Evaluation And Treatment Of Functional Constipation In Infants And Children

Publication Date: November 13, 2013
Last Updated: March 14, 2022

Recommendations

Diagnosis

The Rome III criteria are recommended for the definition of functional constipation for all age groups.
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The diagnosis of functional constipation is based on history and physical examination.
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We recommend using alarm signs and symptoms and diagnostic clues to identify an underlying disease responsible for the constipation.
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If only 1 of the Rome III criteria is present and the diagnosis of functional constipation is uncertain, a digital examination of the anorectum is recommended.
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In the presence of alarm signs or symptoms or in children with intractable constipation, a digital examination of the anorectum is recommended to exclude underlying medical conditions.
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The routine use of an abdominal radiograph has no role to diagnose functional constipation.
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A plain abdominal radiography may be used in a child in whom fecal impaction is suspected but in whom physical examination is unreliable/not possible.
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Colonic transit studies are not recommended to diagnose functional constipation.
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A colonic transit study may be useful to discriminate between functional constipation and functional nonretentive fecal incontinence and in situations in which the diagnosis is not clear.
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Rectal ultrasound is not recommended to diagnose functional constipation.
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Routine allergy testing to diagnose cow’s-milk allergy is not recommended in children with constipation in the absence of alarm symptoms.
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Based on expert opinion, a 2- to 4-week trial of avoidance of CMP may be indicated in the child with intractable constipation.
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Routine laboratory testing to screen for hypothyroidism, celiac disease, and hypercalcemia is not recommended in children with constipation in the absence of alarm symptoms.
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Based on expert opinion, the main indication to perform ARM in the evaluation of intractable constipation is to assess the presence of the RAIR.
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Rectal biopsy is the gold standard for diagnosing HD.
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We do not recommend performing barium enema as an initial diagnostic tool for the evaluation of children with constipation.
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Colonic manometry may be indicated in patients with intractable constipation before considering surgical intervention.
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The routine use of MRI of the spine is not recommended in patients with intractable constipation without other neurologic abnormalities.
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We do not recommend obtaining full-thickness colonic biopsies to diagnose colonic neuromuscular disorders in children with intractable constipation.
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We do not recommend the routine use of colonic scintigraphy studies in children with intractable constipation.
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Treatment

A normal fiber intake is recommended.
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We recommend a normal physical activity in children with constipation.
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The routine use of prebiotics is not recommended in the treatment of childhood constipation.
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The routine use of probiotics is not recommended in the treatment of childhood constipation.
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The routine use of an intensive behavioral protocolized therapy program in addition to conventional treatment is not recommended in childhood constipation.
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Based on expert opinion, we recommend demystification, explanation, and guidance for toilet training (in children with a developmental age of at least 4 years) in the treatment of childhood constipation.
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The use of biofeedback as additional treatment is not recommended in childhood constipation.
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We do not recommend the routine use of multidisciplinary treatment in childhood constipation.
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We do not recommend the use of alternative treatments in childhood constipation.
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PEG with or without electrolytes orally 1 to 1.5 g/kg/day for 3 to 6 days is recommended as the first-line treatment for children presenting with fecal impaction.
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An enema once per day for 3 to 6 days is recommended for children with fecal impaction, if PEG is not available.
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PEG with or without electrolytes is recommended as the first-line maintenance treatment. A starting dose of 0.4 g/kg/day is recommended, and the dose should be adjusted according to the clinical response.
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Addition of enemas to the chronic use of PEG is not recommended.
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Lactulose is recommended as the first-line maintenance treatment, if PEG is not available.
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Based on expert opinion, the use of milk of magnesia, mineral oil, and stimulant laxatives may be considered as an additional or second-line treatment.
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Maintenance treatment should continue for at least 2 months. All symptoms of constipation symptoms should be resolved for at least 1 month before discontinuation of treatment. Treatment should be decreased gradually.
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In the developmental stage of toilet training, medication should only be stopped once toilet training is achieved.
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The routine use of lubiprostone, linaclotide, and prucalopride in children with intractable constipation is not recommended.
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Antegrade enemas are recommended in the treatment of selected children with intractable constipation.
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The routine use of TNS is not recommended in children with intractable constipation.
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ARM, anorectal manometry; CMP, cow’s-milk protein; HD, Hirschsprung disease; PEG, polyethylene glycol; RAIR, rectoanal-inhibitory reflex; TNS, transcutaneous nerve stimulation.

Recommendation Grading

Overview

Title

Evaluation And Treatment Of Functional Constipation In Infants And Children

Authoring Organization

Publication Month/Year

November 13, 2013

Last Updated Month/Year

June 26, 2023

Supplemental Implementation Tools

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Child, Infant

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D003248 - Constipation

Keywords

children, evidence-based medicine, constipation, laxative, guideline, fecal incontinence, encopresis, enema, fecal soiling, functional constipation, infants