national and international best practice guidelines. The contributors to these plans work in the clinical setting and have expertise and specialisation in paediatric medicine. Thus DHBs’ care plans may differ slightly depending on the local expertise.

Practitioners can access their local DHB care plan through Community HealthPathways website. The care plan should include the definition of chronic constipation, the age range that the plan is for and criteria to thoroughly assess the patient’s history (ie, onset of constipation, frequency and type of stools, soiling, bleeding, pain with stool, diet, exercise, abdominal pain). The clinical assessment should include height, weight, nutritional status, abdomen, spine and lower limbs (muscle tone, reflexes, gait) and perianal conditions (fissures, fistula, lipoma). An abdomen x-ray is not required. Blood mixed within a stool and vomiting in the setting of faecal impaction requires urgent referral.[[12]] The care plan should include guidelines for disimpaction (prescription), management (medication, diet, behavioural, exercise, toileting) and ongoing management, whether or not the child responds over the defined duration.[[12]] A constipation care plan may also include red flags (eg, when the child is unwell and has any of the following: greater than 48 hours delayed passage of meconium or symptoms within two weeks of birth, passage of toothpaste or ribbon stools, abdominal distension and vomiting, abnormalities of anus, spine or gluteal region, unexplained weakness or deformity of lower extremities, neurological findings and weight loss or faltering growth).[[13]]

Recent international research identified that a paediatric constipation action plan (AP) requires key evidence-based concepts, including imagery, comprehension, quality, readability and suitability using jargon free language.[[14]] The researchers investigated the use a pictogram-based constipation AP to assist clinicians, caregivers and children in the management of functional constipation (Figure 3).[[14]] The AP was designed to optimise knowledge transfer between the health service and caregiver at the time of discharge and empower home management of constipation. The AP adopted a health-informed approach to provide information on evidence-based medication and behavioural interventions, and to reduce disparities in constipation outcomes related to low health literacy.

The AP included four sections:

  1. Cleanout: green (feeling good).
  2. Maintenance: yellow (feeling bad).
  3. Acute: red (feeling worse).
  4. Severely acute.

Each section included the type, amount and frequency of medication, with key behaviours highlighted in the green, yellow and red sections. According to the authors, the twelve images in the pictogram were easily interpreted and facilitated comprehension for patient and caregiver. Using lay language with the images maximised the caregivers’ comprehension, which further empowered caregivers to improve their child’s compliance and clinical outcomes.[[14]]

Figure 3: An international example of an action plan for paediatric functional constipation.

In New Zealand, the Auckland Region Community HealthPathways has compiled a constipation AP[[15]] with the aim for children to pass at least three soft, painless bowel motions per week (type 4 stool). The AP includes a YouTube video link on constipation and conveys to the caregiver key bullet points about providing three servings per week of foods containing seeds (kiwifruit) or segments (mandarins), increasing fibre and water intake, encouraging regular exercise and practising regular and good toilet technique. It also provides a disimpaction plan (similar to the Waitematā DHB schedule[[16]]), regular maintenance medication prescription and a stool dairy for monitoring bowel movements, to assist the caregiver and child with the progress and the medical staff in determining the correct treatment. Finally, a reward star chart is included to motivate and encourage positive behaviour from the child.

Diagnosis

Rome IV17provides a method for diagnosing functional constipation, according to which two or more criteria must occur one or more times per week for a minimum of one month (Table 1). It is important that a thorough and correct assessment is undertaken. This should include a physical examination to assess the abdomen for faecal masses, anal patency, anal fissures and patulous anus, as well as neurological testing for reflexes, lower-limb tone, spine and gait.[[5]] Further examination should identify or discard other underlying pathophysiology, such as perianal disease, Hirschsprungs disease, inflammatory bowel disease, urinary symptoms and systemic symptoms (reduced body mass, decline in growth, lethargy).[[5]] Laboratory testing should only be performed to exclude an underlying condition such as hypothyroidism or hypercalcaemia. Coeliac disease, associated with iron deficiency anaemia, abdominal pain and poor growth, should be considered for assessment if constipation arises early with the introduction of gluten.[[6]]

Table 1: Rome IV constipation criteria.

Due to its poor reliability, abdominal radiography is not recommended for diagnosis.[[1]] However, there are exceptions: for example, when a child’s history is unclear, when confirming faecal impaction or when planning treatment for disimpaction.[[3]] In cases with a history of chronic constipation, anorectal manometry can assess anal sphincter function, pelvic floor function and anorectal reflexes. When the constipation is severe and unresponsive to conventional treatment, colonic manometry is used to assess colon motility.[[3]] Magnetic resonance imaging is not advised in the absence of neurological abnormalities.[[6]] Other diagnostic techniques include colonic transit time, scintigraphy, rectal barostat and wireless motility capsule.[[1]]

Management

The treatment plan should include a holistic team approach involving the paediatric clinician, paediatric continence nurse, parents, whānau, dietician, clinical psychologist, physiotherapist and, when required, Māori and Pacific health specialist staff. The common approach to treating functional constipation is education, behavioural modification and laxatives.[[3]] In New Zealand, when paediatric constipation is more severe and treatment is unresponsive, there may be an underlying condition. The general practitioner will refer the child to a continence service or paediatric department of the local DHB. Under a paediatric continence nurse-led intervention, the nurse works in close co-operation with the consultant paediatrician to determine a treatment plan. The paediatric continence nurse also works closely with the caregiver by providing regular telephone follow-ups. This close communication allows for ongoing medical management, reduces emotional stress and provides reassurance to the caregiver of the long-term plan for their child. The approach of a nurse-led intervention is considered internationally an effective use of services and cost-efficient in providing greater care for paediatric constipation.[[18]]

Depending on the severity and longevity of the constipation, some caregivers become frustrated with the lack of therapeutic diagnostic testing, which can unpropitiously affect the treatment due to misunderstanding and noncompliance. It is imperative that the medical team provide clear and succinct written and verbal communication about the diagnosis to the caregiver. The medical team should focus on all treatment being individualised and long-term. Therefore, it is important that caregivers follow the instructions given to them by the medical team and enact the treatment plan. Central to the plan is the caregiver’s ability to be educated. This requires time and effort to bring a positive change. In addition, caregivers are encouraged to provide healthy, well-balanced meals with adequate fibre to soften the stool consistency. Increasing fibre also requires increasing the child’s water intake. The action plan (Figure 3) is a key document in assisting with monitoring, treatment and ongoing care of the child.

Diary

It is imperative caregivers complete a daily diary on the amount of medication, frequency and type of stool (using Bristol Stool Form Scale), associated behaviours, fluid intake and food intake. The recording of data can be tedious and a burden for the caregiver, but it is an invaluable source of information for the medical team to determine the defecation pattern, quantify therapeutic progress and enhance treatment adherence. Various mobile applications (apps) currently exist (Stool Log—Bowel Movement Journal, GutTracker, Poop Tracker, PoopLog) that allow the user to track and analyse bowel movements. PoopMD+, a mobile app that uses a smartphone’s camera and colour-recognition software to analyse an infant’s stool, can accurately identify images of pale-coloured stools.[[19]] However, a comprehensive, cloud-based diary app that includes the aspects described above should be developed. This would expedite data entry, increase compliance and allow proactive monitoring, diagnosis and treatment, which would benefit both the caregiver, child and medical team.

Toilet training

It is often difficult to undertake toilet training when a child has functional constipation. Out of despair of trying, some caregivers abandon toilet training, which they later regret because their child may not become toilet trained before starting school. This can cause distress for both caregiver and child. For children not toilet trained, it may be appropriate to continue with nappies. Toilet training should be encouraged when laxatives have softened the stool and the child has regained confidence . Caregivers need to create a non-threatening and pleasant environment. This requires patience, consistency, regularity and encouragement. A child may have increased anxiety when using toilets outside their home, which further increases the likelihood of withholding. A study revealed that school toilets were an unpleasant, terrifying place where bullying occurred, which is likely to exacerbate withholding.[[20]] Using the toilet requires comfort, safety and appropriate ambience. Day-care centres, kindergartens and schools may need to address the state and environment of their toilets.

The rectum ampulla stores the stool and expands the rectal walls, which stimulates the stretch receptors. This sends a message to the brain indicating that it’s toilet time. The problem occurs if the child decides to withhold; as the stool sits in the rectum, water continues to be absorbed by the colon and the stools become very hard, and as more food is digested, additional stools fill the rectum and it backfills into the colon. When the child eventually visits the toilet, the stool is very hard and large, which makes it difficult to pass. Therefore, it is beneficial to establish a toilet-training routine. Regularity is important for toilet training. Children should be encouraged to sit on the toilet at frequent periods: for example, it is preferable to schedule using the toilet 20 minutes after a meal,[[21]] and following breakfast and dinner is considered the best time.[[13]] Encouraging and praising the child are important aspects for successful toilet training. Incentives, such as star charts, new underwear or special ‘treats’, may help to reinforce positive behaviour.[[13,21]] It is important that the child performs correct toilet posture. This means knees higher than hips (use a footstool), elbows on knees, leaning forward, pushing the abdomen out and straightening the spine.[[13,21]]

Medication

Many caregivers have concerns about the frequency and amount of prescribed medication. Laxatives are essential for the treatment of constipation as they re-establish regular, painless bowel movements,[[5]] so that the enlarged rectum can return to a normal size. The aim of the medication is to soften the stool. Common laxatives include lactulose, docusate tablets, magnesium hydroxide or macrogol. Magnesium hydroxide (8%) is a mixture that pharmacists need to prepare before being dispensed, and it is not recommended for long-term use unless under medical supervision.[[22]] Macrogol-3350 (Molaxole®, Movicol®, Movicol®-Half, Lax-Sachets®) is a powder that gets mixed with liquid. Each sachet of macrogol contains 13.125 g and electrolytes. Stimulant laxatives, such as bisacodyl, glycerol, poloxamer 188 and sodium picosulfate, are effective in generating propagated colonic contractions. At certain times, these strong and sustained colonic contractions can be interpreted as abdominal cramping. Some children have a negative response to this cramping sensation. They may complain, withhold and misuse the opportunity to have a bowel movement. It is important that caregivers are aware of the cramping, and if the cramping is severe, the dose may need adjusting.[[3]]

For disimpaction, a high dosage and large volume of liquid consumption is required until the bowel is emptied. Initially, macrogol is prescribed for disimpaction. If there is no response to macrogol, sodium picosulphate can be considered.[[13]] An alternative method to delivering the powerful laxative solution is a nasogastric tube, which requires hospitalisation for approximately seven days. The procedure of the nasogastric tube can be a terrifying experience for both child and caregiver. Recently, a 3-year-old diagnosed with faecel impaction rejected the nasogastric tube by vomiting its displacement, causing severe distress and anxiety to both child and caregiver. Oral treatment of macrogol is advised when possible. However, this relies on the child consuming the prescribed liquid, which is sometimes difficult to achieve. International research for disimpaction recommends a dosage 1–1.5 g/kg/day for 3–6 days.[[23]] In New Zealand, Waitematā DHB recommends different dosages for children aged 2–5 years and 6–11 years (Table 2).[[16]] This is based from the Movicol Junior® disimpactment dosage approved by Medsafe.[[24]] Maintenance therapy for macrogol ranges from 0.75 g/kg/day[[25]] to 1 g/kg/day.

Table 2: Recommended dosage for child faecal disimpaction.[[16]]

If faecal impaction is untreated, the overall treatment for constipation will be ineffective. The prescription of laxatives will require ongoing adjustment (higher or lower) depending on the child’s response to the medication. The duration of laxatives often ranges from months to years rather than weeks.[[22]]

Most laxatives have a disclaimer that prolonged use is not usually recommended and may lead to dependence. This heightens a caregiver’s apprehension about their child’s long-term medication use. Although the chronic effects have not been extensively investigated, the bowel does not become ‘dependent’ on the medication.[[26]] The benefits of pharmacologic treatment outweigh its potential adverse effects, and the concern of developing dependence is unfounded.[[3]] Medicating for a soft stool will allow the bowel to return to its normal size, shape and function. This requires medication to be administered regularly for a prolonged time and caregivers should therefore remain attentive to the treatment plan.

Other treatments

Functional constipation may require multidisciplinary treatment, but currently there is a lack of evidence to support this.[[6]] Novel therapies, such as sacral nerve stimulation, have yielded positive results and may be considered in the overall treatment plan. Research reported that six months of transcutaneous electrical stimulation treatment significantly improved defecation frequency, soiling, abdominal pain, urge to defecate and quality of life in 50% of children with chronic constipation.[[27]] Greater research is required to confirm its use. Other therapies of pre- and pro-biotics are considered ineffective in treating paediatric constipation.[[6]] A normal fibre intake is recommended and can be achieved with at least three servings each of fruit and vegetables, selecting wholemeal bread and cereals high in fibre, adding bran to baking and including legumes. There is no evidence to date to support the use of fibre supplements to treat functional constipation, and allergy testing is not recommended for diagnosing suspected cow’s-milk allergy in children with constipation.[[6]]

It is unclear whether physical activity assists with constipation. Physical activity was associated with a reduced risk of functional constipation in pre-school-aged children. [[28]] But, in contrast, a higher level of physical activity was observed in preadolescent children diagnosed with functional constipation.[[29]] Expert opinion recommends a normal level of physical activity for children with constipation.[[6]] In New Zealand, it is recommended that toddlers and pre-schoolers disperse at least three hours of physical activity across each day,[[30]] and that 5–17-year-olds accumulate at least one hour a day of moderate to vigorous physical activity, plus strengthening activities at least three days a week.[[31]]

The use of physiotherapy treatment remains equivocal. Six weeks of physiotherapy treatment involving muscle training of the abdominals, breathing exercises and abdominal massage improved the frequency of bowel movements compared to the medication group.[[32]] Similarly, an eight-week programme focused on pelvic floor muscles reported a significant increase in stool frequency and stool diameter, but no changes were observed in stool withholding, faecal impaction and defecating pain.[[33]] A recent study, however, reported that after eight-months of combining physiotherapy treatment activating abdominal and pelvic floor muscles with conventional treatment (toilet training, nutritional advice, laxatives) was not effective compared to conventional treatment alone.[[34]]

Surgical intervention

Despite aggressive therapy of high-dose laxatives and behavioural modification, some children with chronic, intractable constipation do not progress. Intractable constipation is defined as not responding to optimal conventional treatment for at least three months.[[6]] It can become so severe that it adversely affects the child’s self-esteem and ability to socialise, which impacts the quality of life of the child and family.[[35]] Surgical intervention is considered a treatment of last resort, but it may be advised in difficult intractable cases. The type of surgery will be determined by a comprehensive evaluation of the colonic and anorectal anatomy and physiology, and anorectal and colonic manometry are often used to guide surgical decision-making.[[36]] Surgical strategies vary across New Zealand. They are limited to a number of regions and are not available to the primary care physician. A survey of physicians specialising in paediatric surgery and paediatric gastroenterology reported considerable variation in the diagnosis and treatment of children with intractable constipation. The authors of the survey suggested there is a great need for evidence-based guidelines for children who respond inadequately to pharmacological management.[[36]]

In summary, constipation is a chronic condition and its treatment requires medication to keep the stool soft and behavioural interventions. A thorough history, including questions about the frequency of bowel movements and stool type, is required. If no red flags are found after examining the abdomen, spine, lower limbs and perianal area, the practitioner should have confidence to aggressively manage the constipation[[37]] through a constipation action plan.[[15,37]]

Summary

Abstract

Constipation is common in young children and results in approximately 350 hospitalisations per 100,000 population for 0–4-year-olds. Constipation can become chronic in more than one-third of those affected. The purpose of this article is to provide an awareness and highlight the care planning, diagnosis and management in paediatric functional constipation. It is intended for general practitioners and those in primary healthcare who may be unfamiliar with functional constipation. Paediatric functional constipation affects the child’s physical, psychological and social wellbeing while causing significant stress to the caregiver/whānau. Despite its prevalence, functional constipation is often misdiagnosed and inadequately treated. Functional constipation requires a comprehensive therapeutic plan, including education, behavioural intervention and medication. Pharmacological treatment often causes concern and misapprehension for developing ‘dependence’, which is unfounded. Children with chronic constipation who do not progress, despite aggressive medical therapy and behavioural modification, may benefit from further assessment with colonic transit or anorectal and colonic manometry. In the future, novel medical, exercise and surgical strategies will have a role in advancing improved outcomes in children who are unresponsive to conventional medical and behavioural interventions. However, this will require more evidence-based guidelines. Unresponsive constipation cases should be included in the care planning of district health boards, which may assist in a multidisciplinary approach to assisting the physical and psychosocial aspects of constipation.

Aim

Method

Results

Conclusion

Author Information

Darryl J Cochrane: Associate Professor, School of Sport, Exercise & Nutrition, Massey University, New Zealand.

Acknowledgements

Correspondence

Darryl Cochrane, School of Sport, Exercise & Nutrition, Massey University, Private Bag 11 222, Palmerston North, New Zealand, +64 6 951 7532

Correspondence Email

D.Cochrane@massey.ac.nz

Competing Interests

Nil.

1 Tambucci R, Quitadamo P, Thapar N, et al. Diagnostic tests in pediatric constipation. J Pediatr Gastroenterol Nutr. 2018; 66:89-98.

2 Trajanovska M, Liew A, Gibb S, Goldfeld S, King SK. Retrospective audit of referral and triage pathways of paediatric patients with constipation and soiling. J Paediatr Child Health. 2020; 56:298-303.

3 Yacob D, Di Lorenzo C. Constipation in children: A guide to prompt diagnosis and effective treatment. Curr Treat Options Peds. 2020; 6:101-15.

4 Nurko S, Zimmerman LA. Evaluation and Treatment of Constipation in Children and Adolescents. Am Fam Physician. 2014; 90:82-90.

5 Singh H, Connor F. Paediatric constipation: An approach and evidence-based treatment regimen. Aust J Gen Pract. 2018; 47:273-7.

6 Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014; 58:258-74.

7 Peeters B, Benninga MA, Hennekam RC. Childhood constipation; an overview of genetic studies and associated syndromes. Best Pract Res Cl Ga. 2011; 25:73-88.

8 Pijpers MA, Bongers ME, Benninga MA, Berger MY. Functional constipation in children: a systematic review on prognosis and predictive factors. J Pediatr Gastroenterol Nutr. 2010; 50:256-68.

9 Lindgren H, Nejstgaard MC, Salö M, Stenström P. Evaluation of bowel function in healthy children: untreated constipation is common. Acta Paediatr. 2018; 107:875-85.

10 Michie S, Miles J, Weinman J. Patient-centredness in chronic illness: what is it and does it matter? Patient Educ Couns. 2003; 51:197-206.

11 Health Navigator New Zealand [Internet]. Care planning. Edition. [cited 4 February 2021]. Available from: https://www.healthnavigator.org.nz/clinicians/c/care-planning/

12 MidCentral District Health Board [Internet]. Constipation in children. Edition. [cited 6 May 2020]. Available from: https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Latest%20Updates/HP_Constipation%20in%20children.pdf

13 Auckland Region Community Health Pathways [Internet]. Constipation in children. Edition. [cited 4 February 2021]. Available from: https://aucklandregion.communityhealthpathways.org/14683.htm

14 Reeves PT, Kolasinski NT, Yin HS, et al. Development and assessment of a pictographic pediatric constipation action plan. J Paediatr Child Health. 2021; 229:118-26.

15 Dillon C. Child constipation action plan. Auckland Regional Health Pathways, 2020.

16 Waitematā District Health Board [Internet]. Macrogol 3350 - For constipation and disimpaction in children. Edition. Waitemata District Health Board. [cited 18 May 2020]. Available from: https://www.healthnavigator.org.nz/medicines/m/macrogol/

17 Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology. 2016; 150:1456-68.

18 Tappin D, Nawaz S, McKay C, MacLaren L, Griffiths P, Mohammed TA. Development of an early nurse led intervention to treat children referred to secondary paediatric care with constipation with or without soiling. BMC Pediatr. 2013; 13:1-9.

19 Franciscovich A, Vaidya D, Doyle J, et al. PoopMD, a mobile health application, accurately identifies infant acholic stools. Plos One. 2015; 10:1-9.

20 Vernon S, Lundblad B, Hellstrom AL. Children's experiences of school toilets present a risk to their physical and psychological health. Child Care Hlth Dev. 2003; 29:47-53.

21 MidCentral District Health Board. A guide for parents/whānau and caregivers toilet training your preschool child. MidCentral District Health Board, 2018.

22 KidsHealth. Laxatives. Edition. [cited 22 May 2020]. Available from: https://kidshealth.org.nz/laxatives

23 Youssef NN, Peters JM, Henderson W, Shultz-Peters S, Lockhart DK, Di Lorenzo C. Dose response of PEG 3350 for the treatment of childhood fecal impaction. J Pediatr. 2002; 141:410-4.

24 Medsafe [Internet]. New Zealand Datasheet for MOVICOL® Junior. Edition. MedSafe [cited 18 May 2020]. Available from: https://www.medsafe.govt.nz/Profs/Datasheet/m/MovicolHalfpwdr.pdf

25 Pashankar DS, Bishop WP. Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children. J Pediatr. 2001; 139:428-32.

26 Nurko S, Zimmerman LA. Evaluation and treatment of constipation in children and adolescents. Am Fam Physician. 2014; 90:82-90.

27 Yik YI, Hutson J, Southwell B. Home-based transabdominal interferential electrical stimulation for six months improves paediatric slow transit constipation (STC). Neuromodulation. 2018; 21:676-81.

28 Driessen LM, Kiefte-de Jong JC, Wijtzes A, et al. Preschool physical activity and functional constipation: the Generation R study. J Pediatr Gastroenterol Nutr. 2013; 57:768-74.

29 Jennings A, Davies GJ, Costarelli V, Dettmar PW. Dietary fibre, fluids and physical activity in relation to constipation symptoms in pre-adolescent children. J Child Health Care. 2009; 13:116-27.

30 Ministry of Health. Sit Less, Move More, Sleep Well: Active Play Guidelines for Under-Five. Wellington: Ministry of Health, 2017.

31 Ministry of Health. Sit Less, Move More, Sleep Well: Physical Activity Guidelines for Children and Young People. Wellington: Ministry of Health, 2017.

32 Silva CAG, Motta M. The use of abdominal muscle training, breathing exercises and abdominal massage to treat paediatric chronic functional constipation. Colorectal Dis. 2013; 15:250-5.

33 Farahmand F, Abedi A, Esmaeili-Dooki MR, Jalilian R, Tabari SM. Pelvic floor muscle exercise for paediatric functional constipation. J Clin Diagn Res. 2015; 9:16-7.

34 van Summeren J, Holtman GA, Kollen BJ, et al. Physiotherapy for children with functional constipation: A pragmatic randomized controlled trial in primary care. J Pediatr. 2020; 216:25-31.e2.

35 Kaugars AS, Silverman A, Kinservik M, et al. Families' perspectives on the effect of constipation and fecal incontinence on quality of life. J Pediatr Gastroenterol Nutr. 2010; 51:747-52.

36 Koppen IJ, Kuizenga-Wessel S, Lu PL, et al. Surgical decision-making in the management of children with intractable functional constipation: What are we doing and are we doing it right? J Pediatr Surg. 2016; 51:1607-12.

37 Hayman R [Internet]. Constipation in children. https://www.goodfellowunit.org/podcast/constipation-children: Goodfellow Unit, 2020.

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Paediatric functional constipation is a growing medical condition in New Zealand and worldwide, with a reported average prevalence of ~12%[[1]] (range 0.5% to 32.2%).[[2]] It accounts for 10% and 25% of admissions in general paediatric and paediatric gastroenterology clinics.[[3]] In the state of Victoria, Australia, paediatric constipation costs $5.5 million annually,[[2]] while in the United States the estimation is $3.9 billion,[[3]] which creates additional financial pressure on burgeoning healthcare systems.

The number of bowel movements varies with chronological age: for instance, 5–40 motions per week are regarded as the normal range for a 3-month-old, and 4–20 and 3–14 motions per week for 12-month- and 3-year-olds, respectively.[[4,5]] According to Yacob et al, constipation onset can occur at three different stages.[[3]] It can occur from (1) the transition from breast-feeding or formula milk to solids, (2) toilet training or (3) the commencement of day care, kindergarten or school. Functional constipation is distinguished by painful bowel movements, irregular defecation, extreme stool retention and large stool calibre.[[3]] It may also include faecal incontinence that is caused by the overflow of soft stools around a hard and large faecal deposit accumulated in the rectum.[[6]]

The aetiology of functional constipation remains unclear, although nutritional, behavioural and psychosocial abnormalities and genetic factors may be contributing factors.[[7]] More than 33% of children develop chronic symptoms where pain is an important aspect in prompting fear and the withholding of defecation. It has been reported that 50% of children with functional constipation have persistent symptoms after 6–12 months of conventional treatment and 25% have symptoms that continue into adulthood.[[8]] Despite these realities, the majority of children with functional constipation do not receive timely treatment.[[9]] Predicting which children will benefit from treatment is difficult due to inconsistent prognostic factors.[[8]]

Care planning

Care planning focuses on patient-centred care that considers the needs, concerns, beliefs and goals of the person rather than the needs of the systems or professionals.[[10]] It is underpinned by shared decision-making and communication to support behaviour change and improve health knowledge. Typically, a care plan includes assessment, diagnosis, prioritised interventions, medical management, key actions and tasks, role responsibility, crisis or contingency planning and times and methods for review and follow-up. There are various paediatric constipation care plans, some of which are complex and others simplistic (Figures 1 and 2).

Figure 1: A New Zealand example of a paediatric constipation care plan.

Figure 2: An international example of a paediatric constipation care plan for infants 6 months of age or older.[[6]]

ACE = antegrade continence enema; MRI= magnetic resonance imaging; SNS = sacral nerve stimulation; TENS = transcutaneous electric nerve stimulation; TSH = thyroid-stimulating hormone.

The benefit of a care plan is to enable and improve communication between the patient and healthcare team in real time. There are various generic hard copy and electronic care plans that are available on the Health Navigator New Zealand website.[[11]] Increasingly, web-based and electronic tools are being used to document care plans and are usually part of an extensive patient system that may include a patient portal.[[11]] The majority of New Zealand district health boards (DHBs) will have a child constipation care plan that will be based on high-quality information and known national and international best practice guidelines. The contributors to these plans work in the clinical setting and have expertise and specialisation in paediatric medicine. Thus DHBs’ care plans may differ slightly depending on the local expertise.

Practitioners can access their local DHB care plan through Community HealthPathways website. The care plan should include the definition of chronic constipation, the age range that the plan is for and criteria to thoroughly assess the patient’s history (ie, onset of constipation, frequency and type of stools, soiling, bleeding, pain with stool, diet, exercise, abdominal pain). The clinical assessment should include height, weight, nutritional status, abdomen, spine and lower limbs (muscle tone, reflexes, gait) and perianal conditions (fissures, fistula, lipoma). An abdomen x-ray is not required. Blood mixed within a stool and vomiting in the setting of faecal impaction requires urgent referral.[[12]] The care plan should include guidelines for disimpaction (prescription), management (medication, diet, behavioural, exercise, toileting) and ongoing management, whether or not the child responds over the defined duration.[[12]] A constipation care plan may also include red flags (eg, when the child is unwell and has any of the following: greater than 48 hours delayed passage of meconium or symptoms within two weeks of birth, passage of toothpaste or ribbon stools, abdominal distension and vomiting, abnormalities of anus, spine or gluteal region, unexplained weakness or deformity of lower extremities, neurological findings and weight loss or faltering growth).[[13]]

Recent international research identified that a paediatric constipation action plan (AP) requires key evidence-based concepts, including imagery, comprehension, quality, readability and suitability using jargon free language.[[14]] The researchers investigated the use a pictogram-based constipation AP to assist clinicians, caregivers and children in the management of functional constipation (Figure 3).[[14]] The AP was designed to optimise knowledge transfer between the health service and caregiver at the time of discharge and empower home management of constipation. The AP adopted a health-informed approach to provide information on evidence-based medication and behavioural interventions, and to reduce disparities in constipation outcomes related to low health literacy.

The AP included four sections:

  1. Cleanout: green (feeling good).
  2. Maintenance: yellow (feeling bad).
  3. Acute: red (feeling worse).
  4. Severely acute.

Each section included the type, amount and frequency of medication, with key behaviours highlighted in the green, yellow and red sections. According to the authors, the twelve images in the pictogram were easily interpreted and facilitated comprehension for patient and caregiver. Using lay language with the images maximised the caregivers’ comprehension, which further empowered caregivers to improve their child’s compliance and clinical outcomes.[[14]]

Figure 3: An international example of an action plan for paediatric functional constipation.

In New Zealand, the Auckland Region Community HealthPathways has compiled a constipation AP[[15]] with the aim for children to pass at least three soft, painless bowel motions per week (type 4 stool). The AP includes a YouTube video link on constipation and conveys to the caregiver key bullet points about providing three servings per week of foods containing seeds (kiwifruit) or segments (mandarins), increasing fibre and water intake, encouraging regular exercise and practising regular and good toilet technique. It also provides a disimpaction plan (similar to the Waitematā DHB schedule[[16]]), regular maintenance medication prescription and a stool dairy for monitoring bowel movements, to assist the caregiver and child with the progress and the medical staff in determining the correct treatment. Finally, a reward star chart is included to motivate and encourage positive behaviour from the child.

Diagnosis

Rome IV17provides a method for diagnosing functional constipation, according to which two or more criteria must occur one or more times per week for a minimum of one month (Table 1). It is important that a thorough and correct assessment is undertaken. This should include a physical examination to assess the abdomen for faecal masses, anal patency, anal fissures and patulous anus, as well as neurological testing for reflexes, lower-limb tone, spine and gait.[[5]] Further examination should identify or discard other underlying pathophysiology, such as perianal disease, Hirschsprungs disease, inflammatory bowel disease, urinary symptoms and systemic symptoms (reduced body mass, decline in growth, lethargy).[[5]] Laboratory testing should only be performed to exclude an underlying condition such as hypothyroidism or hypercalcaemia. Coeliac disease, associated with iron deficiency anaemia, abdominal pain and poor growth, should be considered for assessment if constipation arises early with the introduction of gluten.[[6]]

Table 1: Rome IV constipation criteria.

Due to its poor reliability, abdominal radiography is not recommended for diagnosis.[[1]] However, there are exceptions: for example, when a child’s history is unclear, when confirming faecal impaction or when planning treatment for disimpaction.[[3]] In cases with a history of chronic constipation, anorectal manometry can assess anal sphincter function, pelvic floor function and anorectal reflexes. When the constipation is severe and unresponsive to conventional treatment, colonic manometry is used to assess colon motility.[[3]] Magnetic resonance imaging is not advised in the absence of neurological abnormalities.[[6]] Other diagnostic techniques include colonic transit time, scintigraphy, rectal barostat and wireless motility capsule.[[1]]

Management

The treatment plan should include a holistic team approach involving the paediatric clinician, paediatric continence nurse, parents, whānau, dietician, clinical psychologist, physiotherapist and, when required, Māori and Pacific health specialist staff. The common approach to treating functional constipation is education, behavioural modification and laxatives.[[3]] In New Zealand, when paediatric constipation is more severe and treatment is unresponsive, there may be an underlying condition. The general practitioner will refer the child to a continence service or paediatric department of the local DHB. Under a paediatric continence nurse-led intervention, the nurse works in close co-operation with the consultant paediatrician to determine a treatment plan. The paediatric continence nurse also works closely with the caregiver by providing regular telephone follow-ups. This close communication allows for ongoing medical management, reduces emotional stress and provides reassurance to the caregiver of the long-term plan for their child. The approach of a nurse-led intervention is considered internationally an effective use of services and cost-efficient in providing greater care for paediatric constipation.[[18]]

Depending on the severity and longevity of the constipation, some caregivers become frustrated with the lack of therapeutic diagnostic testing, which can unpropitiously affect the treatment due to misunderstanding and noncompliance. It is imperative that the medical team provide clear and succinct written and verbal communication about the diagnosis to the caregiver. The medical team should focus on all treatment being individualised and long-term. Therefore, it is important that caregivers follow the instructions given to them by the medical team and enact the treatment plan. Central to the plan is the caregiver’s ability to be educated. This requires time and effort to bring a positive change. In addition, caregivers are encouraged to provide healthy, well-balanced meals with adequate fibre to soften the stool consistency. Increasing fibre also requires increasing the child’s water intake. The action plan (Figure 3) is a key document in assisting with monitoring, treatment and ongoing care of the child.

Diary

It is imperative caregivers complete a daily diary on the amount of medication, frequency and type of stool (using Bristol Stool Form Scale), associated behaviours, fluid intake and food intake. The recording of data can be tedious and a burden for the caregiver, but it is an invaluable source of information for the medical team to determine the defecation pattern, quantify therapeutic progress and enhance treatment adherence. Various mobile applications (apps) currently exist (Stool Log—Bowel Movement Journal, GutTracker, Poop Tracker, PoopLog) that allow the user to track and analyse bowel movements. PoopMD+, a mobile app that uses a smartphone’s camera and colour-recognition software to analyse an infant’s stool, can accurately identify images of pale-coloured stools.[[19]] However, a comprehensive, cloud-based diary app that includes the aspects described above should be developed. This would expedite data entry, increase compliance and allow proactive monitoring, diagnosis and treatment, which would benefit both the caregiver, child and medical team.

Toilet training

It is often difficult to undertake toilet training when a child has functional constipation. Out of despair of trying, some caregivers abandon toilet training, which they later regret because their child may not become toilet trained before starting school. This can cause distress for both caregiver and child. For children not toilet trained, it may be appropriate to continue with nappies. Toilet training should be encouraged when laxatives have softened the stool and the child has regained confidence . Caregivers need to create a non-threatening and pleasant environment. This requires patience, consistency, regularity and encouragement. A child may have increased anxiety when using toilets outside their home, which further increases the likelihood of withholding. A study revealed that school toilets were an unpleasant, terrifying place where bullying occurred, which is likely to exacerbate withholding.[[20]] Using the toilet requires comfort, safety and appropriate ambience. Day-care centres, kindergartens and schools may need to address the state and environment of their toilets.

The rectum ampulla stores the stool and expands the rectal walls, which stimulates the stretch receptors. This sends a message to the brain indicating that it’s toilet time. The problem occurs if the child decides to withhold; as the stool sits in the rectum, water continues to be absorbed by the colon and the stools become very hard, and as more food is digested, additional stools fill the rectum and it backfills into the colon. When the child eventually visits the toilet, the stool is very hard and large, which makes it difficult to pass. Therefore, it is beneficial to establish a toilet-training routine. Regularity is important for toilet training. Children should be encouraged to sit on the toilet at frequent periods: for example, it is preferable to schedule using the toilet 20 minutes after a meal,[[21]] and following breakfast and dinner is considered the best time.[[13]] Encouraging and praising the child are important aspects for successful toilet training. Incentives, such as star charts, new underwear or special ‘treats’, may help to reinforce positive behaviour.[[13,21]] It is important that the child performs correct toilet posture. This means knees higher than hips (use a footstool), elbows on knees, leaning forward, pushing the abdomen out and straightening the spine.[[13,21]]

Medication

Many caregivers have concerns about the frequency and amount of prescribed medication. Laxatives are essential for the treatment of constipation as they re-establish regular, painless bowel movements,[[5]] so that the enlarged rectum can return to a normal size. The aim of the medication is to soften the stool. Common laxatives include lactulose, docusate tablets, magnesium hydroxide or macrogol. Magnesium hydroxide (8%) is a mixture that pharmacists need to prepare before being dispensed, and it is not recommended for long-term use unless under medical supervision.[[22]] Macrogol-3350 (Molaxole®, Movicol®, Movicol®-Half, Lax-Sachets®) is a powder that gets mixed with liquid. Each sachet of macrogol contains 13.125 g and electrolytes. Stimulant laxatives, such as bisacodyl, glycerol, poloxamer 188 and sodium picosulfate, are effective in generating propagated colonic contractions. At certain times, these strong and sustained colonic contractions can be interpreted as abdominal cramping. Some children have a negative response to this cramping sensation. They may complain, withhold and misuse the opportunity to have a bowel movement. It is important that caregivers are aware of the cramping, and if the cramping is severe, the dose may need adjusting.[[3]]

For disimpaction, a high dosage and large volume of liquid consumption is required until the bowel is emptied. Initially, macrogol is prescribed for disimpaction. If there is no response to macrogol, sodium picosulphate can be considered.[[13]] An alternative method to delivering the powerful laxative solution is a nasogastric tube, which requires hospitalisation for approximately seven days. The procedure of the nasogastric tube can be a terrifying experience for both child and caregiver. Recently, a 3-year-old diagnosed with faecel impaction rejected the nasogastric tube by vomiting its displacement, causing severe distress and anxiety to both child and caregiver. Oral treatment of macrogol is advised when possible. However, this relies on the child consuming the prescribed liquid, which is sometimes difficult to achieve. International research for disimpaction recommends a dosage 1–1.5 g/kg/day for 3–6 days.[[23]] In New Zealand, Waitematā DHB recommends different dosages for children aged 2–5 years and 6–11 years (Table 2).[[16]] This is based from the Movicol Junior® disimpactment dosage approved by Medsafe.[[24]] Maintenance therapy for macrogol ranges from 0.75 g/kg/day[[25]] to 1 g/kg/day.

Table 2: Recommended dosage for child faecal disimpaction.[[16]]

If faecal impaction is untreated, the overall treatment for constipation will be ineffective. The prescription of laxatives will require ongoing adjustment (higher or lower) depending on the child’s response to the medication. The duration of laxatives often ranges from months to years rather than weeks.[[22]]

Most laxatives have a disclaimer that prolonged use is not usually recommended and may lead to dependence. This heightens a caregiver’s apprehension about their child’s long-term medication use. Although the chronic effects have not been extensively investigated, the bowel does not become ‘dependent’ on the medication.[[26]] The benefits of pharmacologic treatment outweigh its potential adverse effects, and the concern of developing dependence is unfounded.[[3]] Medicating for a soft stool will allow the bowel to return to its normal size, shape and function. This requires medication to be administered regularly for a prolonged time and caregivers should therefore remain attentive to the treatment plan.

Other treatments

Functional constipation may require multidisciplinary treatment, but currently there is a lack of evidence to support this.[[6]] Novel therapies, such as sacral nerve stimulation, have yielded positive results and may be considered in the overall treatment plan. Research reported that six months of transcutaneous electrical stimulation treatment significantly improved defecation frequency, soiling, abdominal pain, urge to defecate and quality of life in 50% of children with chronic constipation.[[27]] Greater research is required to confirm its use. Other therapies of pre- and pro-biotics are considered ineffective in treating paediatric constipation.[[6]] A normal fibre intake is recommended and can be achieved with at least three servings each of fruit and vegetables, selecting wholemeal bread and cereals high in fibre, adding bran to baking and including legumes. There is no evidence to date to support the use of fibre supplements to treat functional constipation, and allergy testing is not recommended for diagnosing suspected cow’s-milk allergy in children with constipation.[[6]]

It is unclear whether physical activity assists with constipation. Physical activity was associated with a reduced risk of functional constipation in pre-school-aged children. [[28]] But, in contrast, a higher level of physical activity was observed in preadolescent children diagnosed with functional constipation.[[29]] Expert opinion recommends a normal level of physical activity for children with constipation.[[6]] In New Zealand, it is recommended that toddlers and pre-schoolers disperse at least three hours of physical activity across each day,[[30]] and that 5–17-year-olds accumulate at least one hour a day of moderate to vigorous physical activity, plus strengthening activities at least three days a week.[[31]]

The use of physiotherapy treatment remains equivocal. Six weeks of physiotherapy treatment involving muscle training of the abdominals, breathing exercises and abdominal massage improved the frequency of bowel movements compared to the medication group.[[32]] Similarly, an eight-week programme focused on pelvic floor muscles reported a significant increase in stool frequency and stool diameter, but no changes were observed in stool withholding, faecal impaction and defecating pain.[[33]] A recent study, however, reported that after eight-months of combining physiotherapy treatment activating abdominal and pelvic floor muscles with conventional treatment (toilet training, nutritional advice, laxatives) was not effective compared to conventional treatment alone.[[34]]

Surgical intervention

Despite aggressive therapy of high-dose laxatives and behavioural modification, some children with chronic, intractable constipation do not progress. Intractable constipation is defined as not responding to optimal conventional treatment for at least three months.[[6]] It can become so severe that it adversely affects the child’s self-esteem and ability to socialise, which impacts the quality of life of the child and family.[[35]] Surgical intervention is considered a treatment of last resort, but it may be advised in difficult intractable cases. The type of surgery will be determined by a comprehensive evaluation of the colonic and anorectal anatomy and physiology, and anorectal and colonic manometry are often used to guide surgical decision-making.[[36]] Surgical strategies vary across New Zealand. They are limited to a number of regions and are not available to the primary care physician. A survey of physicians specialising in paediatric surgery and paediatric gastroenterology reported considerable variation in the diagnosis and treatment of children with intractable constipation. The authors of the survey suggested there is a great need for evidence-based guidelines for children who respond inadequately to pharmacological management.[[36]]

In summary, constipation is a chronic condition and its treatment requires medication to keep the stool soft and behavioural interventions. A thorough history, including questions about the frequency of bowel movements and stool type, is required. If no red flags are found after examining the abdomen, spine, lower limbs and perianal area, the practitioner should have confidence to aggressively manage the constipation[[37]] through a constipation action plan.[[15,37]]

Summary

Abstract

Constipation is common in young children and results in approximately 350 hospitalisations per 100,000 population for 0–4-year-olds. Constipation can become chronic in more than one-third of those affected. The purpose of this article is to provide an awareness and highlight the care planning, diagnosis and management in paediatric functional constipation. It is intended for general practitioners and those in primary healthcare who may be unfamiliar with functional constipation. Paediatric functional constipation affects the child’s physical, psychological and social wellbeing while causing significant stress to the caregiver/whānau. Despite its prevalence, functional constipation is often misdiagnosed and inadequately treated. Functional constipation requires a comprehensive therapeutic plan, including education, behavioural intervention and medication. Pharmacological treatment often causes concern and misapprehension for developing ‘dependence’, which is unfounded. Children with chronic constipation who do not progress, despite aggressive medical therapy and behavioural modification, may benefit from further assessment with colonic transit or anorectal and colonic manometry. In the future, novel medical, exercise and surgical strategies will have a role in advancing improved outcomes in children who are unresponsive to conventional medical and behavioural interventions. However, this will require more evidence-based guidelines. Unresponsive constipation cases should be included in the care planning of district health boards, which may assist in a multidisciplinary approach to assisting the physical and psychosocial aspects of constipation.

Aim

Method

Results

Conclusion

Author Information

Darryl J Cochrane: Associate Professor, School of Sport, Exercise & Nutrition, Massey University, New Zealand.

Acknowledgements

Correspondence

Darryl Cochrane, School of Sport, Exercise & Nutrition, Massey University, Private Bag 11 222, Palmerston North, New Zealand, +64 6 951 7532

Correspondence Email

D.Cochrane@massey.ac.nz

Competing Interests

Nil.

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