Provider News

Functional Constipation: A Q&A with Kyle Lewis, PA-C

March 4, 2020

Constipation is incredibly common in the pediatric population. It affects up to 30% of children, accounts for 3-5% of general pediatric outpatient visits and up to a quarter of all pediatric gastroenterology visits. This represents significant cost to our healthcare system.

Peak prevalence of constipation occurs during preschool years. Painful stooling during this time can lead to withholding of stool. This can lead to harder, less frequent stools, which further reinforces the withholding cycle. Starting daycare or grade school often restricts access to the bathroom and it is common for our patients to avoid stooling in these environments. Other factors that can lead to constipation include diets without enough fruits, vegetables and fiber, inadequate water intake and a lack of physical exercise.

Constipation is a frustrating experience for both children and parents. It often takes a dedicated, long-term, multifactorial approach consisting of behavioral, lifestyle and medication management.

At Seattle Children’s, we use the Rome IV criteria to define constipation in children. There are separate definitions for children older and younger than 4 years old. Our detailed practical clinical protocol for constipation evaluation and treatment, which includes an algorithm, is found here.

Is Seattle Children’s accepting new referrals for functional constipation?

Kyle Lewis, PA-CKyle Lewis

Kyle Lewis, PA-C, Gastroenterology: We are temporarily not accepting new patients with functional constipation. Several of our providers moved on to new opportunities this year, which has created longer-than-normal wait times for new and established patients to see us. We have a backlog of more than 1,000 patients with conditions not considered urgent, for whom we do not currently have available appointment slots. For this reason, we are triaging referrals daily to prioritize those who need to be seen most urgently.

Patients with non-urgent constipation, abdominal pain and GERD are being directed back to their primary care provider for management. We hope to have capacity to see more of these patients again by fall 2020.

If your patient shows alarm symptoms or red flags, please do refer them. Our algorithm for functional constipation can be found on page 12 of the Functional Constipation Clinical Protocol.

A list of functional constipation red flags is available below. Additional physical exam red flags, along with this list, can be found in the protocol document.

Red flags include:

  • Delayed passage of meconium
  • Constipation starting at less than 1 month of age
  • Fever, vomiting and diarrhea
  • Rectal bleeding (without anal fissure)
  • Severe abdominal distention-Ribbon stools
  • Urinary incontinence
  • Failure to thrive
  • Congenital anomalies associated with Hirschsprung disease (Trisomy 21, MEN2A, Smith-Lemli Opitz, Mowat-Wilson)
  • History of physical or sexual abuse

What advice do you have for PCPs managing constipation?

Kyle Lewis: I would set clear expectations for families that management of constipation is a long process, and that adherence to behavioral, lifestyle and medication therapy (when indicated) is important. The length of time that treatment is required often surprises families, so regular reassurance and follow-up during this process can be helpful. Up to 25% of children with functional constipation are dependent on therapy through adolescence and relapses are common.

We usually recommend a cleanout consisting of a stool softener and stimulant if there is concern for impaction, and regular maintenance therapy with a stool softener for a minimum of 3 months and a wean over 6-12 months. Consider regular follow-up communication and visits with families to assess adherence to and effectiveness of the plan.

Resources:

One of the most important behavioral changes that I would like to highlight is the importance of regular toilet sitting. This can be helpful for children with functional constipation and is important especially for children that withhold because they are easily distracted, and for kids that have difficulty sensing the need to use the bathroom because of longstanding constipation. In general, we recommend taking advantage of the gastrocolic reflex by having children sit for 5 minutes after each meal and discussing barriers to using the bathroom at school or outside of the home. Consider incorporating positive reinforcement (such as star charts) and focus on rewarding the effort and process of sitting rather than just stooling. Proper positioning on the toilet includes sitting upright and using a stool to raise the knees to the level of the bottom if needed.

Other behavioral interventions include increasing fiber (use a child’s age plus 5 for an estimate of fiber needs), increasing hydration and recommending regular physical activity.

Should PCPs order labs or abdominal X-rays?

Kyle Lewis: In most cases, organic causes of constipation can be excluded from a detailed history of physical exam. We consider a focused lab evaluation and imaging studies if there is concern for underlying organic pathology or alarm signs. Labs and imaging may also be considered for patients who fail to respond to a management program despite adherence to the plan.

Labs we consider include:

  • CBC and serologic screening for celiac if failure to thrive or recurrent abdominal pain
  • TSH and free T4 in children with impaired linear growth and depressed
  • Electrolytes and calcium for children at risk for electrolyte abnormalities
  • Blood-lead level for children with lead toxicity factors

Abdominal x-rays are not routinely recommended for the evaluation of functional constipation. They can be considered if you are unable to determine if the patient has constipation based on history or if your physical exam is limited by patient cooperation, obesity or deferred for psychosocial concerns.

What resources are available?

Kyle Lewis: Below are resources that are also found on the last page of our Functional Constipation Clinical Protocol.

Seattle Children’s Division of Gastroenterology – Patient Education Resources

External Resources