Infant Dyschezia NHS | A4Medicine

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Infant Dyschezia NHS

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What is constipation currently the most widely
accepted definitions for childhood functional
constipation are the Rome III definitions. These
are different based on age groups Functional
constipation is an umbrella term that encompasses
a group of disorders associated with persistent
difficulty , infrequent or seemingly incomplete
defecation without evidence of a structural or
biochemical explanation (Manu R Sood , FRCPCH. MD
ref 5 )Age lt 4 yrs No organic pathology 2 or
more of the following for atleast 1 month-Two or
lt 2 defecations / week At least 1 episode of
incontinence / week after the acquisition of
toileting skills H/O excessive stool retention
H/O painful or hard bowel movements Presence of a
large faecal mass in the rectum H/O
large-diameter stools that may obstruct the
toiletAge gt 4 yrs Insufficient criteria for
irritable bowel syndrome Criteria fulfilled
atleast once/ week for atleast 2 months before
diagnosis Two or lt 2 defaecations / week At least
episode of fecal incontinence / week H/O
retentive posturing or excessive volitional stool
retention H/O painful or hard bowel movements
Presence of large fecal mass in the rectum H/O
large diameter stools that may obstruct the
toiltAbdominal pain is a frequent associated
symptom but its presence is not considered a
criterion for functional constipation Infant
dyschezia NHS a sub group of children has
defecation-related difficulties and has been
sub-categorized according to the Rome III has
having infant dyschezia . This is described as
? occurring in infants gt 6 months? atleast 10
minutes of straining and crying before successful
passage of soft stools ? no other health
problemsChildhood constipation is very common
Nearly all childhood constipation is functional
but 5-10 are due to an organic cause Accounts
for up to 25 of referrals to tertiary pediatric
OP clinics Responsible for 3-5 of paediatric
primary care visits Peak incidence is at the time
of toilet training Peak incidence between ages
2-4 yrs Gender differences not clear although
some papers mention it to be ?? in girls
Prevalence varies widely? In the UK 10-20 (
Auth et al, 2002 )? Worldwide 0.8 to 28 ?
Lowest in Finland highest in USA

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Cause unclear possibly multifactorial
Withholding behaviour often starts with a
painful frightening bowel movement -gt stool
remains in rectum gt rectal mucosa rebsorbs water
from retained stool gt becomes more difficult to
evacuate gt vicious cycle gt faecal impaction ,
loss of rectal sensationand ultimately loss of
normal urge to defaecate Diet Slow transit Family
history ie genetic factors may play a role Toilet
training Some behaviour conditions as autism and
ADHD Children with underlying bladder dysfunction
Parental-child rearing attitudes Stress ( e.g
child abuse )Organic causes of constipation in
children include metabolic , endocrine disorders
, anorectal anomalies , neuromuscular disroders
or Hirschsprungs diseaseHistory-What do
parents mean by constipation Delay in passage of
meconium Toilet history -Frequency , consistency
, soiling , blood , pain Age at onset Abdominal
pain -between 10-70 of children with
constipation c/o non-specific abdominal pain
Faecal incontinence ( impaction , overflow ) Diet
and fluid intake ( e.g with cows milk )
Withholding behavior ( e.g retentive posturing )
Urinary symptoms?UTIs and enuresis are reported
in 30 of constipated children Social history
Any treatment tried and response Any medication
use e.g antacids , opiatesExamination Physical
growth ( eg cystic fibrosis , hypothyroidism?
stunted growth failure to thrive )Height / weight
Plot on chart General examination Abdominal
examination ? evidence faecal loading Perineal
inspection- ? particularly infants to r/o
anorectal abnormality? position of anus ( any
anotomical anomalies )? fissures? tags ( clue to
anal fissures )? inflammation Neurological
examination -inspection of spine to exclude spina
bifida or cerebral palsy Rectal examination is
usually not carried out in primary care and would
be done by specialists if they feel it can
provide additional information ( for e.g alarm
signs present , intractable constipation
)Complications Anal fissure Haemorrhoids
Rectal prolapse Megarectum Faecal impaction and
soiling Volvulus Distress ,missed school , poor
school performance , social isolation

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Red flags-Symptoms appear from birth or during
the 1st few weeks of life ( may indicate
Hirschsprungs disease- congenital aganglionic
megacolon )Delayed meconium gt 48 hrs after birth
in a full term baby ( may indicate Hirschsprungs
disease or cystic fibrosis )Abdominal distension
with vomiting- may indicate Hirschsprungs
disease or intestinal obstruction ) Family h/o
Hirschsprungs disease Ribbon stool pattern -may
indicate anal stenosis likely if child lt 1 yr )
Leg weakness or motor delay ( neurological or
spinal cord abnormality )Abnormal appearance of
anus -? fistulae ? bruising ? fissure ? tight or
patalous-widely patent ? anteriorly placed anus?
absent anal wink?reflex contraction of the
external anal sphincter when the skin around anus
is stroked Abnormalities in lumbosacral and
gluteal regions? asymmetry of gluteal muscles?
evidence of sacral agenesis?? scoliosis?
discolored skin? naevi? hairy patch? sinus or
central pitAmber flags- Evidence of faltering
growth , developmental delay or indications of a
systemic illness ( liaise with specialist to
arrange testing for possible Coeliac disease ,
hypothyroidism ,cystic fibrosis and electrolyte
disturbance ) Constipation triggered by the
introduction of cows milk Child maltreatment
concernFaecal impaction Faecal impaction is
defined as a hard mass in the lower abdomen
identified on physical examination or a dilated
rectum filled with a large amount of stool on
rectal examination or excessive stool in the
distal colon on abdominal radiography An
impaction is present in 30 to 75 of constipated
children and more than 90 of children with
faecal incontinence Majority of constipated
children have palpable abdominal masses and/ or
fecal impaction of the rectal on physical
examination

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References

• Management of Childhood Functional Constipation
  Lisa Philchi , MN, CPNP The Journal of Pediatric
  Health Care Jan-Feb 2018 , Volume 32, Issue 1,
  Pages 103-111
• Levy EI, Lemmens R, Vandenplas Y, Devreker T.
  Functional constipation in children challenges
  and solutions. Pediatric Health Med Ther.
  201781927. Published 2017 Mar 9.
  doi10.2147/PHMT.S110940
• Management of Functional Constipation in Children
  Therapy in Practice Koppen, I.J.N., Lammers,
  L.A., Benninga, M.A. et al. Pediatr Drugs (2015)
  17 349. https//doi.org/10.1007/s40272-015-0142-4
  
• Childhood Constipation is There Light in the
  Tunnel Benninga, M A et al Journal of Pediatric
  Gatroenterology and Nutrition Issue Volume 39
  (5), November 2004 , pp 448-464
• Chronic functional constipation and fecal
  inconctinence in infants and children Treatment
  Manu R sood, FRCPCH via Uptodate.com
• CKS NHS Constipation in children revised June
  2019
• Mistakes in paediatric functional constipation
  diagnosis and treatment and how to avoid them
  Marc A Benninga and Daniel R Hoekman UEG
  education Oct 2016
• Evaluation and Treatment of Functional
  Constipation in Infants and Children Evidence
  Based Recommendations From ESPGHAN and NASPGHAN
  JPGN Volume 58, Number 2 , February 2014