Note from the National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline recommendations. Refer to the full text for additional information, including detailed information on dosing, possible side effects, and other interventions.
Each recommendation is identified as falling into one of five categories of evidence, indicated by a bracketed Roman numeral. The five categories represent varying levels of clinical confidence regarding the recommendation.
Definitions for the categories of evidence (I, II-1, II-2, II-3, III) are provided at the end of the "Major Recommendations" field.
General Recommendations
A thorough history and physical examination are an important part of the complete evaluation of the infant or child with constipation [III].
Performing a thorough history and physical examination is sufficient to diagnose functional constipation in most cases [III].
A stool test for occult blood is recommended in all constipated infants and in those children who also have abdominal pain, failure to thrive, diarrhea or a family history of colonic cancer or polyps [III].
In selected patients, an abdominal radiograph, when interpreted correctly, can be useful to diagnose fecal impaction [II-2].
Rectal biopsy with histopathologic examination and rectal manometry are the only tests that can reliably exclude Hirschsprung disease [II-1].
In selected patients, measurement of transit time using radiopaque markers can determine whether constipation is present [II-2].
Recommendations for Infants
In infants, rectal disimpaction can be carried out with glycerin suppositories. Enemas are to be avoided [II-3].
In infants, juices that contain sorbitol, such as prune, pear, and apple juice, can decrease constipation [II-3].
Barley malt extract, corn syrup, lactulose, or sorbitol (osmotic laxatives) can be used as stool softeners [III].
Mineral oil and stimulant laxatives are not recommended for infants [III].
Recommendations for Children
In children, disimpaction can be achieved with either oral or rectal medication, including enemas [II-3].
In children, a balanced diet, containing whole grains, fruits, and vegetables, is recommended as part of the treatment for constipation [III].
The use of medications in combination with behavioral management can decrease the time to remission in children with functional constipation [I].
Mineral oil (a lubricant) and magnesium hydroxide, lactulose, and sorbitol (osmotic laxatives) are safe and effective medications [I].
Rescue therapy with short-term administration of stimulant laxatives can be useful in selected patients [II-3].
Senna and bisacodyl (stimulant laxatives) can be useful in selected patients who are more difficult to treat [II-1].
Polyethylene glycol electrolyte solution, given in low dosage, may be an effective long-term treatment for constipation that is difficult to manage [III].
Biofeedback therapy can be effective short-term treatment of intractable constipation [II-2].
Definitions:
Categories of the Quality of Evidence
I Evidence obtained from at least one properly designed randomized controlled study.
II-1 Evidence obtained from well-designed cohort or case-controlled trials without randomization.
II-2 Evidence obtained from well-designed cohort or case-controlled analytic studies, preferably from more than one center or research group.
II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
