Not enough universally approved definition of constipation is a key concern inside the studies of constipation. In children, it truly is more challenging mainly because it depends on the presentation of symptoms by parents. Baker ain al include defined constipation as “a delay or perhaps difficulty in defecation, for two weeks or more and sufficient to cause significant distress to patient”. The Paris Consensus on Child years Constipation Terms (PACCT) group defined constipation as “two or more from the following, to get 8 weeks:
- Fecal incontinence >1 show per week
- Large bar stools palpable in abdominal examination or in the rectum
- Agonizing defecation
- Bowel movements
- Stool withholding behavior or perhaps retentive posturing
- Very large bar stools that can obstruct the toilet” Rome Requirements for the definition of constipation The most widely accepted definition of constipation when the study was initiated was your ROME III criteria
- Defecation frequency two or much less per week
- Fecal incontinence at least one event per week after acquiring toileting skills
- Existence of large fecal mass inside the rectum
/p>
/p>
/p>
/p>
/p>
/p>
/p>
Studies have shown the prevalence of constipation in the pediatric population to range from 0. 7% to 29. 6%. 3% of pediatric patients presenting to OPD have constipation. Also, constipation constitutes 10-25 % of patients referred to pediatric gastroenterology clinics. Most studies have reported no significant gender difference. It is also known to be more common in low socioeconomic status and low parental income. Formula-fed infants are known to be more likely to have constipation than breast-fed infants. Diagnosis of Constipation The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) attempted to formulate Uniform Evidence-based guidelines for evaluation and management of functional constipation in 2014. Despite the unreliability and non-specificity of symptom description in infants and young children, history and physical examination is still the main basis of the diagnosis.
The main points to be noted are age of onset of symptoms, frequency of defecation, consistency of stools (expressed in some scale like Bristol scale, Lane’s modified Bristol stool form scale or Amsterdam infant stool scale),status of toilet training, pain during defecation, blood in stools, Constipation associated Fecal Incontinence (CFI), retentive posturing, diet history, weight loss and nausea/vomiting. Children may display retentive posturing or withholding actions in the form of standing on toes, swaying back and forth, tightening of the lower limbs and backward bending of the spine which is often mistaken by the parents as straining. Age of onset prior to one month suggests a strong probability of Hirschprung’s disease. Time of passing first meconium also needs to be enquired as the lag of >48 hours strongly favors the associated with Hirschsprungs disease. Many times there would be a precipitating factor pertaining to constipation for instance a painful intestinal movement, changeover of feeds from breastfeeding to formula feeding or perhaps beginning of toilet teaching, etc . Likewise, dietary background, treatment history, developmental background, and psychosocial history are important. The family history of gastrointestinal disorders (Hirschsprungs disease, inflammatory intestinal disease, celiac disease, foodstuff allergies, etc) and disorders of different organs like thyroid, parathyroid, kidneys or other conditions like cystic fibrosis must be enquired.
Physical examination should include:
- Anthropometry to evaluate growth
- Abdominal assessment (palpable waste mass, belly distension)
- Lumbosacral area ( sacral dimple, a tuft of locks, gluteal cleft deviation, sacral agenesis, toned buttocks)
- Perianal inspection ( perianal cracks or skin tags, the place of the anal opening, feces in the rectum or internal clothing)
- Anal wink response and cremasteric reflex
- Digital rectal exam (anal stenosis, fecal mass). Explosive stools after removal of finger suggest Hirschsprungs disease
- Neuromuscular examination: Tone, electricity, deep tendon reflexes Digital rectal examination (DRE) in the diagnosis of constipation
/p>
The moment history and abs examination will not accurately discover the diagnosis of constipation, DRE can be used. Beckman et ‘s did a report to determine the precision of specialized medical variables to diagnose radiographically established congestion. Taking digestive tract filled with fecal material to radiographically define obstipation, it was found that chair present in the rectal test was the finest variable that differentiates between patients with and without constipation. If you will discover no manifiesto abdominal fecoliths and no great CFI, DRE would be instructed to detect “fecal mass inside the rectum” which can be one of the conditions for ROME III definition of constipation. The NASPGHAN and ESPGHAN 2014 guideline suggest DRE intended for diagnosis of obstipation if only you out of 6 standards in Rome III is satisfied and attempts routine make use of DRE to diagnose obstipation.
Gear Diagnosis Although functional obstipation is the most common cause of congestion, another differential diagnosis should be considered and should end up being ruled out of all time and assessment. The following burglar alarm signs and symptoms will help to recognize the presence of a natural disease leading to constipation:
/p>
Passage of meconium after twenty four hours of birth
- Constipation beginning very early on (
- Bows stools
- Family history of Hirschsprung’s disease
- Inability to thrive
- Blood in stools in the absence of anal fissures
- Fever
- Abnormal situation of rectum
- Bilious vomiting
- Absent cremasteric/anal reflex
- Sacral dimple
- Tuft of curly hair on backbone
- Decreased strength/ tone/reflex in lower extremities
- Anal marks
- Extreme fear during anal inspection
/p>
Fecal impaction is defined as a difficult mass inside the lower abdominal identified upon physical evaluation or a dilated rectum packed with a stool about rectal examination or abnormal stool inside the distal intestines on stomach radiography. Great CFI likewise points out the diagnosis of fecal impaction. Although abdominal radiography may give less discomfort to the child compared to rectal evaluation, it uses more time, cost and unearths to light. It is not routinely recommended for diagnosing fecal impaction. Therefore in kids suspected to obtain fecal impaction but with out history of CFI or palpable fecal mass per belly, DRE is needed. But the 2014 NASPGHAN and ESPGHAN rules do not have definite recommendation upon using DRE for the diagnosis of fecal impaction. The NICE suggestions recommend to find fecal impaction in all instances of idiopathic constipation and also to do DRE if mentioned. But it can be not explained what the signs are. In children below 1 year age it suggests DRE to find fecal impaction only if it is not necessarily responding to treatment in 4 weeks. These tips would result in unnecessary postpone in the remedying of impaction. Treatment of constipation without prior disimpaction in a kid is likely to be ineffective in a kid with waste impaction. Treatment In existence of waste impaction, the first thing is disimpaction. The most preferred agent used for disimpaction is oral Polyethylene glycol with electrolytes. Enemas although equally effective are considered even more invasive can also be used if there is the unavailability of polyethylene glycol. The next step is to get started on maintenance remedy. Among the numerous agents applied polyethylene glycol is once again the most effective a single but the dose is lower than for disimpaction.
Inside the absence of fecal impaction, treatment is straight started with maintenance remedy. Maintenance remedy has to be titrated according to response. In the mean time, parents must be counseled about high fibers diet and toilet schooling. The gastrocolic reflex is utilized as well as the child is inspired to take a seat in the toilet for defecation after each meal. Confident reinforcement by rewards and maintenance of bowel diary is also advised. Treatment is continued for at least 2 weeks with a symptom-free period of the at least 1-month following which dosage is slowly but surely tapered. Many children require treatment for a few months or perhaps years. Regular follow up is required to assess for relapse and also to reinforce food and bathroom habits. Beginning maintenance therapy without disimpaction in a kid with waste impaction can be unlikely to succeed and causes unneeded distress for the child and family and increases chances of poor compliance. Using DRE DRE seems to be underutilized in medical practice. A report by Precious metal et approach showed that 77% of youngsters referred to Pediatric Gastroenterology did not undergo preceding rectal evaluation.
An additional study performed by Scholer et approach showed DRE was required for only five per cent of children delivering with severe abdominal pain in Center or urgent. A possible reason for this underutilization could be a doctor not being comfortable with the procedure, excessive apprehension with the child as well as the risk of ruining a physician-child relationship. One other possible cause could be an underestimation of fecal retention by physician since fecal impaction may often have a subtle and nonspecific presentation. Usefulness of DRE Though there were studies within the utilization of DRE, there are not any studies displaying the actual performance of DRE. Hence it is difficult to touch upon what amount of instances is likely to be overlooked if DRE is omitted in program evaluation. In 2014 NASPGHAN and ESPGHAN guidelines, DRE is recommended to get diagnosis of congestion if only one of many ROME 3 criteria is present leading to uncertainty in the prognosis. The guideline also recommends DRE to evaluate underlying organic medical condition in the occurrence of alert signs and symptoms or perhaps in case of intractable constipation. However the guideline does not make any comment on make use of DRE pertaining to diagnosis of fecal impaction. Consequently a study to show frequency of fecal impaction in DRE would show what percentage of DRE shows impaction and would provide a definite facts to support usage of DRE.
