Constipation/Behavioral Issues

Educational Objectives

The goals of this program are to improve management of constipation in children and to improve the health care providers’ ability to counsel parents about behavior management of children with attention deficit/hyperactivity disorder (ADHD). Af­ter hearing and assimilating this program, the clinician will be better able to:

1.   Identify red flags that indicate an organic cause of constipation.

2.   Explain the physiology of stooling.

3.   Diagnose and treat functional constipation by addressing withholding, disimpaction, maintenance therapy, behav­ioral modification, and toilet hygiene.

4.   List predictors of negative outcomes in children with chronic constipation.

5.   Describe simple behavior-modification techniques for parents of children with ADHD and/or other behavioral is­sues.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Zella presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgments

Dr. Zella spoke in Boston, MA, at Primary Care Pediatrics, presented December 2-4, 2009, and sponsored by the Harvard Medical School Department of Continuing Education. Dr. Commins spoke in Hyannis, MA, at Cape Cod Conference on Pe­diatrics for the Primary Care Physician, presented July 31 to August 2, 2009, by Nemours Children's Clinic. The Audio-Di­gest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Note: The 2010 Conference, Primary Care Pediatrics, will be held December 1-3, 2010, in Boston, MA. For more in­formation, visit http://cme.med.harvard.edu/.

Constipation in Children: Let’s Get That Traffic Moving

Garrett C. Zella, MD, Instructor, Department of Pediatrics, Harvard Medical School, Boston, MA

Definition of constipation: North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) defines as delay or difficulty in defecation, present for ³2 wk and sufficient to cause significant dis­tress to patient

Normal stooling: adults  —  3 times per day to 3 times per week; 1 to 2 times per week normal in some people; infants  —  average ³4 times per day to 2 times per day at age 2 yr; large range of stooling frequency for breastfed infants (multiple times per day to 1 time per week); age ³4 yr  —  average 1 to 2 (1.2) times per day (similar to adult stooling patterns)

Prevalence of constipation: in children  —  reported rates vary from 0.3% to 28%; accounts for 3% of general pediatrics visits and 25% of pediatric gastrointestinal (GI) specialist visits; increased prevalence in patients with cerebral palsy (CP) or autism underscores role of neurology and behavior

Stooling physiology: stool enters rectum; at rest, flexed puborectalis muscles keep sigmoid-rectum angle sharp to in­hibit defecation; after stool enters, internal anal sphincter (IAS; under involuntary control) relaxes and accommo­dates stool; simultaneously, external anal sphincter (EAS; partially under voluntary control) contracts; Valsalva maneuver leads to puborectalis relaxation, which allows obtuse sigmoid-rectum angle and EAS relaxation, and re­sults in release of stool

Defects of stooling physiology: decreased propulsive forces in colon  —  hypothyroidism; Hirschsprung’s disease (en­teric system allowing adequate motility absent); impaired rectal sensation  —  due to spinal cord lesion; as result of chronic fecal retention; functional outlet obstruction of anal sphincter complex  —  will of child; spasticity of levator ani or puborectalis in patients with CP

Red flags for organic disease: onset at <1 yr of age; delayed passage of meconium, no history of stool withholding or soiling, failure to thrive, and tight anal sphincter with explosive release of stool on rectal examination may indicate Hirschsprung’s disease; empty rectum; abnormal neurologic examination (particularly in lower extremities); heme-positive stools (observed with allergies or, rarely, with Crohn’s disease); intermittent diarrhea also may indicate Crohn’s disease; no response to conventional treatment

Evaluation: evidence of withholding reduces likelihood of organic disorder; confirming impaction  —  in larger pa­tients, kidneys, ureter, and bladder (KUB) x-rays may allow visualization of impaction in pelvic area beneath abdo­men (beyond finger-length); rectal examination  —  poor negative predictive value (ie, lack of stool does not rule out impaction); good positive predictive value (ie, finding impaction indicates constipation); perform examination slowly to avoid causing painful spasms of sphincter; laboratory studies  —  NASPGHAN recommends 4 sets for complicated constipation and failures of initial therapy; thyroid function; electrolytes and calcium for hypernatre­mia, hyperkalemia, and hypercalcemia; screening for celiac disease; lead level; NASPGHAN criteria for GI referral  —management of complex cases; failure of therapy; concern for organic disease

Functional Constipation

Terminology: also referred to as functional fecal retention or fecal withholding

Physiology: stool enters rectum; IAS relaxes and accommodates stool; voluntary puborectalis and EAS contraction results in more sigmoid-rectum accommodation; stool travels upward; cycle repeats; withholding cycle  —  episode of painful defecation; child withholds to avoid further pain; withheld stools become larger and drier and therefore reinforce pain on defecation; causes toilet clogging, incontinence, and negative attention; results in more anxiety and more withholding

Counseling of parents: educate  —  demystify; explain commonness of withholding; empower to  —  change medication dos­ages; make changes in household; teach other family members about issues; follow through with instructions; encourage  —  reassure about their handling of situation and of your support

Disimpaction: better outcomes if pursued aggressively; speaker does not use enemas due to psychologic trauma sur­rounding emphasis on rectum; polyethylene glycol 3350 (PEG 3350; eg, Miralax)  —  1 to 1.5 g/kg per day for 3 days; for teenagers, 3 capfuls per day; if responsive, may reduce to 2 capfuls per day; if no response, continue 3 capfuls per day; divide into 2 doses if giving >17 g/day; warn parents about cramping; other therapies  —  known to be effective, but no controlled trials in literature; osmotic agents (eg, large doses of magnesium hydroxide [eg, Milk of Magnesia] or various doses of magnesium citrate); mineral oil in adequate amounts (however, compliance diffi­cult); bisacodyl (eg, Dulcolax) effective, but cramp-inducing

Maintenance therapy

PEG 3350: nonabsorbable; cannot be fermented by bacteria; however, patient may perceive movement of stool as gas; studies show superior palatability and similar efficacy to other osmotic agents; recent large multicenter study found less abdominal pain and soiling with 0.4 g/kg per day vs 0.8 g/kg per day; speaker advises erring on side side of stool being soft; uses in infants ³6 mo of age (lactulose in infants <6 mo of age); speaker’s tips for use of PEG 3350  —  every parent fearful of addiction potential; reassure parent of medication’s inert and nonabsorbable qualities; consistent ad­ministration key; inconsistency may result in painful stools and reinitiation of withholding; best given in morning (bed­time administration may cause cramping); change doses by one-fourth capful or 1 tsp (less if taking small dose) and allow 2 to 3 days between dose changes; remind parents to mix into fluid (8 oz for 17 g); mixing with carbonated bev­erages or milk not recommended; mixing with flavored drinks best; dissolves better when warm

Stimulants: useful intermittently; bisacodyl or senna (eg, regular strength chocolate-flavored Ex-Lax); stimulates high-amplitude propagating contractions; speaker uses either 5 mg of bisacodyl or 1 small square of chocolate-fla­vored senna (1 dose per day for 2 days) along with osmotic agent (2 doses per day for 2 days); stimulants can be both helpful and harmful in preventing child from “holding on” to stool; may cause or exacerbate leakage around large fecal mass; “lazy” colon will not develop if use limited to small amount every other day for short course

Dietary factors: sorbitol and fructose in juices helpful; fiber  —  may help or hurt; evidence not sufficient for consensus statement; may worsen impaction; parents should not force any diet; iron  —  no proven relationship to constipation; food allergies  —  NASPGHAN suggests trial of removal of cow's milk from diet; double-blind crossover study of 65 chronically constipated children compared effects of drinking cow’s milk vs soy milk; 68% in soy milk group im­proved in 2 wk; 70% of soy milk-responders radioallergosorbent test (RAST)-positive to cow’s milk; likelihood of anal fissures (painful condition) increased in children with milk allergy; RAST suggested if child constipated and has eczema or family history of food allergy

Future maintenance therapies: aimed at increasing motility; 95% of serotonin in GI system; tegaserod (Zelnorm)  —off market due to cardiovascular side effects; increases secretion by acting as serotonin agonist; decreases vis­ceral afferent stimulation (reduces pain); prucalopride  —not approved as of December 2009; serotonin agonist; lubiprostone (Amitiza)  —  fatty acid metabolite; activates GI chloride channels, which leads to increased intestinal secretion; effective in adults with constipation or constipation-predominant irritable bowel syndrome (IBS); re­sults in children pending

Goals of treatment: “soft-serve ice cream-like stools”, 1 or 2 times per day; no leakage; no pain

Behavior modification: toilet time  —  5 min, 3 times per day; best toilet times in morning and after meals; limit time on toilet; reward toilet time, not stools, with sticker chart and gift; discourage discussing stools in child’s presence; for older child  —  encourage finding ways to stool away from home (“everybody needs an away game”); remind child to respond to stooling urges (“listen to your body”); acknowledge that “nobody poops at school”; discuss ways to overcome fear of public toilets; schedule toilet time before and after school; encourage use of private toilet in nurse's office; toilet hygiene  —  place books or box under feet to prevent dangling (ie, to avoid flexing of rectal muscles); knees should be bent at 90º angle; blowing up balloons while on toilet counters anal sphincter dyssyner­gia (ie, contraction of muscles during pushing; present in »50% of children with functional fecal retention)

Treatment expectations: 60% to 90% of children improve after 1 yr of treatment; first prospective study  —  >400 children with functional constipation; median age 8 yr; followed for 5 yr; 60% had resolved at 1 yr (80% at 5 yr); fecal incontinence and onset at <4 yr of age predicted negative prognosis; 50% of subjects relapse; second prospec­tive study  —  62 children; mean age 5 yr; followed for 5 yr; 50% of subjects improved after 5 yr; negative predictors included onset at <1 yr of age and family history of constipation; questionnaire-based study  —  compared adults with history of childhood constipation to adults with history of childhood GI disorders without constipation; 55% of adults with childhood constipation had IBS, vs 23% in controls; fourth study  —  compared adults with history of childhood constipation to those without; found that adults with successful childhood outcomes had higher quality of life (QOL); adults with unsuccessful childhood outcomes (ie, constipation) had lower QOL, general sense of poor health, and trouble with social contact and intimacy

Key points: functional constipation and withholding very common; recognize red flags, but prepare to treat withholding; educate, empower, and encourage parents; “clear the traffic jam”, “keep the flow”, and get child on toilet; prepare for long ride and relapses, but hopefully with success after 1 yr

Behavioral Therapy on a Post-it Note

Stephen Commins, MD, Chief of Behavioral Pediatrics, Nemours Children's Clinic, Orlando, FL

Case study: Susie  —  bright verbal active 9-yr-old girl; diagnosed at age 5 yr with attention-deficit/hyperactivity dis­order (ADHD); despite frequent attempts to manage behavior, including rewards, punishments, consequences, threats, and occasional corporal punishment, negative behaviors persist at home; good student; seldom receives negative school report; medication helped greatly with attention and activity; however, parents frustrated that after years of treatment, she requires frequent reminders or redirection; no coexisting mood disorders, learning disabili­ties, or health problems; parents live together, but provide inconsistent behavior-management styles; father reports that Susie often obeys him, but mother claims child seldom obeys without argument; both parents regularly display anger when frustrated

Management: meet with child before meeting with parents; speaker does not usually encounter resistance from par­ents; goal to understand (without parents present) child’s perspective on his or her behavior and parents’ response to behavior; speaker suggests asking child to identify parents’ behavior and communication toward him or her, even with parents present; instruct parents to focus on 3 specific behaviors; suggests that writing behaviors on Post-it note with parents present more powerful than giving preprinted copies; instruct parents to be consistent with behav­ioral therapy over time, consistent with each other, and to use techniques without emotion; anger in itself accept­able, but actions and language during anger often problematic

Three rules: 1) the less said, the better  —  when child asked if parents talk too much or give multiple explanations for task, he or she usually responds affirmatively; observe parents’ eyes (parent who diverts eyes often guilty of exces­sive talking); instruct parents to keep directions brief, without repeating; if repetition needed, do so without addi­tions; 2) no questions  —  eg, “what did I tell you to do?”; “do you want to get punished?”; “how many times do I have to tell you not to do that?”; explain rule in respectful manner without criticism; some parents sensitive when made aware of incorrect behavior; explain futility of asking questions that have no acceptable answers; 3) no emotion  —  emphasize that first 2 rules must be carried out without emotion; all households have problems with ³1 rule; third rule most problematic; instruct parents to discuss their frustration and anger with child calmly; other fac­tors (eg, bad day, spouse home late, financial issues) having little to do with child contribute to parents’ emotional state; respectfully tell parents that no excuses for emotional outbursts acceptable; children learn anger behavior from parents; tell parents to model positive behavior for their children; some parents more difficult to influence (may themselves have, eg, ADHD, mood disorders); show sensitivity to these parents, but ensure that they under­stand importance of positive behavior modeling

After behavior management: instruct parents to work on behavior management every day for 3 wk and to then re­turn for follow-up; at return visit, parents report noticing improvement; level, tone, or amount of time spent discuss­ing bad behavior diminishes because parents kept interactions brief; speaker suggests that if parents work on behavior management for 3 wk and child still difficult to manage, then internal, impulse control, ADHD-associ­ated, or mood disorder-associated behaviors not related to parents’ communication style; instruct parents to con­tinue new behavior management techniques; focus on child and assess need for therapy, counseling, or medications; even in child with severe ADHD, speaker recommends working on behavior management before starting medication; behavior management always initiated before medication in children <5 yr of age; if necessary to contradict parent in child's presence, do it without condescension

Suggested Reading

Benninga MA et al: Childhood constipation: is there new light in the tunnel?. J Pediatr Gastroenterol Nutr 5:39, 2004; Borowitz SM et al: Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome. Pediatrics 4:115, 2005; Gremse DA et al: Comparison of polyethylene glycol 3350 and lactulose for treatment of chronic constipation in children. Clin Pediatr 4:41, 2002; Hautmann C et al: Does parent management training for children with externalizing problem behavior in routine care result in clinically significant changes? Psychother Res 2:19, 2009; Iacono G et al: Intolerance of cow's milk and chronic constipation in children. N Engl J Med 16:339, 1998; Khan S et al: Long-term outcome of functional childhood constipation. Dig Dis Sci 1:52, 2007; Loening-Baucke V, Pashankar DS: A randomized prospective, comparison study of polyethylene glycol 3350 without electrolytes with milk of magnesia for children with constipation and fecal incontinence. Pediatrics 2:118, 2006; Michail S et al: Polyethylene glycol for constipation in children younger than eighteen months old. J Pediatr Gastroenterol Nutr 2:39, 2004; 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 3:43, 2006; Nurko S et al: PEG3350 in the treatment of childhood constipation: a multicenter, double-blinded, placebo-controlled trial. J Pediatr 2:153, 2008; Rasquin A et al: Childhood functional gastrointestinal disorders: child/ado­lescent. Gastroenterology 5:130, 2006; van den Hoofdakker BJ et al: Effectiveness of behavioral parent training for children with ADHD in routine clinical practice: a randomized controlled study. J Am Acad Child Adolesc Psychiatry 10:46, 2007; van Ginkel R et al: Childhood constipation: longitudinal follow-up study beyond puberty. Gastroenterology 2:125, 2003; Youssef NN et al: Dose response of PEG 3350 for the treatment of childhood fecal impaction. J Pediatr 3:141, 2002.