Inpatient Clinical Pathway for Evaluation/Treatment of Children with Constipation

Cystic Fibrosis patients are excluded from this pathway
Red Flags
  1. First passage meconium after 48 hours of life
  2. Symptom onset < 1 month
  3. Persistent abdominal distention, vomiting
  4. Bloody diarrhea
  5. Bilious emesis
  6. Family history Hirschsprung’s disease
  7. Failure to thrive
  8. Tight rectum gripping finger; explosive stool and air from rectum upon withdrawal examining finger
  9. Midline dimple, tuft of hair over lower back
  10. Lower limb weakness, motor delay
  11. Signs of systemic illness: fever, mouth sores, joint pain, rash
  12. Weight loss

1-8 Concern Hirschprung, 7 Malabsorption

No Red Flags, Low Concern for Underlying Disease
Functional Constipation Likely
  • Acute Surgical Abdomen
  • Hirschprung Disease
  • Medical Disease - GI, Metabolic
  • Neurologic Disease
Child ≥ 6 Months
No Fecal
Impaction
Fecal Impaction and
significant pain, vomiting
Treatment
Effective

Initial Treatment per Rectum

Matches ED
Skip to 2nd Line Treatment if Admit from ED

Treatment Not Effective
at 1 Hour
Clear
Output
Some stool passed.
Abdominal discomfort
improved.
Discharge
arrow
Treatment
Effective
Admit from ED
Treatment Not Effective
at 1 Hour
Reassess constipation diagnosis and etiology
Review H&P
Reevaluate stool burden
Re-assess for presence of Red Flags
Consider:
  • Diagnostic 2-view XR
  • Surgery vs. GI Consult for manual disimpaction or further evaluation
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
Posted: February 2015
Revised: April 2020
Authors: E. Kane, MD; M. Mittal, MD; K. Wagenman, RN; K. Fiorino, MD; C. Jacobstein, MD; R. Verma, MD; X. Morgan, CRNP; S. Peck, APN; C. McIntyre, PharmD; J. Crawford, CNS; A. Shah, MD; L. Utidjian, MD; J. Lavelle, MD