uptodate.pdf

Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment Author: Manu R Sood, MBBS, FRCPCH, MD, MSc Section E...

Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment Author: Manu R Sood, MBBS, FRCPCH, MD, MSc Section Editor: B UK Li, MD Deputy Editor: Alison G Hoppin, MD INTRODUCTION — Constipation is common among children, a"ecting up to 30 percent of children [1-3], and the vast majority of chronic constipation is functional. The approach to treatment of functional constipation depends on the child's age, presence of underlying behavioral or dietary triggers, and chronicity of the symptoms. The treatment of chronic functional constipation and fecal incontinence in infants and children will be discussed here. Related material is presented in the following topic reviews: (See "Constipation in infants and children: Evaluation".) (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis".) (See "Functional fecal incontinence in infants and children: De#nition, clinical manifestations, and evaluation".) (See "Recent-onset constipation in infants and children".) DEFINITIONS Functional constipation – Functional constipation is de#ned by criteria that include infrequent, hard, and/or large stools; fecal incontinence; painful defecation; or volitional stool retention, if these symptoms are not explained by another medical condition, as outlined by the Rome IV consensus (table 1) [5,6]. Although abdominal pain is often associated with functional constipation, it is not among the diagnostic criteria. (See "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis".) Functional fecal incontinence – Functional fecal incontinence is the repeated involuntary passage of stool in the underwear after the acquisition of toileting skills (typically after four years of age), in the absence of overt neuromuscular anorectal dysfunction. This term is preferred rather than encopresis or soiling. It is classi#ed as "retentive" if it is associated with functional constipation and "nonretentive" if it occurs in the absence of symptoms and signs of functional constipation. (See "Functional fecal incontinence in infants and children: De#nition, clinical manifestations, and evaluation".) Fecal impaction – This term is used to describe markedly increased amounts of stool in the rectum and colon. It is a subjective judgement based on clinical #ndings, such as a large stool mass noted on physical examination and/or radiograph (if performed), especially in association with a history of passing infrequent and large-caliber stools. (See 'Disimpaction (for select children)' below.) TREATMENT OF CONSTIPATION IN INFANTS — Constipation is evaluated and treated somewhat di"erently in infants than in children. When constipation presents early in life, organic disease (eg, cystic #brosis, Hirschsprung disease), an anorectal malformation, and, especially, anal stenosis must be considered. The organic causes of constipation in infants are discussed in a separate topic review. (See "Constipation in infants and children: Evaluation" and "Functional constipation in infants, children, and adolescents: Clinical features and diagnosis", section on 'Di"erential diagnosis'.) Initial measures (nonpharmacologic) — Infants with functional constipation frequently respond to treatment with nondigestible osmotically active carbohydrates, such as sorbitol-containing juices (eg, apple, prune, or pear). Although dark corn syrup was previously used, we no longer suggest it, because not all preparations contain osmotically active carbohydrates. Pharmacotherapy — If these measures are unsuccessful, addition of osmotic laxatives and/or occasional disimpaction with glycerin suppositories can be useful. Appropriate choices for infants include the following (all are o"-label uses for this age group): Lactulose or sorbitol – These are frequently used and are usually e"ective in infants. A typical dose for either lactulose or sorbitol is 1 mL/kg, once or twice daily (table 2). Polyethylene glycol 3350 – Experience with polyethylene glycol 3350 (or Miralax) is increasing in infants, although the safety is less well established than with older age groups. The use of this laxative for infants and toddlers