diagnosis and treatment of functional constipation in infants and children

Table 3. Recommendations

A.     Prevention and management of functional constipation

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

A1

Q1: What is the definition of functional constipation?

ESPGHAN

(1)   Based on expert opinion, we recommend the Rome III criteria for the definition of functional constipation for all age groups.

(2)   Based on expert opinion, the diagnosis of functional constipation is based on history and physical examination

Low

Low

Conditional

Conditional

Q2: What are the alarm signs and symptoms that suggest the presence of an underlying disease causing the constipation?

ESPGHAN

Based on expert opinion, we recommend using for alarm signs and symptoms and diagnostic clues to identify an underlying disease responsible for the constipation.

1.  Constipation starting extremely early in life (48 h

2.  Family history of HD

3. Ribbon stools

4. Blood in the stools in the absence of anal fissures

5. Failure to thrive

6. Fever

7. Bilious vomiting

8. Abnormal thyroid gland

9. Severe abdominal distension

10.  Perianal fistula

11.  Abnormal position of anus

12.  Absent anal or cremasteric reflex

13.  Decreased lower extremity strength/tone/reflex

14.  Tuft of hair on spine Sacral dimple

15.  Gluteal cleft deviation

16.  Extreme fear during anal inspection

Anal scars

Very Low

Conditional

Q3: In the Diagnosis of Functional Constipation in Children, What Is the Diagnostic Value of the Following

Q 3.1 Digital Rectal Examination

ESPGHAN

1. Based on expert opinion, 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.

Based on expert opinion, in the presence of alarm signs or symptoms or in patients with intractable constipation, a digital examination of the anorectum is recommended to exclude underlying medical conditions.

Very Low

Conditional

Q 3.2 Abdominal Radiography

ESPGHAN

The routine uses of an abdominal radiograph to diagnose functional constipation is not indicated.

Based on expert opinion, 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.

Very Low

Conditional

Q3.3 Rectal ultrasound

ESPGHAN

Rectal ultrasound is not recommended to diagnose functional constipation

Very Low

Conditional

Q4. Which of the following diagnostic tests should be performed in children with constipation to diagnose an underlying disease?

4.1 Laboratory Investigations to Diagnose (Cow’s Milk) Allergy, Celiac Disease, Hypothyroidism, and Hypercalcemia?

ESPGHAN

1.  Routine allergy testing is not recommended to diagnose cow’s-milk allergy in children with functional constipation.

2.    Based on expert opinion, a 2- to 4-week trial of avoidance of CMP may be indicated in the child with intractable constipation.

Based on expert opinion, we do not recommend routine laboratory testing for hypothyroidism, celiac disease, and hypercalcemia in children with constipation in the absence of alarm symptoms.

Very Low

Conditional

4.2 Use of Barium Enema to Diagnose Organic Causes Such as HD

ESPGHAN

Based on expert opinion, we do not recommend performing barium enema as an initial diagnostic tool for the evaluation of children with constipation.

Very Low

Conditional

5- Which of the Following Examinations Should Be Performed in Children With Intractable Constipation to Evaluate Pathophysiology and Diagnose an Underlying Abnormality

5.1 Magnetic Resonance Imaging (MRI) of the Spine

ESPGHAN

The routine use of MRI of the spine is not recommended in patients with intractable constipation without other neurologic abnormalities.

Very low

Conditional

5.2 Colonic Full-Thickness Biopsies

ESPGHAN

Based on expert opinion, we do not recommend obtaining full-thickness colonic biopsies to diagnose colonic neuromuscular disorders in children with intractable constipation.

Very low

Conditional

5.3 Colonic Scintigraphy

ESPGHAN

Based on expert opinion we do not recommend routine use of colonic scintigraphy studies in children with intractable constipation

Low

Conditional

6: What Is the Additional Effect of the Following Nonpharmacologic Treatments in Children with Functional Constipation?

6.1 Fiber

ESPGHAN

A normal fiber intake is recommended in children with constipation.

Very low

Conditional

6.2 Fluid

ESPGHAN

Based on expert opinion, we recommend a normal fluid intake in children with constipation.

Low

Conditional

6.3 Physical activity

ESPGHAN

Based on expert opinion, we recommend a normal

physical activity in children with constipation.

Low

Conditional

6.4 Prebiotics and probiotics

ESPGHAN

The routine use of prebiotics and probiotic is not recommended in the treatment of childhood constipation.

Very low

Conditional

6.5 Behavioral therapy

ESPGHAN

1.      The routine use of an intensive behavioral protocolized therapy program in addition to conventional treatment is not recommended in childhood constipation.

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

Low

Conditional

6.6 Biofeedback

ESPGHAN

The use of biofeedback as additional treatment is not recommended in childhood constipation.

Low

Conditional

6.7 multidisciplinary treatment

ESPGHAN

 Based on expert opinion, we do not recommend the

routine use of multidisciplinary treatment in childhood constipation.

Low

Conditional

6.8 Alternative medicine

(Including Acupuncture, Homeopathy, Mind-Body Therapy, Musculoskeletal Manipulations Such As Osteopathic and Chiropractic and Yoga)

ESPGHAN

Based on expert opinion, we do not recommend the use of alternative treatments in childhood constipation.

Low

Conditional

7: What Is the Most Effective and Safest Pharmacologic Treatment in Children with Functional Constipation?

7.1 Which Pharmacologic Treatment Should Be

Given for Dis-impaction?

ESPGHAN

The use of PEG with or without electrolytes orally 1 to 1.5 g _ kg_1 _ day_1 for 3 to 6 days is recommended as the first-line treatment for children presenting with fecal impaction.

 An enema once per day for 3 to 6 days is recommended for children with fecal impaction, if PEG is not available.

Very low

Conditional

7.2 Which Pharmacologic Treatment Should Be Given for Maintenance Therapy?

ESPGHAN

1.      The use of PEG with (mixed with water) or without (mixed with juice) electrolytes is recommended as the first-line maintenance treatment. A starting dose of 0.4 g _ kg_1 _ day_1 is recommended, and the dose should be adjusted according to the clinical response.

2.      The addition of enemas to the chronic use of PEG is not recommended in children with constipation.

The use of lactulose as the first-line maintenance treatment is recommended, if PEG is not available.

Very low

Conditional

7.3 How Long Should Children Receive Medical

Therapy?

ESPGHAN

1.      Based on expert opinion, 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.

2.      Based on expert opinion, in the developmental stage of toilet training, medication should only be stopped once toilet training is achieved.

Low

Conditional

Question 8:  What Is the Efficacy and Safety of Novel Therapies for Children with Intractable Constipation?

Q 8.1

Transcutaneous Nerve Stimulation (TNS)

ESPGHAN

Based on expert opinion, evidence does not support the use of TNS in children with intractable constipation.

Low

Conditional

Q 8.2

Surgery (use of ACE)

ESPGHAN

Based on expert opinion, we recommend antegrade enemas in the treatment of selected children with intractable constipation.

Very low

Conditional

Question 9.1  What is the prognosis of functional constipation in children? 

ESPGHAN

·       Among patients referred to pediatric gastroenterologists

1.     50% will recover and be without laxatives after 6 to 12 months.

2.     10% are well while taking laxatives.

3.     40% will still be symptomatic despite use of laxatives.

·       50% and 80% of the children are recovered after 5 and 10 years, respectively.

delay in initial medical treatment for >3 months from symptom onset correlates with longer duration of symptoms.

Low

Conditional

Question 9.2 What are prognostic factors in children with functional constipation?

ESPGHAN

Based on expert opinion, we recommend using the following to identify the prognostic factors related to functional constipation.

There is limited /insufficient evidence relative to the prognostic value of functional constipation of the following factors

1.     Demographics/history: age at presentation, age at onset, duration of symptoms< 3 months before presentation, treatment duration< 2 month before presentation, premature birth, delayed passage of meconium, history of constipation in the first year of life

2.     Clinical symptoms: defecation frequency, presence of fecal incontinence, abdominal pain at presentation/history of abdominal pain, large stools, urinary tract infection, nighttime urinary incontinence, stool withholding

3.     Physical examination: absence of a rectal or abdominal mass

4.     Additional examination: balloon defecation, relaxation of external sphincter, megarectum and/or megacolon at diagnosis

There is limited evidence for a negative prognostic value for Additional examination: prolonged CTT (colonic transit time)

There is strong evidence that the following factors have no prognostic value Demographics: sex, positive family history

Limited evidence in some and Strong evidence for other prognostic factors