Pediatric Constipation

Introduction

Pediatric constipation is a common condition encountered in Canadian primary care and pediatric practice. This MCCQE1 study guide provides a comprehensive overview of pediatric constipation, focusing on Canadian guidelines and practices to help you prepare for your medical licensing exam.

Definition and Epidemiology

Definition

Pediatric constipation is typically defined as:

• Infrequent bowel movements (less than 3 per week)
• Hard, dry stools that are difficult or painful to pass
• Incomplete evacuation

Epidemiology in Canada

• Prevalence: Approximately 10-15% of Canadian children
• Peak incidence: During toilet training (2-4 years old)
• Gender distribution: Equally affects boys and girls

Etiology and Risk Factors

Clinical Presentation

Common symptoms include:

• Infrequent bowel movements
• Hard, large stools
• Painful defecation
• Abdominal pain
• Fecal incontinence (encopresis)

Diagnostic Approach

Management

Management of pediatric constipation in Canada follows a stepwise approach:

1. Education and Behavioral Modifications

   • Explain normal bowel habits
   • Encourage regular toilet sitting
   • Promote balanced diet and adequate hydration

2. Disimpaction (if needed)

   • Oral polyethylene glycol (PEG) is the first-line treatment in Canada
   • Enemas may be used in severe cases

3. Maintenance Therapy

   • Osmotic laxatives (e.g., PEG, lactulose)
   • Stimulant laxatives (e.g., senna, bisacodyl) as second-line

4. Follow-up and Monitoring

   • Regular follow-up to adjust treatment
   • Gradual weaning of medications

Complications

• Fecal impaction
• Encopresis
• Rectal prolapse
• Urinary tract infections
• Psychological distress

Prevention

Preventive strategies in Canadian pediatric practice include:

• Promoting a high-fiber diet
• Encouraging adequate fluid intake
• Regular physical activity
• Establishing good toilet habits

Canadian Guidelines

The Canadian Paediatric Society (CPS) provides specific guidelines for managing pediatric constipation:

1. Initial evaluation should focus on ruling out organic causes
2. PEG is recommended as the first-line laxative treatment
3. Behavioral interventions should be implemented alongside pharmacological treatment
4. Regular follow-up is essential to monitor progress and adjust treatment

Key Points to Remember for MCCQE1

• Understand the Rome IV criteria for diagnosing functional constipation in children
• Know the first-line pharmacological treatment (PEG) recommended by CPS
• Recognize the importance of behavioral interventions in management
• Be familiar with potential complications of chronic constipation
• Understand the role of investigations in ruling out organic causes

MCCQE1 Mnemonic: CONSTIPATION

• Cause (functional vs. organic)
• Onset and duration of symptoms
• Nutrition and fluid intake
• Stool frequency and consistency
• Toilet training history
• Impaction assessment
• Physical examination findings
• Associated symptoms (e.g., encopresis)
• Treatment plan (education, disimpaction, maintenance)
• Investigations (if needed)
• Ongoing follow-up
• Normal bowel habits education

Sample Question

A 4-year-old boy is brought to the clinic by his mother with a 3-month history of infrequent, hard stools. He has bowel movements every 4-5 days, which are often large and painful to pass. The mother reports that he occasionally soils his underwear. Physical examination reveals a palpable fecal mass in the left lower quadrant. Which one of the following is the most appropriate first-line pharmacological treatment for this patient?

• A. Docusate sodium
• B. Mineral oil
• C. Polyethylene glycol (PEG)
• D. Lactulose
• E. Bisacodyl

Explanation

The correct answer is:

• C. Polyethylene glycol (PEG)

Polyethylene glycol (PEG) is the first-line pharmacological treatment for pediatric constipation in Canada, as recommended by the Canadian Paediatric Society. PEG is an osmotic laxative that is highly effective, well-tolerated, and safe for use in children. It works by drawing water into the intestines, softening the stool and making it easier to pass.

The other options are less suitable as first-line treatments:

• Docusate sodium is a stool softener with limited efficacy in pediatric constipation.
• Mineral oil can be effective but carries a risk of aspiration and is not recommended as a first-line treatment.
• Lactulose is an osmotic laxative but is less effective and can cause more bloating compared to PEG.
• Bisacodyl is a stimulant laxative typically used as a second-line treatment when osmotic laxatives are ineffective.

This question tests your knowledge of current Canadian guidelines for managing pediatric constipation, which is crucial for the MCCQE1 exam and future practice in Canada.

References

1. Canadian Paediatric Society. (2020). Managing functional constipation in children. Paediatrics & Child Health, 25(2), 116-117.

2. Koppen, I. J., et al. (2015). Management of functional constipation in children: Therapy in practice. Paediatric Drugs, 17(5), 349-360.

3. Tabbers, M. M., et al. (2014). Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of Pediatric Gastroenterology and Nutrition, 58(2), 258-274.

4. Rajindrajith, S., et al. (2013). Constipation in children: Novel insight into epidemiology, pathophysiology and management. Journal of Neurogastroenterology and Motility, 19(1), 8-19.

5. van Mill, M. J., et al. (2019). Controversies in the management of functional constipation in children. Current Gastroenterology Reports, 21(6), 23.