Functional constipation (FC): refers to constipation caused by other than intestinal or systemic organic causes and drug factors. 95% of children with constipation over 1 year old belong to functional constipation.
Long-term constipation may lead to abdominal pain, anal fissures, incontinence, and urinary symptoms in 9-13% of patients. It not only affects the quality of life of children, but also causes distress to the families of children.
Infants vs Children
How the diagnostic criteria for functional constipation in adolescents differ
Functional constipation in young children is usually caused by repeated attempts to restrain bowel movements. After the introduction of complementary foods, changes in dietary structure often lead to acute constipation, and the pain of defecation during defecation causes infants and young children to fear the action of “defecation”. It is because of the horrific experience of “defecation” that attempts to restrain defecation eventually lead to functional constipation.
Functional constipation in children and adolescents is often triggered by pain or social factors (school, travel) instinctively refraining from defecation.
The diagnostic criteria for functional constipation in infants and children and adolescents according to Rome IV criteria are compared as follows[1]
Age
(1) Defecation ≤ 2 times per week; (2) History of massive fecal retention; (3) History of painful defecation and laborious defecation; (4) History of thick stools; (5) There is a large mass of stool in the rectum.
For defecation-trained children, the following conditions are also options: (6) Controlled bowel incontinence at least once a week after defecation; (7) Large Feces have clogged toilets.
Age > 4 years old Children and adolescents with constipation at least once a week for more than 1 month, and meet 2 or more of the following conditions, but irritable bowel syndrome (IBS) is under-diagnosed:
Children 4 years of age or older who defecate in the toilet ≤ 2 times per week; Fecal incontinence at least once per week; History of fecal retention or excessive restraint; History of painful or difficult defecation; Large fecal mass in the rectum; thick fecal mass has blocked toilet bowls.
What are the warning signs of constipation?
Alarming signs of constipation: Term neonate with meconium excretion > 48 hours, constipation beginning in the first month of life, Hirschsprung’s disease Family history, growth retardation, biliary vomiting, severe abdominal distension, abnormal thyroid function, anal heterotopia, absence of anus, absence of cremasteric reflex, lower extremity muscle tone, hyporeflexia, hair on the back of the spine, deviation of the gluteal cleft, Anal scar.
Routine digital rectal examination is recommended to detect anal strictures in infants. Congenital aganglionic Hirschsprung’s disease (Hirschsprung disease, HD) is suggested if the anal canal is too tight, the rectal ampulla is empty, and there is a jet of gas and feces (the jet or blast sign) after digital rectal examination.
What checks need to be scheduled?
1. Routine milk protein allergy testing is not recommended in children with constipation, hypothyroidism, celiac disease, and hypercalcemia if there are no alarm symptoms Laboratory screening.
2. When there is evidence of spinal canal insufficiency or evidence of perianal/lower extremity neurological dysfunction in children, lumbosacral spine radiographs should be performed, but not routinely used for functional constipation. Evaluate. If neurological dysfunction is highly suspected, MRI should be considered to evaluate for tethered cord and spinal cord tumors [2].
3. Barium enema and 24-hour follow-up for barium retention are valuable in diagnosing Hirschsprung disease, and false-negative results may be possible in small infants. Intestinal biopsy, including rectal aspiration biopsy and full-thickness rectal biopsy, is the gold standard for the diagnosis of Hirschsprung disease.
4. Anorectal manometry is mainly used in patients with intractable constipation leading to lifestyle restriction, suspected internal anal sphincter achalasia, suspected defecation dyssynergy, or Hirshpen disease [3]. False negatives may occur in infants younger than 6 months of age due to catheter movement (which may resemble the anorectal inhibitory reflex).
Pot training and dietary interventions
1. Lifestyle changes
Encourage participation in various sports activities, cultivate labor habits, and ensure that there should be more than 1 hour of physical exercise every day.
2. Bowel Training
Use a child’s potty chair, or provide foot support (to comfort and relax the pelvic floor) for a child using an adult toilet. It is usually performed 30-60 minutes after meals, and each time lasts 5-10 minutes to avoid fatigue of the anus muscles and fear of failure due to too long time.
3. Dietary Interventions
For children 1 year and older with an episode of uncomplicated constipation, mild symptoms can be improved by dietary changes such as increasing fiber intake and ensuring adequate fluid intake. Williams et al. suggested that the safe intake of fiber for children in the United States is age plus 5-10 g/d [4], and the domestic intake is usually 0.5 g/kg/d.
Fiber intake beyond this goal has not been shown to be beneficial in treating constipation in children [5]. And too much fiber diet will affect the digestion and absorption of protein and other nutrients, increase the intestinalPeristalsis and gas production, causing abdominal discomfort, inhibiting pancreatic enzyme activity.
Add fiber-rich fruits, greens, grains, and legumes to your daily diet. If you are not getting enough dietary fiber, you can use fiber supplements. However, adequate intake of water or other non-dairy fluids is recommended along with fiber supplementation.
In children with constipation or a history of fecal impaction, additional fiber intake should only be encouraged after colorectal tone has returned, such as after successful treatment with laxatives, to avoid intestinal obstruction.
The relationship between milk and constipation is controversial [6]. Constipation improves in some infants or children after switching cow’s milk to soy formula [7]. But more clinical research data is needed.
Medication
The first choice for chronic constipation is bulk laxatives (bulking agents) and osmotic laxatives, and stimulant laxatives (such as xylenes, phenolphthalein, etc.) are used only when necessary . Initial treatment with osmotic or lubricating laxatives rather than dietary interventions is recommended for children with constipation, painful defecation, rectal bleeding, or anal fissures.
1. Osmotic laxatives
Infants over 6 months of age with persistent or recurrent constipation despite dietary interventions, treatment with osmotic laxatives, such as electrolyte-free polyethylene glycol (PEG), is recommended , lactulose or sorbitol [8]. If symptoms improve after using laxatives, the dose should be maintained at a minimum or tapered, rather than abruptly stopped.
The recommended dose of PEG is 0.4 g/(kg·d); if the child has fecal impaction, a higher dose of 1~1.5 g/(kg·d) can be used, the highest dose being the highest Long-term continuous use for 6 days, after which the recommended dose is resumed.
2. Softeners/lubricants: Kaisai lotion, paraffin oil, can stimulate colon contraction and soften stool, it is a temporary treatment, not suitable for long-term Use to avoid dependencies.
3. Probiotics: Absence of gut microbes may lead to abnormal gut morphology and function, such as prolonged transit time and reduced gut volume. The expert consensus on pediatric application of probiotics recommends the use of probiotics such as Bifidobacterium, Lactobacillus, Streptococcus faecalis, Bacillus subtilis, and Clostridium butyricum for functional constipation [9].
4. Gastrointestinal motility drugs: Gastrointestinal motility drugs are used for slow transit constipation, but are ineffective for outlet obstruction constipation. Cisapride is a 5-HT receptor agonist, which promotes the increase of transverse colon motility by stimulating the release of acetylcholine from the myenteric plexus, but it has poor selectivity.
Micro-dose erythromycin therapy for slow transit constipation has been reported in China, 5~10 mg/kg/time, 2 times/day, and the course of treatment is 7~10 days.
Summary of key points
1. Functional constipation is the main cause of chronic constipation, but when warning symptoms appear, it is necessary to exclude organic causes through laboratory and imaging tests.
2. Increased outdoor exercise and proper bowel training are the basis of treatment.
3. Increasing dietary fiber intake and ensuring adequate fluid intake can improve functional constipation. The relationship between milk and constipation remains controversial.
4. Bulk laxatives and osmotic laxatives are preferred for persistent or recurrent constipation after dietary intervention, and probiotics may be helpful. Gastrointestinal motility drugs are not routinely used and are mainly used for slow transit constipation.
Planning: Spring Flowers
The source of the title map: Zhanku Hailuo
References:
[1] Geng Lanlan (translator), Liu Mingnan (translator), Long Gao (translator), Gong Sitang (reviewer), Jiang Mizu (reviewer), Neil L. Schechter, Jeffrey S. Hyams,Carlo Di Lorenzo,Miguel Saps,Robert J. Shulman,Annamaria Staiano,Miranda van Tilburg. Rome IV criteria for functional gastrointestinal disease in children[J]. Chinese Journal of Pediatrics,2017,55(1):4-14.< /p>
[2] Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014 ; 58:258.
[3] Pensabene L, Youssef NN, Griffiths JM, Di Lorenzo C. Colonic manometry in children with defecatory disorders. role in diagnosis and management. Am J Gastroenterol 2003; 98:1052.< /p>
[4] Williams CL, Bollella M, Wynder EL. A new recommendation for dietary fiber in childhood. Pediatrics 1995; 96:985.
[5] Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infantsand children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014;58:258.
[6] Heine RG, Elsayed S, Hosking CS, Hill DJ. Cow’s milk allergy in infancy. Curr Opin Allergy Clin Immunol 2002; 2:217.
[7] Irastorza I, Iba ez B, Delgado-Sanzonetti L, et al. Cow’s-milk-free diet as a therapeutic option in childhood chronic constipation. J Pediatr Gastroenterol Nutr 2010; 51 :171.
[8] Loening-Baucke V. Prevalence, symptoms and outcome of constipation in infants and toddlers. J Pediatr 2005; 146:359.
[9] Zheng Yuejie, Huang Zhihua, Liu Zuoyi, Wang Wenjian, Cheng Qian. Expert consensus on pediatric application of microecological preparations (October 2010)[J]. Chinese Journal of Practical Pediatrics, 2011,26( 1):20-23.