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Constipation in children
PH C
CLINICAL REPORT
SECTION EDITOR
GROWTH AND DEVELOPMENT
Patricia T. Castiglia, PhD, RN, FAAN Dean, University of Texas at El Paso College of Health Sciences Charles and Shirley Leavell Endowed Chair
Constipation in Children
Patricia T. Castiglia, PhD, RN, FAAN
C
onstipation is a problem frequently seen in pediatric practice. Because the exact pathophysiology of constipation has not been well defined, management using one specific therapy is difficult. From a physiologic perspective, some children have delayed colonic transit, and a smaller percentage may have generalized colonic dysmotility. Parents become most frustrated and seek professional help when ordinary measures do not seem to be effective. For example, they may have tried dietary changes or tried to modify their child’s behavior through rewards or punishment. First, it is important to determine whether constipation really exists. Obtaining a complete history is essential. For some people, failure to have a bowel movement every day constitutes a cause for alarm; for others, this is a usual pattern. Constipation is a symptom, not a disease. Most definitions of constipation include the failure to achieve complete evacuation of the lower colon. The cause of constipation may be functional or organic. Functional or idiopathic constipation is common among healthy children. It may, however, become chronic, as evidenced by reports citing that 3% to 5% of all pediatric primary care outpatient visits are for chronic constipation (McClung et al., 1993). It is also estimated that up to 25% of all children seen by primary health care providers for chronic constipation are referred to a pediatric gastroen-
200
terologist. Most of the children who are referred to these specialists have functional constipation. Organic causes are more rare and involve an abnormality of the enteric system. Fortunately, most cases of constipation resolve, that is, they are self-limiting and transient. However, there is a risk that constipation can become a chronic gastrointestinal disturbance.
C
auses of constipation
may include diet, reduced fluid intake, a change in routine, and lack of exercise.
FUNCTIONAL CONSTIPATION Approximately 3% of preschool-aged children and 1% to 2% of school-aged children experience constipation with or without soiling (encopresis) (Felt et al., 1999). Parents often define constipation as hard stools and/or bowel movements that occur every 3 or more days.
When defining chronic constipation, it is best to consider it as a failure to achieve complete evacuation of the lower colon rather than defining it as infrequency or as related to stool firmness (Lake, 1999). For the majority of the children with constipation, parents report that the young child is just “too busy” to go to the bathroom. This holding of stool results in a dilated lower colon, frequent encopresis, and erratic stool patterns (Lake, 1999). Encopresis was presented in the November/December 1987 issue of this Journal (Castiglia, 1987). The reader is referred to this article and other more recent publications for more in-depth information on this topic. Parents usually do not recognize that the child may be trying to keep hard feces out of contact with sensitive portions of the bowel wall and/or trying to reduce the pain caused to anal fissures by defecation. In this situation, that is, fecal holding, the external anal sphincter contracts and forces the feces back into the rectosigmoid, where the feces dry and become hard. This fecal impaction leads to further withholding (Issenman, Filmer, & Gorski, 1999). Thus the cycle of withholding, fecal impaction, and pain becomes established. Other causes of constipation may include diet, reduced fluid intake, a change in routine, and lack of exercise.
J Pediatr Health Care. (2001). 15, 200-202. Copyright © 2001 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2001/$35.00 + 0
25/8/115885
doi:10.1067/mph.2001.115885
July/August 2001
PH GROWTH AND DEVELOPMENT C Excessive drinking of milk, for example, can reduce a child’s appetite for solid food. This scenario is more often seen in toddlers. School-aged children may experience reduced fluid intake. Mothers of young babies frequently report constipation when formulas are changed or when new foods are added to the child’s diet. Furthermore, in today’s society, many children do not get enough exercise. They ride to and from school. After school many “relax” by playing video games or watching television rather than playing outdoors or engaging in other physical activity. Symptoms of constipation include cramping pains that occur when eating large meals, a loss of appetite, and distention of the abdomen in the evening (Lake, 1999). Constipation in babies (1 to 10 weeks of age) is often described in terms of the grunting of the young infant when he or she is having a bowel movement. The infant may have a red face and exhibit straining, sometimes accompanied by crying. By the time a child is in elementary school, the pattern of infrequent defecation has been established, perhaps from as early an age as 1 year. The school-aged child with this stooling pattern will have infrequent and very large bowel movements. Parents often report that the child “plugs” the toilet when defecation occurs. Often the parent becomes even more angry because this unpleasant problem must be handled. The child, in turn, becomes further upset because when he or she finally defecates (often painfully), the parents become angry about the plumbing situation. The cycle is perpetuated. The child may become even more afraid to defecate in school or other sites for fear of plugging the toilet. Fiber deficiency has been identified as a probable contributing factor in constipation because fiber lags behind the increase in other food categories during the preschool period. Consumption of additional dietary fiber will usually increase the frequency of bowel movements. Sometimes parents question the use of iron-fortified formula for infants because they fear the iron content may be causing constipation. Studies have shown that these formulas are not associated with an increased risk of constipation. Actually, therapeutic iron is well tolerated by infants
JOURNAL OF PEDIATRIC HEALTH CARE
Castiglia
and is an important therapy for anemia. Consumption of whole cow’s milk is not associated with constipation, but the question of milk allergy as an associated factor has not been resolved. Nowicki and Bishop (1999) state that insufficient data exist to support routine screening for cow’s milk allergy as a cause of constipation. However, Iacono and colleagues (1998) studied 65 children with chronic constipation and concluded that chronic constipation may be a symptom of intolerance of cow’s milk. Many parents today are interested in homeopathic or natural approaches to management of constipation. Flax seed is a natural stool softener. The seed is simmered in water and the water is used to cook cereal or is given as a tea. Caution must be used with herbs that contain anthraquinone glycosides (eg, Cascara sagrada, senna, and buckthorn bark), because they have a strong laxative effect. Parents using herbs must be made to feel comfortable so they can share this information with the caregiver. Management must include parental involvement.
F
iber deficiency has
been identified as a probable contributing factor in constipation because fiber lags behind the increase in other food categories during the preschool period.
Management focuses on regular complete evacuation of the lower colon, which should be a daily or neardaily goal. Generally 2 to 6 months are required to restore muscle tone (Loening-Baucke, 1993). Stool softeners or mineral oil are used first. Behavior modification also is used, with rewards as a motivation. Stimulants
such as magnesium hydroxide (Milk of Magnesia) or senna (Senokot) are used to help establish regularity. Initial management may require the use of enemas or suppositories, which should be repeated only if the child fails to evacuate more than 3 days after the initial administration (Lake, 1999). After a period of 6 to 8 weeks when the child has two soft stools a day, the condition may be managed with a diet that includes an increased amount of fiber. A study by Nurko, Garcia-Aranda, Worona, and Zlochisky (2000) investigated the use of cisapride for the treatment of constipation in children. Cisapride is a prokinetic agent affecting colonic propulsion. It has been found to be beneficial in adults. The doubleblind placebo-controlled study was conducted during a 2-year period in Mexico. Cisapride was found to be effective, although the response is not immediate. A total of 36 children were included in the study. The investigators do not suggest that cisapride should be used as a first-line drug. The sample studied consisted of children whose constipation was identified as difficult to control and who had been referred for more intensive follow-up. Recovery generally is defined as occurring when the child has 3 or more stools per week with no soiling. If the stool frequency is less than 3 per week, with or without soiling, the maintenance program must be maintained (Felt et al., 1999).
ORGANIC CONSTIPATION Constipation may be a major symptom of disease. In addition to dietary factors discussed, organic causes of constipation include metabolic or endocrine abnormalities, anatomic anorectal anomalies, neuromuscular conditions, and Hirschsprung’s disease. Structural anomalies include anal fissures, perianal abscesses, and hemorrhoids. Rectal prolapse may cause, or result from, constipation. Although it is rare, Hirschsprung’s disease or congenital aganglionic megacolon is the most well-known defect of intestinal mobility. It occurs in only 1 in 5000 births, yet many referrals to pediatric gastroenterologists are made to rule out this condition. Hirschsprung’s disease occurs because of the absence of enteric ganglia in the myen-
July/August 2001
201
PH GROWTH AND DEVELOPMENT C teric (Auerbach’s) plexus and the submucosal (Meissner’s) plexus. “The absence of ganglion cells results in the loss of the inhibitory parasympathetic input, thus inhibiting relaxation of the involved segment” (Nowicki & Bishop, 1999, p. 296). This condition usually occurs in males, and there is no clear inheritance pattern. It is frequently seen in children with Down syndrome. Most cases involve the rectosigmoid colon. In 64% of the cases, the diagnosis is made before the child is 3 months old. Signs and symptoms of Hirschsprung’s disease include constipation, vomiting, diarrhea, distension of the abdomen, and failure to thrive. Bowel perforation or enterocolitis might also occur. Ninety-four percent of newborns with Hirschsprung’s disease fail to pass meconium in the first 24 hours after birth. Children from 3 to 14 years of age with Hirschsprung’s disease (less than a 10% occurrence) have a history of constipation, an absence of retentive posturing, an absence of encopresis, and a history of failure of medical and behavioral therapy (Nowicki & Bishop, 1999). Children with Hirschsprung’s disease do not usually have a history of rectal bleeding or anal fissures. Digital rectal examination is required; it reveals an anal canal and rectum that are narrow and empty. When the finger is removed there may be a sudden expulsion of stool as the obstruction is released. Other diagnostic tests include barium enemas, anorectal manometry, and rectal biopsy. A rectal biopsy is not indicated if the age
Castiglia
at the onset of constipation is after the neonatal period (Ghosh & Griffiths, 1998). Treatment is the surgical resection of the aganglionic segment. Organic causes of constipation usually can be treated successfully. Organic causes of constipation are pursued for children who have suspicious histories or whose physical examination leads to suspicion of an organic cause.
FECAL IMPACTION AND MEGARECTUM Fecal impaction is a filled rectum detected on digital rectal examination. It is frequently observed in children with chronic constipation. Megarectum is a large filled rectum. It results from nerve supply abnormalities or muscle dysfunction that remains after an impaction has been removed. It is not known if a large rectum is the cause of, or is caused by, constipation. Symptoms of fecal impaction include decreased frequency of defecation, passing massive stools, abdominal distension, abdominal pain, and overflow incontinence. It has been suggested that in children with constipation who have an enlarged rectum, the function of the proximal colon is relatively normal up to the rectosigmoid. It is thought that dysfunction in the rectosigmoid might be responsible for delayed chronic transit time (van der Plas et al., 2000).
SUMMARY Constipation in children can be a simple or a complex problem. Each case
requires a carefully obtained history and a complete physical examination. Most cases of constipation are of a functional origin. Those of organic origin require more in-depth discussion than can be presented in this article.
REFERENCES Castiglia, P. (1987). Encopresis. Journal of Pediatric Health Care, 6, 335-337. Felt, B., Wise, C. G., Olsen, A., Kochhar, C., Marcus, S., & Coran, A. (1999). Guideline for the management of pediatric idiopathic constipation and soiling. Archives of Pediatric Adolescent Medicine, 153, 380-385. Ghosh, A., & Griffiths, D. M. (1998). Rectal biopsy in the investigation of constipation. Archives of Diseases in Children, 79, 266-268. Iacono, G., Cavataio, F., Montalto, G., Florena, A., Tumminello, M., Soresi, M., Notarbartolo, A., & Carroccio, A. (1998). Intolerance of cow’s milk and chronic constipation in children. New England Journal of Medicine, 339, 1100-1104. Issenman, R. M., Filmer, R. B., & Gorski, P. A. (1999). A review of bowel and bladder control development in children: How gastrointestinal and urologic conditions relate to problems in toilet training. Pediatrics, 103, 1246-1352. Lake, A. M. (1999). Chronic abdominal pain in childhood: Diagnosis and management. American Family Physician, 59, 1823-1830. Loening-Baucke, V. (1993). Chronic constipation in children. Gastroenterology, 105, 1557-1564. McClung, H. J., Boyne, L. J., Linstheid, T., Heitlinger, L. A., Murray, R. D., Fyda, J., & Li, B. U. (1993). Is combination therapy for encopresis nutritionally safe? Pediatrics, 91, 591-594. Nowicki, M. J., & Bishop, P. R. (1999). Organic causes of constipation in infants and children. Pediatric Annals, 28, 293-300. Nurko, S., Garcia-Aranda, J. A., Worona, L. B., & Zlochisky, O. (2000). Cisapride for the treatment of constipation in children: A doubleblind study. Journal of Pediatrics, 136, 35-40. Van der Plas, R. N., Benninga, M. A., Staalman, C. R., Akkermans, L. M. A., Redekop, W. K., Taminiau, J. A., & Buller, H. A. (2000). Megarectum in constipation. Archives of Diseases in Children, 83, 52-58.
Pediatric Pearl Fiber formula Fiber intake is important for the prevention of constipation and encopresis. To determine the recommended daily intake of fiber in milligrams for a child, use the following formula: the child’s age in years + 5. For example, if a child is 6 years old, his recommended daily fiber intake is 11 mg (6 + 5). Susan Kulewicz, MS, RN, PNP Former PNP Student at Ohio State University Columbus, Ohio
202
Volume 15 Number 4
JOURNAL OF PEDIATRIC HEALTH CARE
CLINICAL REPORT
SECTION EDITOR
GROWTH AND DEVELOPMENT
Patricia T. Castiglia, PhD, RN, FAAN Dean, University of Texas at El Paso College of Health Sciences Charles and Shirley Leavell Endowed Chair
Constipation in Children
Patricia T. Castiglia, PhD, RN, FAAN
C
onstipation is a problem frequently seen in pediatric practice. Because the exact pathophysiology of constipation has not been well defined, management using one specific therapy is difficult. From a physiologic perspective, some children have delayed colonic transit, and a smaller percentage may have generalized colonic dysmotility. Parents become most frustrated and seek professional help when ordinary measures do not seem to be effective. For example, they may have tried dietary changes or tried to modify their child’s behavior through rewards or punishment. First, it is important to determine whether constipation really exists. Obtaining a complete history is essential. For some people, failure to have a bowel movement every day constitutes a cause for alarm; for others, this is a usual pattern. Constipation is a symptom, not a disease. Most definitions of constipation include the failure to achieve complete evacuation of the lower colon. The cause of constipation may be functional or organic. Functional or idiopathic constipation is common among healthy children. It may, however, become chronic, as evidenced by reports citing that 3% to 5% of all pediatric primary care outpatient visits are for chronic constipation (McClung et al., 1993). It is also estimated that up to 25% of all children seen by primary health care providers for chronic constipation are referred to a pediatric gastroen-
200
terologist. Most of the children who are referred to these specialists have functional constipation. Organic causes are more rare and involve an abnormality of the enteric system. Fortunately, most cases of constipation resolve, that is, they are self-limiting and transient. However, there is a risk that constipation can become a chronic gastrointestinal disturbance.
C
auses of constipation
may include diet, reduced fluid intake, a change in routine, and lack of exercise.
FUNCTIONAL CONSTIPATION Approximately 3% of preschool-aged children and 1% to 2% of school-aged children experience constipation with or without soiling (encopresis) (Felt et al., 1999). Parents often define constipation as hard stools and/or bowel movements that occur every 3 or more days.
When defining chronic constipation, it is best to consider it as a failure to achieve complete evacuation of the lower colon rather than defining it as infrequency or as related to stool firmness (Lake, 1999). For the majority of the children with constipation, parents report that the young child is just “too busy” to go to the bathroom. This holding of stool results in a dilated lower colon, frequent encopresis, and erratic stool patterns (Lake, 1999). Encopresis was presented in the November/December 1987 issue of this Journal (Castiglia, 1987). The reader is referred to this article and other more recent publications for more in-depth information on this topic. Parents usually do not recognize that the child may be trying to keep hard feces out of contact with sensitive portions of the bowel wall and/or trying to reduce the pain caused to anal fissures by defecation. In this situation, that is, fecal holding, the external anal sphincter contracts and forces the feces back into the rectosigmoid, where the feces dry and become hard. This fecal impaction leads to further withholding (Issenman, Filmer, & Gorski, 1999). Thus the cycle of withholding, fecal impaction, and pain becomes established. Other causes of constipation may include diet, reduced fluid intake, a change in routine, and lack of exercise.
J Pediatr Health Care. (2001). 15, 200-202. Copyright © 2001 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2001/$35.00 + 0
25/8/115885
doi:10.1067/mph.2001.115885
July/August 2001
PH GROWTH AND DEVELOPMENT C Excessive drinking of milk, for example, can reduce a child’s appetite for solid food. This scenario is more often seen in toddlers. School-aged children may experience reduced fluid intake. Mothers of young babies frequently report constipation when formulas are changed or when new foods are added to the child’s diet. Furthermore, in today’s society, many children do not get enough exercise. They ride to and from school. After school many “relax” by playing video games or watching television rather than playing outdoors or engaging in other physical activity. Symptoms of constipation include cramping pains that occur when eating large meals, a loss of appetite, and distention of the abdomen in the evening (Lake, 1999). Constipation in babies (1 to 10 weeks of age) is often described in terms of the grunting of the young infant when he or she is having a bowel movement. The infant may have a red face and exhibit straining, sometimes accompanied by crying. By the time a child is in elementary school, the pattern of infrequent defecation has been established, perhaps from as early an age as 1 year. The school-aged child with this stooling pattern will have infrequent and very large bowel movements. Parents often report that the child “plugs” the toilet when defecation occurs. Often the parent becomes even more angry because this unpleasant problem must be handled. The child, in turn, becomes further upset because when he or she finally defecates (often painfully), the parents become angry about the plumbing situation. The cycle is perpetuated. The child may become even more afraid to defecate in school or other sites for fear of plugging the toilet. Fiber deficiency has been identified as a probable contributing factor in constipation because fiber lags behind the increase in other food categories during the preschool period. Consumption of additional dietary fiber will usually increase the frequency of bowel movements. Sometimes parents question the use of iron-fortified formula for infants because they fear the iron content may be causing constipation. Studies have shown that these formulas are not associated with an increased risk of constipation. Actually, therapeutic iron is well tolerated by infants
JOURNAL OF PEDIATRIC HEALTH CARE
Castiglia
and is an important therapy for anemia. Consumption of whole cow’s milk is not associated with constipation, but the question of milk allergy as an associated factor has not been resolved. Nowicki and Bishop (1999) state that insufficient data exist to support routine screening for cow’s milk allergy as a cause of constipation. However, Iacono and colleagues (1998) studied 65 children with chronic constipation and concluded that chronic constipation may be a symptom of intolerance of cow’s milk. Many parents today are interested in homeopathic or natural approaches to management of constipation. Flax seed is a natural stool softener. The seed is simmered in water and the water is used to cook cereal or is given as a tea. Caution must be used with herbs that contain anthraquinone glycosides (eg, Cascara sagrada, senna, and buckthorn bark), because they have a strong laxative effect. Parents using herbs must be made to feel comfortable so they can share this information with the caregiver. Management must include parental involvement.
F
iber deficiency has
been identified as a probable contributing factor in constipation because fiber lags behind the increase in other food categories during the preschool period.
Management focuses on regular complete evacuation of the lower colon, which should be a daily or neardaily goal. Generally 2 to 6 months are required to restore muscle tone (Loening-Baucke, 1993). Stool softeners or mineral oil are used first. Behavior modification also is used, with rewards as a motivation. Stimulants
such as magnesium hydroxide (Milk of Magnesia) or senna (Senokot) are used to help establish regularity. Initial management may require the use of enemas or suppositories, which should be repeated only if the child fails to evacuate more than 3 days after the initial administration (Lake, 1999). After a period of 6 to 8 weeks when the child has two soft stools a day, the condition may be managed with a diet that includes an increased amount of fiber. A study by Nurko, Garcia-Aranda, Worona, and Zlochisky (2000) investigated the use of cisapride for the treatment of constipation in children. Cisapride is a prokinetic agent affecting colonic propulsion. It has been found to be beneficial in adults. The doubleblind placebo-controlled study was conducted during a 2-year period in Mexico. Cisapride was found to be effective, although the response is not immediate. A total of 36 children were included in the study. The investigators do not suggest that cisapride should be used as a first-line drug. The sample studied consisted of children whose constipation was identified as difficult to control and who had been referred for more intensive follow-up. Recovery generally is defined as occurring when the child has 3 or more stools per week with no soiling. If the stool frequency is less than 3 per week, with or without soiling, the maintenance program must be maintained (Felt et al., 1999).
ORGANIC CONSTIPATION Constipation may be a major symptom of disease. In addition to dietary factors discussed, organic causes of constipation include metabolic or endocrine abnormalities, anatomic anorectal anomalies, neuromuscular conditions, and Hirschsprung’s disease. Structural anomalies include anal fissures, perianal abscesses, and hemorrhoids. Rectal prolapse may cause, or result from, constipation. Although it is rare, Hirschsprung’s disease or congenital aganglionic megacolon is the most well-known defect of intestinal mobility. It occurs in only 1 in 5000 births, yet many referrals to pediatric gastroenterologists are made to rule out this condition. Hirschsprung’s disease occurs because of the absence of enteric ganglia in the myen-
July/August 2001
201
PH GROWTH AND DEVELOPMENT C teric (Auerbach’s) plexus and the submucosal (Meissner’s) plexus. “The absence of ganglion cells results in the loss of the inhibitory parasympathetic input, thus inhibiting relaxation of the involved segment” (Nowicki & Bishop, 1999, p. 296). This condition usually occurs in males, and there is no clear inheritance pattern. It is frequently seen in children with Down syndrome. Most cases involve the rectosigmoid colon. In 64% of the cases, the diagnosis is made before the child is 3 months old. Signs and symptoms of Hirschsprung’s disease include constipation, vomiting, diarrhea, distension of the abdomen, and failure to thrive. Bowel perforation or enterocolitis might also occur. Ninety-four percent of newborns with Hirschsprung’s disease fail to pass meconium in the first 24 hours after birth. Children from 3 to 14 years of age with Hirschsprung’s disease (less than a 10% occurrence) have a history of constipation, an absence of retentive posturing, an absence of encopresis, and a history of failure of medical and behavioral therapy (Nowicki & Bishop, 1999). Children with Hirschsprung’s disease do not usually have a history of rectal bleeding or anal fissures. Digital rectal examination is required; it reveals an anal canal and rectum that are narrow and empty. When the finger is removed there may be a sudden expulsion of stool as the obstruction is released. Other diagnostic tests include barium enemas, anorectal manometry, and rectal biopsy. A rectal biopsy is not indicated if the age
Castiglia
at the onset of constipation is after the neonatal period (Ghosh & Griffiths, 1998). Treatment is the surgical resection of the aganglionic segment. Organic causes of constipation usually can be treated successfully. Organic causes of constipation are pursued for children who have suspicious histories or whose physical examination leads to suspicion of an organic cause.
FECAL IMPACTION AND MEGARECTUM Fecal impaction is a filled rectum detected on digital rectal examination. It is frequently observed in children with chronic constipation. Megarectum is a large filled rectum. It results from nerve supply abnormalities or muscle dysfunction that remains after an impaction has been removed. It is not known if a large rectum is the cause of, or is caused by, constipation. Symptoms of fecal impaction include decreased frequency of defecation, passing massive stools, abdominal distension, abdominal pain, and overflow incontinence. It has been suggested that in children with constipation who have an enlarged rectum, the function of the proximal colon is relatively normal up to the rectosigmoid. It is thought that dysfunction in the rectosigmoid might be responsible for delayed chronic transit time (van der Plas et al., 2000).
SUMMARY Constipation in children can be a simple or a complex problem. Each case
requires a carefully obtained history and a complete physical examination. Most cases of constipation are of a functional origin. Those of organic origin require more in-depth discussion than can be presented in this article.
REFERENCES Castiglia, P. (1987). Encopresis. Journal of Pediatric Health Care, 6, 335-337. Felt, B., Wise, C. G., Olsen, A., Kochhar, C., Marcus, S., & Coran, A. (1999). Guideline for the management of pediatric idiopathic constipation and soiling. Archives of Pediatric Adolescent Medicine, 153, 380-385. Ghosh, A., & Griffiths, D. M. (1998). Rectal biopsy in the investigation of constipation. Archives of Diseases in Children, 79, 266-268. Iacono, G., Cavataio, F., Montalto, G., Florena, A., Tumminello, M., Soresi, M., Notarbartolo, A., & Carroccio, A. (1998). Intolerance of cow’s milk and chronic constipation in children. New England Journal of Medicine, 339, 1100-1104. Issenman, R. M., Filmer, R. B., & Gorski, P. A. (1999). A review of bowel and bladder control development in children: How gastrointestinal and urologic conditions relate to problems in toilet training. Pediatrics, 103, 1246-1352. Lake, A. M. (1999). Chronic abdominal pain in childhood: Diagnosis and management. American Family Physician, 59, 1823-1830. Loening-Baucke, V. (1993). Chronic constipation in children. Gastroenterology, 105, 1557-1564. McClung, H. J., Boyne, L. J., Linstheid, T., Heitlinger, L. A., Murray, R. D., Fyda, J., & Li, B. U. (1993). Is combination therapy for encopresis nutritionally safe? Pediatrics, 91, 591-594. Nowicki, M. J., & Bishop, P. R. (1999). Organic causes of constipation in infants and children. Pediatric Annals, 28, 293-300. Nurko, S., Garcia-Aranda, J. A., Worona, L. B., & Zlochisky, O. (2000). Cisapride for the treatment of constipation in children: A doubleblind study. Journal of Pediatrics, 136, 35-40. Van der Plas, R. N., Benninga, M. A., Staalman, C. R., Akkermans, L. M. A., Redekop, W. K., Taminiau, J. A., & Buller, H. A. (2000). Megarectum in constipation. Archives of Diseases in Children, 83, 52-58.
Pediatric Pearl Fiber formula Fiber intake is important for the prevention of constipation and encopresis. To determine the recommended daily intake of fiber in milligrams for a child, use the following formula: the child’s age in years + 5. For example, if a child is 6 years old, his recommended daily fiber intake is 11 mg (6 + 5). Susan Kulewicz, MS, RN, PNP Former PNP Student at Ohio State University Columbus, Ohio
202
Volume 15 Number 4
JOURNAL OF PEDIATRIC HEALTH CARE