Constipation (peds)

Differential Diagnosis

Infant Constipation

• Constipation
• Hirschsprung's disease
• Congenital anorectal malformations
  • Imperforate anus
• Bowel obstruction
• Neurologic disorders
• Encephalopathy
• Spinal cord abnormalities: myelomeningocele, spina bifida, tethered cord
• Meconium ileus
  • Cystic fibrosis
• Metabolic causes
  • Hypothyroidism
  • Hypercalcemia
  • Hypokalemia
  • Diabetes insipidus
• Heavy-metal poisoning
• Medication side effects

Children (older than 1 year) Constipation

• Functional constipation (>95% of cases)
• Organic causes
  • Hirschsprung’s disease
  • Metabolic causes
    • Hypothyroidism
    • Hypercalcemia
    • Hypokalemia
    • Diabetes insipidus
    • Diabetes Mellitus
  • Cystic fibrosis
  • Gluten enteropathy
  • Spinal cord trauma or abnormalities
  • Neurofibromatosis
  • Heavy-metal poisoning
  • Medication side effects
  • Developmental delays
  • Sexual abuse

Pediatric Abdominal Pain

0–3 Months Old

• Emergent
  • Necrotizing Enterocolitis
  • Volvulus
  • Testicular torsion
  • Inguinal hernia
    • Incarcerated hernia
  • Trauma
  • Pyloric stenosis
  • Toxic megacolon
  • Hirschsprung's Disease
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Colic

3 mo–3 y old

• Emergent
  • Intussusception
  • Testicular Torsion
  • Trauma
  • Volvulus
  • Appendicitis
  • Toxic megacolon
  • Vaso-occlusive crisis
• Nonemergent
  • Acute Gastroenteritis
  • Constipation
  • UTI
  • HSP

3 y old–adolescence

• Emergent
  • Appendicitis
  • DKA
  • Vaso-occlusive crisis
  • Toxic ingestion
  • Testicular Torsion
  • Ovarian Torsion
  • Ectopic Pregnancy
  • Trauma
  • Toxic megacolon
  • Inflammatory bowel disease
  • Gastric ulcer disease
  • Ovarian cyst
  • Pregnancy
  • Pancreatitis
  • Cholecystitis
  • Intussusception (to age 6)
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Nonspecific viral syndrome
  • Streptococcus pharyngitis
  • Urinary Tract Infections
  • Pneumonia
  • Renal Stone
  • Henoch-Schonlein purpura
  • Inflammatory bowel disease

Management

Infants

Glycerin suppositories or rectal stimulation with a lubricated rectal thermometer can be used if there is very hard stool in rectum, but may cause irritation and develop tolerance.

• Not yet begun solid foods
  • Sorbitol-containing juices (eg, apple, prune, or pear)
  • For infants four months and older, starting dose: 2-4 ounces of 100-percent fruit juice per day
  • Karo syrup, add 1 tsp to 4 oz cooled, boiled water; give 1 oz of solution to baby just before feeds twice a day until stool softens
• Who have begun solid foods
  • Substitute multigrain or barley cereal for rice cereal

Toddlers and children

• WITHOUT withholding behavior, bleeding, or anal fissure
  • Fiber: age + (5 to 10) grams daily
  • Adequate fluid intake: 32-64 ounces [960-1920 mL] per day
• WITH withholding behavior, pain while defecating, rectal bleeding or anal fissure
  • Polyethylene glycol (PEG) (e.g., Miralax) 0.4 gms/kg/day MAX 6 days

See Also

• Constipation

References

Authors

Ross Donaldson, Kevin Lu, Neil Young, Daniel Ostermayer