Functional constipation: A guideline review
Functional constipation in children is no news to pediatricians. What may be news is that recommendations on how to diagnose and treat this common malady keep evolving as more evidence becomes available.
Reviewed by Samuel Nurko, MD, MPH
Functional constipation in children is a common problem. Prevalence rates worldwide range between 0.7% and 30%, with a higher prevalence found in younger children (aged 2 to 6 years) compared with older children, and often in children during times of change. Children aged 5 to 6 years have the highest reported prevalence (35.4%).1 The burden of this condition on children, families, and society is highlighted by data showing that children with constipation use more health services than those without constipation, and incur an estimated additional cost of 3.9 billion per year.2 This childhood health problem is no news to pediatricians. It is estimated that 3% of all visits to general pediatricians are for functional constipation, and the problem accounts for up to 25% of visits to pediatric gastroenterologists.1
What may be news is that recommendations on how to diagnose and treat this common malady keep evolving as more evidence becomes available. To keep up with this evolution, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) developed a joint guideline that presents the most up-to-date evidence.3 Published in 2014, the guideline updates an earlier 2006 guideline by the NASPGHAN.4
In 2015, a study that looked at how pediatricians apply the updated 2014 guidelines found that about 84% of those surveyed reported no or only slight familiarity with the updated guidelines.5 The study highlighted the need for more education on functional constipation in children, with a particular emphasis on updating pediatricians via the new guideline on the proper use of medications to reduce time to remission, among other issues.
To help broaden the reach of the guidelines so that pediatricians are up-to-date on the latest evidence on the diagnosis and treatment of functional constipation in children, Samuel Nurko, MD, MPH, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Massachusetts, discussed the key recommendations presented in the guidelines at the 2015 American Academy of Pediatrics (AAP) annual conference.
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In his presentation “Got Colon Congestion? New Evidence-Based Guidelines for Evaluating and Treating Functional Constipation in Kids,”6 Nurko emphasized 2 take-home messages supported by the latest evidence: 1) X-rays and other tests are not needed to diagnose functional constipation in most children as it is a symptom-based diagnosis, and 2) treatment incudes education and pharmacologic treatment, the latter of which should be administered for at least 2 months and be only gradually discontinued after resolution of constipation symptoms for 1 month.
Diagnosis
The first step to diagnosing functional constipation is knowing what it is. Similar to the criteria used in the 2006 guidelines, the updated 2014 guidelines recommend using the widely accepted Rome III definitions to define functional constipation.3 Since the publication of the 2014 guidelines, updated Rome IV definitions have been published that are similar to Rome III definitions but with 1 change indicating a shorter duration of symptoms needed to define constipation (from 2 months to 1 month).7,8 Tables 1 and 2 list Rome IV definitions for functional constipation in children aged 4 years and younger and children aged 4 years and older, respectively. For children aged younger than 4 years, irritability, decreased appetite, and/or early satiety may accompany the symptoms of constipation. These symptoms may disappear immediately after the child passes a large stool.
Making the diagnosis is based on history and physical examination, which are done to also rule out other potential underlying conditions such as anatomic malformations, neuroenteric disorders, neuropathic conditions, metabolic endocrine and gastrointestinal disorders, psychologic problems, systemic problems, and drugs.
NEXT: Recommendations against using imaging
Table 3 highlights the major diagnostic steps recommended in the guidelines based on the symptoms presented, and Table 4 highlights the specific recommendations against the use of imaging and other tests.
Unless the history and physical exam suggest the possibility of an underlying disorder, x-rays and other imaging or invasive tests are not recommended, emphasizes Nurko, citing the latest evidence that recommend against the use of x-rays to “rule in” constipation and the evidence to support the lack of utility of abdominal x-rays for diagnosis.3,9,10
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If the history and physical exam suggest an underlying condition, specific additional tests for suspected conditions are recommended (Table 5).
Nurko emphasizes that most children with constipation do not have an underlying organic disorder. As such, diagnosis based on history and physical exam is sufficient for most cases of functional constipation, he says.
Key message: Most cases of constipation in children can be diagnosed by history and physical exam alone and do not require additional testing.
NEXT: Treatment
Treatment
An ongoing evolution in the clinical management of functional constipation in children is in regard to treatment. Nurko highlights that treatment of constipation in children is evolving from expert recommendations to evidence-based treatments.
Table 6 lists the recommendations for treatment based on the current evidence in the guidelines. Table 7 lists specific treatments not recommended in routine cases.
In his presentation, Nurko discussed a number of these recommendations, highlighting and clarifying the current evidence on many of them. From the current evidence, polyethylene glycol (PEG)-based therapies remain the mainstay for both disimpaction and first-line maintenance therapies. Although the evidence showed a similar efficacy between PEG-based therapy and enemas to treat fecal impaction, the guidelines prioritize PEG-based therapy as first-line treatment because it can be administered orally.3 The guidelines recommend PEG-based solutions as the first-line maintenance medication, or lactulose if PEG is not available. The guidelines do not recommend adding an enema to PEG therapy in routine cases based on evidence showing no benefit to the combined therapy versus PEG alone.
The guidelines also recommend PEG-based therapy for maintenance therapy. If PEG-based therapy is not available, the guidelines recommend lactulose based on its safety and more available data compared with other therapies such as milk of magnesia and mineral oil.3
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Important to highlight is the duration of treatment. Although evidence remains lacking on this issue, expert opinion suggests that maintenance therapy should continue for at least 2 months with a gradual tapering of treatment only after a full month after symptoms of constipation have resolved. For infants, expert opinion suggests stopping therapy only after toilet training has been achieved. As for nonpharmacologic treatments, Nurko says that no evidence indicates a benefit for additional fluid or fiber intake in children with constipation. He also notes that no evidence shows a benefit of combining behavioral therapy with laxatives compared with conventional treatment that includes education and toileting. However, evidence does suggest considering referral for children with behavioral problems to behavioral therapy or mental health services.
Key message: Pharmacotherapy treatment should be administered for at least 2 months and be only gradually discontinued after 1 full month of resolution of constipation symptoms.
Summary
Functional constipation in children is a common problem. For most cases, history and physical exam are sufficient to make the diagnosis without the need for additional imaging or other tests. The mainstay of treatment is PEG-based therapy, with current recommendations suggesting a duration of treatment of at least 2 months with a gradual reduction of therapy only after resolution of constipation symptoms for 1 month.
REFERENCES
1. Koppen IJ, Lammers LA, Benninga MA, Tabbers MM. Management of functional constipation in children: therapy in practice. Paediatr Drugs. 2015;17(5):349-360.
2. Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C. Health utilization and cost impact of childhood constipation in the United States. J Pediatr. 2009;154(2):258-262.
3. Tabbers MM, DiLorenzo C, Berger MY, et al; European Society for Pediatric Gastroenterology, Hepatology, and Nutrition; North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274.
4. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):405-407.
5. Yang CH, Punati J. Practice patterns of pediatricians and trainees for the management of functional constipation compared with 2006 NASPGHAN guidelines. J Pediatr Gastroenterol Nutr. 2015;60(3):308-311.
6. Nurko S. Got Colon Congestion? New Evidence-Based Guidelines for Evaluating and Treating Functional Constipation in Kids. Presented at: American Academy of Pediatrics (AAP) National Conference and Exhibition; October 24-27, 2015; Washington, DC.
7. Benninga MA, Faure C, Hyman PE, St James Roberts I, Schechter NL, Nurko S. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016;150(6):1443.e2-1455.e2.
8. Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016;150(6):1456.e2-1468.e2.
9. Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83.e2-88.e2.
10. Benninga MA, Tabbers MM, van Rijn RR. How to use a plain abdominal radiograph in children with functional defecation disorders. Arch Dis Child Educ Pract Ed. 2016;101(4):187-193.
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