Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Constipation
Related Pathway
Cystic Fibrosis patients are excluded from this pathway
Red Flags
- First passage meconium after 48 hours of life
- Symptom onset < 1 month
- Persistent abdominal distention, vomiting
- Bloody diarrhea
- Bilious emesis
- Family history Hirschsprung’s disease
- Failure to thrive
- Tight rectum gripping finger; explosive stool and air from rectum upon withdrawal examining finger
- Midline dimple, tuft of hair over lower back
- Lower limb weakness, motor delay
- Signs of systemic illness: fever, mouth sores, joint pain, rash
- Weight loss
1-8 Concern Hirschprung, 7 Malabsorption
- MD/CRNP/RN Rapid Assessment
- History & Physical
- Assess Red Flags, Risk Underlying Disease
- Review Diagnostic Criteria for Constipation
No Red Flags, Low Concern for Underlying Disease
Functional Constipation Likely
Functional Constipation Likely
- Acute Surgical Abdomen
- Hirschprung Disease
- Medical Disease - GI, Metabolic
- Neurologic Disease
Child < 6 Months
Child > 6 Months
Consider Glycerin
Suppository
Suppository
No Fecal
Impaction
Impaction
Fecal Impaction and
Significant pain, vomiting or
Family desire for enema
Significant pain, vomiting or
Family desire for enema
Effective
Not Effective
After 1 Hour
After 1 Hour
Discharge
Admit
Diagnostic Criteria for Constipation
At least 2 criteria present
(symptoms present for at least 2 weeks)
At least 2 criteria present
(symptoms present for at least 2 weeks)
- ≤ 2 defecations per week
- At least 1 episode of incontinence per week after the acquisition of toileting skills
- History of excessive stool retention
- History of painful or hard bowel movements
- Presence of a large fecal mass in the rectum
- History of large-diameter stools that may obstruct the toilet
Fecal Impaction
- History of no stool passage > several days
- History of encopresis
- Stool in rectum on digital rectal exam or in the descending colon/rectum on imaging
- Palpable abdominal stool mass on physical exam
Age | Medication | Dose |
---|---|---|
< 1 yr | Glycerin (pediatric) | 1 suppository if no stool in previous 24 hrs |
≥ 1 yr to < 2 yrs |
NS enema | 10 mL/kg Max dose of 120 mL |
≥ 2 yrs | Sodium Phosphate (Fleet) | 2-11 yrs: Pediatric preparation 66 mL > 12 yrs: Adult preparation 133 mL |
Mineral oil enema | 2-11 yrs: 60 mL ≥ 12 yrs: 133 mL |
Posted: February 2015
Revised: November 2020
Authors: E. Kane, MD; M. Mittal, MD; K. Fiorino, MD; C. Jacobstein, MD; X. Morgan, CRNP; J. Crawford, CNS; A. Shah, MD; L. Utidjian, MD; J. Lavelle, MD; A. Moore, PharmD
Revised: November 2020
Authors: E. Kane, MD; M. Mittal, MD; K. Fiorino, MD; C. Jacobstein, MD; X. Morgan, CRNP; J. Crawford, CNS; A. Shah, MD; L. Utidjian, MD; J. Lavelle, MD; A. Moore, PharmD
Evidence
- Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN
- Diagnosis and management of idiopathic childhood constipation: summary of NICE guidance
Media
- Primary Care Perspectives: Podcast for Pediatricians
Episode 24: Constipation in Children