Approach
Constipation can vary from mild and short-lived to severe and chronic.[40] It can be accompanied by faecal impaction, faecal and urinary incontinence, urinary tract infection, and occasionally abdominal pain. At all ages, the aim of treatment is to achieve early resolution of pain on defecation to prevent learned avoidance of defecation.
Constipation with no impaction
For these children, softening the stool with laxatives and improving water, food, and fibre intake is usually sufficient.[40] Social, psychological, and behavioural issues that may accompany the condition should also be addressed.
Dietary changes remain a common initial recommendation as low fluid and fibre intake often contribute to the development of constipation.[15] Recommended daily fluid intake is around 4 cups per day for 1 to 3 year olds, 5 cups for 4 to 8 year olds, and 7 to 8 cups for older children.[15] Adding 5 g to the child's age in years can be used to calculate recommended daily fibre intake.[15] Fluid and fibre intake should not be increased above daily recommendations as there is no evidence to suggest that this improves constipation.[15][41] Prune or pear juice may be given to infants to increase stool water content and frequency. For infants younger than 6 months, 1-3 mL of juice per kg diluted with 30-60 mL of water may be an appropriate dose. A trial of removal of milk from the diet may also be warranted. Increase in physical activity may be suggested for older children.
Laxatives and faecal softeners can be used to soften the stools and ensure that bowel movements occur at normal intervals with good evacuation, to prevent progression to chronic constipation and faecal impaction. Osmotic laxatives such as polyethylene glycol (PEG) electrolyte solutions or lactulose,[42]
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or faecal softeners such as docusate or mineral oil/liquid paraffin, have been shown to be effective. There is evidence that PEG is more effective than lactulose in the treatment of chronic constipation in terms of stool frequency per week, form of stool, and relief of abdominal pain.[42][43][44][45] PEG has also been shown to be superior to other osmotic agents with regard to taste and patient acceptance.[46]
The anxiety of both parent and child should be addressed. The child may be fearful of painful defecation, and parents need to understand that forcing toilet training in this situation will be ineffective. In older children, faecal incontinence and its social consequences need a non-accusatory, sympathetic management approach. It may be necessary to repeat the education several times during treatment.
Regular toilet habits and behavioural modification are important aspects of treatment.[15] Unhurried time on the toilet after meals is recommended, with relaxation techniques encouraged. While on the toilet, the child's feet should be supported with their knees just above their hips.[4] A reward system, especially one linked with successful use of the toilet as opposed to clean pants, is important. A diary of stool frequency could be recommended.
Constipation with impaction
The first stage is to ensure complete evacuation of any retained stools in the rectum. Overflow faecal incontinence because of faecal impaction will not be resolved without the evacuation of the retained stool in the rectum. Disimpaction may be accomplished with either oral or rectal medication. The rectal approach is faster than the oral route but more invasive. The major harm from disimpaction depends on the intensity and the route of administration. For example, the use of an nasogastric tube to give the PEG solution, or the rectal route for enemas, may exacerbate the child's fear and intensify the psychological disturbance. Furthermore, repeated use of phosphate enemas may induce water and electrolyte disturbance.[47]
Osmotic laxatives, such as PEG 3350 electrolyte solutions, have been shown to be effective.[48] Other oral medications for initial disimpaction include the osmotic laxatives lactulose, glycerol, and magnesium salts such as magnesium citrate, and the stimulant laxatives senna and bisacodyl. PEG appears to be a safe medication; however, there have been no long-term studies completed in children. There is consistent evidence that PEG is superior to lactulose with regard to rates of clinical remission, improvement in symptoms, and patient tolerance.[43][44][45][46]
In general, treatment approach depends on age. For infants, softening the stool with laxatives and improving fluid, food, and fibre intake is usually sufficient. Older children may require suppositories, incrementally increased doses of PEG, or an enema (e.g., phosphate laxative) to clear the impacted rectum.
Maintenance therapy
Children with no impaction should maintain dietary improvements and behavioural modification (unhurried time on the toilet after meals, a reward system linked with successful toilet usage, and a diary of stool frequency), and use osmotic laxatives to establish normal bowel habits. Generally, osmotic laxative maintenance therapy is recommended for at least 1 month after a good response to treatment.[15]
For children with impaction, maintenance treatment may be protracted and depends on the duration of the problem. There may be considerable difficulty in using sufficient medication to empty the rectum, but not so much as to increase the degree of faecal incontinence. Adherence to medication by the child who links treatment with defecation and so refuses both can be a major problem, as can the parent who dislikes prolonged medication for the child. Generally, it is necessary to maintain medication until the child has achieved regular bowel movements without difficulty. It is essential to prevent re-accumulation of faeces by maintaining sufficient softener (e.g., osmotic laxatives, such as PEG and lactulose) and stimulant laxative (e.g., senna or bisacodyl) to oppose the withholding behaviour that tends to lead to incomplete rectal emptying. PEG appears to be a safe medication; however, there have been no long-term studies completed in children.[46] There is conflicting response to prolonged use of stimulant laxatives as they have been found to be useful when used short-term and in the acute setting, but no information is available for long-term tolerance and safety. Despite this, they are often used long-term in chronic cases when an osmotic laxative is not enough. Dietary improvements and behavioural modifications should be encouraged.
Pelvic physiotherapy and biofeedback, long used and proven in adults, may be a helpful adjunct therapy in children as well.[49]
Procedural intervention
Children with longstanding constipation unresponsive to maximal medical management may be considered for procedural intervention. Procedural options include surgery via the Malone appendicostomy; or surgical, endoscopic, or radiological placement of a caecostomy tube. These procedures allow the administration of antegrade cleansing solutions directly to the colon promoting regular evacuation of stool.[50] The use of antegrade continence enemas can be effective in improving incontinence. Evidence also supports an improvement in quality of life after such interventions.[51] Large-volume rectal irrigations using the Peristeen® device (which involves a balloon inflated in the rectum to generate pressure and hold the enema in the colon) have shown similar results to those achieved using anterograde enemas.[52]
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