By Sue Hubbard, M.D.
Constipation is a topic that every pediatrician discusses at least weekly, sometimes daily. It is estimated that up to 3 percent of all visits to the pediatrician may be due to constipation. Constipation is most common in children between the ages of 2 and 6 years. I have been reading an article on updated recommendations for diagnosing and treating common constipation, and the most important take home message is “most children with constipation do not have an underlying organic disorder. Diagnosis should be based on a good history and physical exam for most cases of functional constipation.”
Like many things in medicine, the evaluation and treatment of constipation has also changed a bit since the last guidelines were published in 2006. It is now appropriate to define constipation with a shorter duration of symptoms (one month versus two), and some of the most common diagnostic criteria (Rome IV Diagnostic Criteria) include the child having less than two stools/week, painful or hard bowel movements, and history of large diameter stools (parents will tell me their 3-year-olds' “poops” clog the toilet). Some may have a history of soiling their underpants.
By taking a good history you can avoid unnecessary tests, including X-rays, which are not routinely recommended when evaluating a child with possible constipation. In most cases, physical findings on the abdominal exam in combination with the history will confirm the diagnosis. I often can feel hard stool in a child's left lower quadrant and when asked the last time they “pooped,” no one can really recall.
The preferred treatment is now polyethylene glycol (PEG) therapy. PEG is now used to help “disimpact a child” as well as for maintenance therapy. Whereas enemas were often previously prescribed, PEG therapy has been shown to be equally effective in most cases; it is given orally and is much less traumatic (for parent and child!).
PEG works by drawing more water into the stool, causing more stool frequency. There are many brands of PEG including MiraLAX and GoLYTELY among others. MiraLAX works well for children, as it is tasteless and odorless and can easily be mixed in many liquids without your child knowing it is there.
The guidelines now state that children receiving functional constipation maintenance therapy should continue for at least two months with a gradual tapering of treatment only after a full month after the constipation symptoms have been resolved. I usually tell parents that this is equivalent to about how long it takes for them to forget that they have been dealing with constipation, and then begin tapering.
Lastly, there is no evidence that adding additional fluid or fiber to a child's diet is of benefit to alleviate constipation; although it may “just be good for them in general.”
Dr. Sue Hubbard is an award-winning pediatrician, medical editor and media host. “The Kid’s Doctor” TV feature can be seen on more than 90 stations across the U.S. Submit questions at http://www.kidsdr.com. The Kid’s Doctor e-book, “Tattoos to Texting: Parenting Today’s Teen,” is now available from Amazon and other e-book vendors.
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Printed in the November 12, 2017 – November 25, 2017 edition