Emergency Department and Inpatient Clinical Pathway for Evaluation/Treatment of Children with Constipation
Diagnostic Criteria for Constipation
Symptoms present for at least 2 wks with 2 criteria present:
Symptoms present for at least 2 wks with 2 criteria present:
- ≤ 2 defecations per week
- At least 1 episode of incontinence per week after toilet trained
- 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 for more than several days
- History of encopresis
- Stool in rectum on digital rectal exam or in the descending colon/rectum
on imaging - Palpable LLQ abdominal stool mass
ED Team Assessment
- History and Physical
- Review:
- Diagnostic criteria for constipation
- Fecal impaction
- Lab/Radiology considerations
- Review Differential Diagnosis
-
Risk for Alternative Diagnoses
- Differential Diagnosis
- Further workup as indicated
Functional Constipation Likely
Low risk for alternative diagnoses
Low risk for alternative diagnoses
< 12 mos
≥ 12 mos
Consider glycerin suppository
- No fecal impaction
- Mild/moderate pain
- Adequate intake
- Fecal impaction or
- Significant pain
- Vomiting, inadequate intake
Discharge
- Discharge Medications
- Follow-up with PCP for education, maintenance
- Patient Family Education
- The Poo in You Video
- Create/revise Constipation Action Plan
- Some stool passed
- Pain improved
- Tolerating PO
- Not effective at 1 hr
- Pain not improved
- Not tolerating PO
Admit
- Review History and Physical
- Differential Diagnosis
- Lab/Radiology Considerations
- Some stool passed
- Pain improved
- Tolerating PO
Not effective at 1 hr
Reassess for Alternative Cause
- Review History and Physical
- Consider:
- 2-view XR
- Rectal exam if not already completed
- GI vs. Surgery Consult
- Manual disimpaction or further evaluation
- Clear output
- Pain improved
- Tolerating PO
Continued symptoms
Discharge
Further Evaluation as indicated
- Discharge Medications
- Follow-up with PCP for education, maintenance
- Patient Family Education
- The Poo in You Video
- Create/revise Constipation Action Plan
Posted: April 2024
Editors: Clinical Pathways Team
Editors: Clinical Pathways Team
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