January Week 2: Constipation


Evaluation and Treatment of Constipation in Infants and Children

Managing Functional Constipation in Children


1. You receive a call from a nurse taking care of a newborn (60 hours old), who has failed to pass meconium.
(a.) Are you concerned?
(b.) What is the differential diagnosis? Of these, which is the most common? 
(c.) For each of the differentials, what will you look for on exam?

2. A 3 month old girl is brought to the CYAS clinic by her mother for ‘constipation’. She is exclusively breastfed and since birth has had infrequent stools (every 4-5 days), which are thin and ‘stringy’. On exam, she has abdominal distension and an empty rectal vault. She is below the 5th% for height and weight.
(a.) How do you define constipation?
(b.) What is the normal number of stools for infants (breast- vs bottle-fed), toddlers and older children?
(c.) What is the differential diagnosis? For each differential, state what specific questions you would ask in your history.

3. A 7 year old boy is brought to the CYAS clinic by his mother for soiling his pants. This started about 2 weeks ago, prior to which she noticed her son exhibiting odd behaviour, such as rocking, walking stiffly on tip toes and crossing his legs. He has 1-2 bowel movements per week, which are hard, painful and sometimes streaked with blood. Mom states the only change in his life is that she returned to work and drops him off at school early and picks him up from the school daycare later in the evening. You suspect functional abdominal pain.

(a.) What is functional abdominal pain?
(b.) What are the four pillars of the management paradigm?
(c.) What is the mechanism?
(d.) Mom would like to know what behavioural changes she can implement.
(e.) What diet would you recommend?
(f.) You feel a large and hard abdominal mass on abdominal exam and suspect fecal impaction. What medication(s) would you recommend and at what dose? What are the 
(g.) Do you need any imaging or blood work to confirm your diagnosis?
(h.) Your fecal disimpaction plan works and you would now like to start a daily stool softener. What are your options? Which one do you choose and why.
(i.) How long does he need to be on a stool softener?
(j.) At what point do you refer to a paediatric gastroenterologist?

Questions written by Dr. Anica Bulic