The normal frequency and consistency of stool varies with the child’s age and diet; there are also considerable differences from child to child.
Constipation is responsible for up to 5% of pediatric office visits. It is described as a difficult or slow defecation. The normal frequency and consistency of stool varies with the child’s age and diet; there are also considerable differences from child to child. Most (90%) normal newborns have meconium within the first 24 hours of life. During the first week of life, infants have an average of 4 to 8 bowel movements per day; Infants who are breastfed have more bowel movements than infants who are fed with formulas in the rule. During the first months of life, infants who are breastfed, an average of about 2 to 3 bowel movements per day compared to 2 bowel movements per day in infants fed with formulas. By the age of 2 years, the number of bowel movements reduced to slightly <2 / day. From the age of 4 years, it is easy> 1 / day. Usually signs of exertion (eg. As presses) point in a young infant not indicate constipation. The muscles in support of bowel movements develop only gradually in infants. Etiology constipation in children suspected 2 causes: Organic (5%) Functional (95%) Organic causes include Organic causes of constipation specific structural neurological toxic / metabolic disorders or intestinal diseases. They are rare, but important to realize (see Table: Organic causes of constipation in infants and children). The most frequent organic cause is Hirschsprung’s disease Other organic causes that may manifest themselves in the neonatal period or later Anorectal Malformations Cystic Fibrosis metabolic disorders (eg. As hypothyroidism, hypercalcemia, hyperkalemia) spinal abnormalities Functional causes sub-functional causes of blockage is understood reasons that not organic in nature. Children are prone to the development of functional constipation during three periods: After the introduction of grain and solid food during toilet training during the school commencement Each of these milestones has the potential to make the stools an unpleasant experience. Children may feel sometimes beyond the stool because the stool are unpleasant and hard bowel movements or because they do not want to interrupt their game. To avoid bowel movements, it may happen that children contract the external sphincter, which has the consequence that the chair is pushed back. If this behavior is repeated, the rectum stretches to accommodate the retained chair. This reduces the urge to defecate while the chair is harder, leading to a vicious cycle of painful bowel movements and constipation. Occasionally a soft chair by the hard passes and leads to fecal incontinence. In older children, a diet that is low in fiber and rich in Milchproduktien, may be responsible for ensuring that the stool is unpleasant and it is necessary to anal fissures. Anal fissures produce pain during bowel movements, resulting in a similar vicious cycle delayed bowel movements, resulting in a harder chair that is painful to excrete. Stress, desire for control and sexual abuse can also be counted among the causes of functional chair restraint and subsequent constipation. Organic causes of constipation in infants and children due suspects findings Diagnostic procedure Anatomically anal stenosis Delayed bowel movement within the first 24-48 hours of life explosion-like and painful bowel movements Bloated belly abnormal appearance or position of the anus Tense anal canal in digital investigation palpated Clinical Evaluation Front displaced anus severity chronic Ve rstopfung with labeled tension and pain during bowel movements Normally no response to aggressive use of stool softeners and laxatives The anal opening is not in the middle of the pigmented perineum The calculation of the API * indicates a forward position, which varies according to sex. Girl: <0.29 boys: <0.49 anal atresia Bloated stomach No bowel movements abnormal appearance or position of the anus or may not Anus Clinical examination Endocrine or metabolic disorders diabetes insipidus polydipsia polyuria Excessive crying that calmed down after water supply weight loss vomiting osmolality of urine and serum ADH levels serum sodium Sometimes thirst test hypercalcemia Nausea and vomiting muscle weakness abdominal pain anorexia, weight loss polydipsia polyuria serum calcium hypokalemia muscle weakness, polyuria, dehydration Past growth disorders Possible taking aminoglycoside, diuretics, cisplatin or amphotericin electrolyte panel hypothyroidism Poor nutrition bradycardia Large fontanelle in neonates and hypotension sensitivity to cold, dry skin, fatigue, prolonged jaundice thyroid-stimulating hormone (TSH), thyroxine (T4) Spinal cord defects myelomeningocele Stark visible lesion of the spine at birth decrease in the lower extremities or reflexes muscle tone Missing bulbokavernöser reflex Simple radiographs of the lumbosacral spine magnetic resonance imaging of the spine Occult spina bifida tufts of hair or pit at the sacrum magnetic resonance imaging of the spine Unset spine change in gear pain or weakness in the lower extremities Harninkonti incontinence back pain Magnetic resonance imaging of the spine spinal cord tumor or infection back pain or weakness in the lower extremities loss of reflexes in the lower limbs change in transition urinary incontinence magnetic resonance imaging of the spine Intestinal diseases Celiac Disease (Glutenenteropathie) symptom onset after the introduction of wheat in the diet (usually after the age of 4 to 6 months) failure to thrive Recurrent abdominal pain bloating or diarrhea Verstopfu ng blood Serological screening for celiac disease (IgA antibodies against tissue transglutaminase) endoscopy for duodenal biopsy cow's milk protein intolerance (milk protein allergy), vomiting, diarrhea or constipation Hematochezia anal fissures failure to thrive symptom resolution at Beseitiung of cow's milk protein Occasionally endoscopy or colonoscopy Cystic fibrosis Delayed passage of meconium or meconium ileus the newborn Possible repeated episodes of small bowel obstruction (meconium ileus equivalent) in older children failure to thrive Recurrent episodes of pneumonia or wheezing Sweat test genetic testing Hirschsprung's disease Delayed passage of meconium Bloated belly A tense anal canal palpated in digital investigation. Barium enema anorectal manometry and rectal biopsy to confirm irritable bowel syndrome Chronic recurrent abdominal pain often alternating diarrhea and constipation sensation of incomplete emptying disposal of mucus No anorexia or weight loss Clinical evaluation pseudo-bowel obstruction nausea, vomiting abdominal pain and bloating plain abdominal intestinal transit time antroduodenal manometry intestinal tumor weight loss night sweats fever abdominal pain and / or flatulence en Palpable masses in the abdomen intestinal obstruction magnetic resonance imaging cerebral palsy and other serious neurological deficits In most children with cerebral palsy, the intestinal hypotonia and motor paralysis caused gavage Clinical with low-fiber formulas Clinical study medication side effects taking anticholinergics, antidepressants, chemotherapeutics or opioids Unclear medical history Review Toxins Botulism new occurrence of poor sucking, feeding difficulties, anorexia, drooling Weak cry Irritability ptosis Decreasing or global hypotonia and weakness Possible history of honey consumption in the first 12 months of testing on botulinum toxin in the stool lead poisoning Most asymptomatic Possibly intermittent abdominal pain, sporadic vomiting, fatigue, irritability regression lead levels in the blood * The API (anal position index) calculated as success t: Girl: distance from the anus fourchette / distance from the coccyx to the fourchette (normal mean ± SD 0.45 ± 0.08) boys: Distance from the anus scrotum / distance up scrotum (from the coccyx normal mean ± SD 0.54 ± 0 07) SD = standard deviation. Clarification should first be clarified whether this is a functional constipation or constipation with an organic cause. History The history of the current disease in newborns should reveal whether meconium ever came off, and if so at what time. In older infants and children the history of the onset and duration of constipation, frequency and consistency of stools and the dates should document when the symptoms have occurred. It should also be noted that the symptoms of constipation after a certain event occurred that could put the child under stress such. As the introduction of certain foods or toilet training. Important Accompanying symptoms include contamination (fecal incontinence), pain during bowel movements and blood on or in stools. The composition of the diet should be noted, in particular the intake of fluids and fiber. A review of organ systems should ask about symptoms that suggest an organic cause, including recurrence of breastfeeding problems, hypotension and taking honey before 12 months of age (infantile botulism); Sensitivity to cold, dry skin, fatigue, muscle weakness, prolonged neonatal hyperbilirubinemia, frequent urination and excessive thirst (endocrine), changes in gait, pain or weakness in the lower extremities and urinary incontinence (spinal injury); Night sweats, fever and weight loss (cancer) and vomiting, abdominal pain, poor growth and intermittent diarrhea (intestinal disorders). In the history of history should be asked that can lead to constipation, including cystic fibrosis and celiac disease according to known diseases. Exposure to drugs or lead paint dust should be excluded. Physicians should determine whether there was or delayed passage of meconium within the first 24-48 hours of life if it has been previous episodes of constipation. He should also ask whether a family history of constipation known sind.Körperliche examination The physical examination begins how much the child has with the general assessment under his situation and how the general condition of the child (including the condition of skin and hair). Height and weight should be measured and compared with growth standard curves. The investigation should focus on the abdomen and anus and on the neurological exam. The doctor examines whether the abdomen is swollen or bowel sounds are heard. He scans the abdominal wall from sensitivity and hard areas. The anus is examined with great care and attention to fissures. A gentle digital rectal exam is performed to check the stool consistency and to obtain a sample for a test for occult blood. Rectal exam should be paid attention to how tight or tense the anus and whether chair can be found in the rectal vault. The study includes an examination on the placement of the anus and the presence of tufts of hair or pits above the sacrum. In infants, the neurological examination focused on tone and muscle strength. In older children, the focus is on the transition, the tendon reflexes and signs of weakness in the lower Extremitäten.Warnhinweise The following findings are considered to be particularly severe, delayed passage of meconium (> 24-48 h after birth) hypotension and poor sucking (reference to infant botulism ) gait disturbance and tendon reflexes (indicating spinal cord involvement) interpretation of the findings, if newborns have a constipation since birth, in all likelihood exists for an organic cause. If already have newborn contrast, normal digestion had, it is relatively unlikely that there is a serious underlying disease. In older children, are evidence of an organic cause physical symptoms such. As weight loss, fever or vomiting, stagnant growth (decreasing percentile on the growth curve) and a sick-looking overall appearance. Abnormal findings from the physical examination are also included (see Table: Organic causes of constipation in infants and children). A functional disorder is likely when the child looks healthy, has no other symptoms except constipation, has a normal findings on physical examination and takes no medications that cause constipation. A bloated rectum, which is filled with stool or anal fissures can be seen in the context of a functional constipation of an otherwise healthy child. A blockage, which began after taking a drug or leading to blockage associated with a change in diet, may be associated with this drug or another food. Foods that are associated with constipation include dairy products (eg. As milk, cheese, yogurt) and strength as well as finished food that contains no fiber. However, if the blockage occurs after ingestion of wheat should be given to celiac disease. A newly emerged strain such. As a new sibling or other possible causes of constipation associated with normal physical findings support the suspicion of a functional Ursache.Tests For patients suffering from functional constipation, no testing is required, unless there is no improvement after conventional treatment of constipation. A plain abdominal should be made when the finding has not improved after treatment or an organic cause is suspected. Tests on organic causes should be made if the medical history and physical examination was performed (see Table: Organic causes of constipation in infants and children): barium enema, rectal manometry and biopsy (Hirschsprung’s disease) Regular radiograph of the lumbosacral spine; optionally MRT (captive spinal cord or tumor) thyroid stimulating hormone and thyroxine (hypothyroidism) lead levels in the blood (lead poisoning) stool examination for botulinum toxin (infant botulism) welding test and genetic test (cystic fibrosis) calcium and other electrolytes (metabolic imbalance) Serological screening in usually for IgA antibodies against tissue transglutaminase (celiac disease) treatment-specific organic causes of constipation should be treated. Functional constipation is ideally initially treated with: diet behavior modification diet includes the addition of prune juice in the processed foods for infants, increasing the share of fruit, vegetables or other sources of fiber in the diet for older infants and children and increasing fluid intake and reducing of food, which can lead to constipation (eg. as milk and cheese). Behavior modification for older children means that the children are encouraged to walk regularly after every meal on the toilet when they are dry. When children are about to be dry, it is sometimes useful to take a break in the toilet training until the blockage is over. Persistent constipation is treated by the fact that the intestine is emptied and a normal diet and defecation is introduced. The defecation by preparations can be administered orally or rectally. When oral preparations should be taken to defecation, the inclusion of large amounts of liquid is important. The introduction rectal means can be uncomfortable and sometimes difficult to perform. Both methods can be carried out by parents under medical supervision, but sometimes hospitalization is necessary for the defecation when outpatient treatment is not successful. Normally, babies need no elaborate measures. If an intervention however be necessary to submit a glycerin suppository as a rule. For maintaining a healthy gut some children should receive counter fiber supplements as a dietary supplement. When taking these supplements, it is necessary to drink 1-2 liters of water a day (see table: treatment of constipation). Treatment of constipation type of treatment drugs dose Selected side effects defecation Oral Ingestion of a high dose of mineral oil (should not be given to infants <1 year or neurologically impaired children to prevent aspiration) 15-20 ml / age (max. 240 ml / day) over a period of 3 days or until chair appears fecal incontinence, malabsorption of fat soluble vitamins (in case of repeated treatments) Oral polyethylene glycol electrolyte solution 25 ml / kg / h (max. ) Appears to 1000 ml / h by NGT to chair or 20 ml / kg / h for 4 h / day Nausea, vomiting, cramps, bloating oral polyethylene glycol without electrolytes 1-1.5 g / kg dissolved in 10 ml / kg of water once a day for 3 days fecal incontinence rectal glycerin suppository toddlers and older children: 1 / 2-1 suppositories once daily for 3 days or until chair No inlet with mineral oil 2-11 years appears: 64 ml (2.25 oz) once daily for 3 days or to S tuhl appears ? 12 years: 127 ml (4.5 oz) once daily for 3 days or until stool fecal incontinence, mechanical trauma enema with sodium phosphate 2- 4 years appears: 32ml (1.13 oz) once daily for 3 days or until chair appears 5-11 years: 64 ml (2.25 oz) once daily for 3 days or until chair appears ? 12 years: 127 ml (4.5 oz) once daily for 3 days or until chair appears Mechanical trauma, hyperphosphatemia intestinal care products osmotic laxatives and lubricants (oral) lactulose (70% solution) 1 ml / kg 1-2 times daily (at most 60 ml / day) abdominal cramping, bloating, magnesium-sodium hydroxide (400 mg / 5 ml solution) 1-2 ml / kg once a day in the case of overdose risk of hypermagnesemia, hypophosphatemia or secondary hypocalcemia mineral oil 1-3 ml / kg once daily fecal incontinence polyethylene glycol 3350 powder dissolved in water 1-18 months: 1 teaspoon of powder in 60 ml (2 oz) of water 1 time daily> 18 months 3 years old: 1/2 packets powder (8.5 g) in 120 ml (4 oz) of water 1 time daily ? 3 years: 1 sachet (17 g) in 240 ml (8 oz) of water (to be used only for a limited period) 1-times daily fecal incontinence oral laxative bisacodyl (5 mg tablets) 2-11: 1-2 tablets once daily ? 12 years of age: 1-3 tablets once daily fecal incontinence, hypokalemia, abdominal cramps Senna syrup: 8.8 mg sennosides to 5 ml Senna tablets: 8.6 mg sennosides / tablet> 1 year old: 1.25 ml once a day, to 2.25 ml of 2 times daily 2-5 years: 2.5 ml once a day and up to 3.75 ml 2 times a day 6-11 years: 5 ml once daily and to z and 7.5 mL 2 times daily ? 12 years: 1 tablet once a day and up to 2 tablets 2 times daily abdominal cramps, melanosis coli supplements Balla material supplements methylcellulose * <6 years: 0.5 to 1 g 1 times a day 6- 11 years: 1 g 1-3 times daily ? 12 years: 2 g 1-3 times a day less bloating than other fiber supplement psyllium * 6-11 years: 1.25 to 15 g 1-3 times daily ? 12 years : 2.5 to 30 g 1-3 times daily bloating, flatulence Sorbitol-containing fruit juices (eg. B. plum, pear, apple) infants and older children: 30-120 ml (1-4 oz) per day flatulence wheat dextrin * 2-20 years: 5 g plus 1 g per year 1 times daily bloating, flatulence * Numerous commercial products and formulations are available in different concentrations, so that doses are given in gram of the fiber. Important points Functional constipation accounts for about 95% of cases Organic causes are rare, but have to be considered. Delayed passage of meconium> 24-48 h after birth raises the suspicion of a structural disease close, especially Hirschsprung’s disease. Early intervention with nutritional and behavioral changes can treat functional constipation successful.