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How to Take on Chronic Childhood Constipation, From Diagnosis to Treatment
Most pediatric constipation can be treated with dietary changes and over-the-counter medications. But what do you do when standard medical management fails?
“Chronic, severe constipation could be a sign of a more serious issue. Untreated constipation can cause side effects ranging from anal fissures to fecal incontinence, which can lead to social anxiety and depression. Pediatricians should refer children to a gastroenterologist for further testing to identify underlying issues if they fail usual treatments for constipation including usual laxatives and diet/lifestyle changes,” says Rinarani Sanghavi, M.D., Director of the Children’s Health℠ Neurogastroenterology and GI Motility Program and Associate Professor of Pediatrics at UT Southwestern, who presented on constipation at the 2019 Pediatric Academic Societies Meeting. “Our goal is to quickly find out what’s causing chronic constipation, and set children up with treatments that get them back to doing what they love most.”
Finding the Source of Chronic, Refractory Constipation
Motility tests can tease out which treatments will work best for each child. In the motility lab, Dr. Sanghavi, and her colleagues use several state-of-the-art tests, including:
- Anorectal manometry tests, which measure anorectal pressures, the sensations in the rectum and neural reflexes. This can help identify issues with pelvic and rectal muscles, such as dyssynergic defecation.
- Colonic manometry tests, which measure pressure to assess colon muscle strength, and can help identify underlying neuropathic or myopathic disorders.
“X-rays aren’t particularly useful because there’s no objective criteria that can determine if it’s a regular or excess amount of stool,” she says.
There are a few exceptions: X-rays may be the best option for obese patients, children who refuse rectal exams or if there’s suspicion of sexual abuse or psychological factors that would make rectal exams inappropriate or traumatic. X-rays are best used when the same person is looking at the stool burden on the x-ray over time in the same patient.
Chronic and severe constipation requires different management approaches, depending on motility test results. Children’s Health offers a number of options, including:
- Biofeedback: We offer the region’s only biofeedback program designed to address dyssynergic defecation – a condition that affects nearly 50 percent of chronic constipation patients. Biofeedback therapy uses a rectal balloon and a computer program to teach children how to contract and relax their pelvic floor muscles.
- Peristeen rectal irrigation system: We’re the only center in North Texas offering the Peristeen rectal irrigation system, which uses an inflatable balloon to generate enough pressure for an enema to be given. The treatment is best for children with weak gluteal muscles.
- Antegrade continence enemas (ACE): This surgical procedure can help children with nerve or muscular issues and/or anorectal malformations overcome chronic constipation – while avoiding daily rectal enemas. During the procedure, a device (called a button) is placed into the beginning of the colon through either the appendix or cecum. This allows the patient to pass saline through the device which then flush out stool from the colon.
The Importance of Long-Term Management
Childhood constipation often requires more than one treatment. In a longitudinal study of 403 children, half had at least one relapse within five years of successful treatment. One-third had symptoms into early adulthood.
“Treating childhood constipation is a marathon, not a sprint,” Dr. Sanghavi says. “To really help these kids, physicians need to continue to monitor patients and follow-up with their parents. Long-term care will help ensure that any relapse is treated quickly and effectively.”