Pediatric emergency medicine trisk 118

examination typically reveals palpable stool in the abdomen. The sacrum should
be inspected for skin changes suggestive of spinal dysraphism and for an
abnormally placed anus. Normal deep tendon reflexes and lower extremity
strength in conjunction with a normal anal-wink reflex make neurologic
impairment unlikely. The anus should also be normal in placement and
appearance. Rectal examination typically yields a dilated vault filled with hard
stool. Abdominal x-ray can be helpful if the diagnosis of fecal impaction is
unclear but is not necessary ( Fig. 18.2 ). Failure to thrive is not typically
associated with functional constipation and, if present, should prompt further
investigation.
Although functional constipation encompasses most cases of chronic
constipation in the child ≥6 months of age, less common causes must always be
considered. As in the younger infant, endocrine disorders can present as
constipation. Hypothyroidism is associated with constipation, as well as
sluggishness, somnolence, hypothermia, weight gain, and peripheral edema.
Diabetes mellitus is associated with increased urinary water loss and intestinal
dysmotility, which can lead to constipation. Hyperparathyroidism and
hypervitaminosis D lead to increased serum calcium, which cause constipation
through decreased peristalsis. Celiac disease is also recognized as a cause of
chronic constipation.
Rarely, an abdominal or pelvic mass may present with chronic constipation.
Follow-up again is emphasized because a mass that does not resolve after
clearance of impaction needs further evaluation. Hematometrocolpos can present
with constipation and urinary frequency or even urinary retention; therefore, a
genital examination is indicated in girls to assess for an imperforate hymen. One
must also remember that intrauterine pregnancy is a common cause of pelvic
mass and constipation in adolescent girls.


FIGURE 18.2 Both abdominal radiographs demonstrate evidence of constipation with
extensive retained fecal material throughout the colon and rectum. The rectum in figure (A ) is

widened and contains a large fecal impaction while that in figure (B ) is less widened and the
stool is less compacted.

Children with neuromuscular disorders often develop chronic constipation.
Myasthenia gravis, the muscular dystrophies, and other dystonic states can
predispose children to constipation through several mechanisms. A detailed
history and physical examination should recognize most neuromuscular
problems, allowing symptomatic treatment to be provided.
Psychiatric etiologies must also be considered in the evaluation of constipation.
Depression can be associated with constipation secondary to decreased intake,
irregular diet, and decreased activity. Additionally, many psychotropic drugs can
cause constipation. Anorexia nervosa may present with constipation because of
decreased intake, metabolic abnormalities, or laxative abuse causing paradoxical
constipation.

TREATMENT
Simple acute constipation in an infant <1 year of age should be treated initially
with dietary changes ( Table 18.7 ). Decreasing consumption of cow’s milk,
changing a formula to a protein hydrolysate and increasing fluid intake when
appropriate may be enough to alleviate the symptoms. In addition, supplementing


with sorbitol-containing juices such as prune, pear, white grape, or apple juice can
be helpful to soften the stool and improve stool passage. If dietary measures are
insufficient, lactulose or polyethylene glycol (PEG) 3350 (MiraLAX, GlycoLax)
may be useful as osmotic agents. The occasional glycerin suppository may also
be helpful but should not be used routinely. Historically, Karo corn syrup was
used, but is no longer recommended due to concerns that the syrup may contain
spores of Clostridium botulinum. Stool lubricants such as mineral oil should not
be used in children <3 years of age and should also be avoided in children at risk

for aspiration. PEG solutions have gained increased use in the outpatient setting
(see discussion below). When perianal irritation or anal fissures are present, local
perianal care may decrease painful defecation, which, in turn, may decrease stoolretentive behavior. Follow-up is the most important aspect of treating simple
constipation.


TABLE 18.7
TREATMENT STEPS FOR FUNCTIONAL CONSTIPATION:
“DEFECATE”
D —Disimpact
Oral route: PEG 3350 (MiraLAX), PEG electrolyte solution, magnesium
hydroxide, magnesium citrate, lactulose, sorbitol, senna, or bisacodyl
Rectal route: saline enema (Fleet), mineral oil enema, phosphate enema,
glycerin suppository (infants), bisacodyl suppository (children)
E —Evacuate/empty bowel
PEG 3350 (MiraLAX), PEG electrolyte solution (GoLYTELY), lactulose,
senna, bisacodyl
F —Fluids
Increase fluid intake, decrease caffeine intake
E —Eat fiber
Foods high in fiber or fiber supplements, increase nonabsorbable
carbohydrates (i.e., sorbitol)
C —Cathartics, softeners, and lubricants (maintenance)
PEG 3350 (MiraLAX), lactulose, lubricants (mineral oil [>3 yrs])
A —Album (diary/journal)
Daily record of bowel movements with details
T —Toileting
Set bathroom time after meals, proper height of toilet with foot support,
reward systems/positive reinforcement, local perineal care, ointment, Sitz
baths

E —Education and early follow-up critical for success of therapy
Therapy for acute functional constipation in the child ≥1 year of age is similar
to that for the infant, with dietary changes and stool softeners as the mainstays of
therapy. Additionally, attention should be paid to psychological factors such as
recent stress that may be complicating the situation. Treatment ( Table 18.7 ) for
chronic functional constipation in the child older than 1 year of age begins with
disimpaction and evacuation of the stool remaining in the colon. This is
accomplished with either oral or rectal therapy or a combination of the two.
Youssef et al. demonstrated that in fecally impacted children whose palpable stool