A 1992 study showed that 7% of patients presenting to a pediatric emergency department (ED) with abdominal pain were diagnosed with constipation. Misdiagnosis of constipation may lead to multiple unresolved physician visits, utilization of emergency medical services, high doses of ionizing radiation, unnecessary laboratory tests, and even surgical procedures. This issue examines existing literature on constipation, though few randomized double-blind, controlled clinical trials of good quality existed in the literature until recently. The study populations in many articles are obtained from pediatric specialty clinics with subjects who carry a known diagnosis of chronic and often poorly controlled constipation. Analysis of the literature is hampered by lack of a concrete definition of constipation and the variability in outcome measures. The primary evidence-based recommendations are based on published guidelines and include management of constipation in children divided into 3 stages of therapy: (1) disimpaction, (2) maintenance therapy, and (3) behavior modification. Special consideration should be given to neonates and to children with pre-existing medical conditions.
In the middle of a busy shift, you receive a call from a local general pediatrician who would like to transfer a 3-year-old boy whom she suspects has acute appendicitis. She describes the child as extremely uncomfortable, screaming, and grabbing his stomach in intense pain. She would like to have him evaluated by a pediatric surgeon as soon as possible. You accept the patient and agree that transporting the child by ambulance would be the most appropriate method of transfer. Upon arrival, the child is happy, playful, and in no obvious discomfort. This change in behavior is bewildering to his parents who explain to you that this is not the way the child looked earlier. Further history reveals that the child was in his usual state of good health until this morning when he suddenly began grabbing his belly and crying. He has had no fever, one episode of vomiting, which the mother relates to crying, and no stool changes. Your physical examination reveals a playful child who is running around the examination room, who is very well-appearing, and who laughs when you palpate his abdomen. The referring pediatrician has requested blood work, a CT scan, and a surgery consult. You do not want to expose this child to the unnecessary radiation of a CT, nor do you want to ignore the concern of the referring physician. What do you do next?
Constipation is a seemingly benign condition that may be misunderstood as a simple and transient annoyance rather than a chronic condition. Misdiagnosis may lead to expensive, potentially harmful, and often unnecessary workups. Multiple unresolved physician visits, utilization of emergency medical services, high doses of ionizing radiation, unnecessary laboratory tests, and even surgical procedures may be ordered and performed when a simple digital rectal examination or an abdominal radiograph would have provided the diagnosis.1
Alternatively, some children who are appropriately diagnosed with constipation are not treated aggressively enough, parents are not fully educated about the condition and its management, and the diagnosis may be minimized by both the provider and caregiver. One longitudinal study of constipated children found that 30% of subjects continued with complaints into young adulthood, and half of them experienced at least 1 relapse within 5 years of initially successful treatment.2
Lack of a concrete definition of constipation, great variability in the management of this condition, and lack of evidence-based treatment recommendations further complicate the diagnosis and treatment of constipation. Successful management of the constipated pediatric patient depends on accurate diagnosis, appropriate initial and maintenance therapy, detailed parental education, and consistent follow-up.3 The emergency clinician is often the first to make the diagnosis of constipation, plan initial therapy, make appropriate subspecialty referrals, and prevent unnecessary and wasteful evaluations.
To date, much of the evaluation and management of constipation in children is based on opinion, authority, and personal preference rather than evidence. There have been few randomized double-blind controlled clinical trials of good quality in the literature until recently. Furthermore, it is difficult to perform a systemic analysis of the literature because of the lack of a concrete definition of constipation and the variability in outcome measures (ie, definition of treatment success). The study populations in many of these articles are obtained from pediatric specialty clinics with subjects who carry a known diagnosis of chronic and often poorly controlled constipation.
Pijpers et al searched the MEDLINE® and Embase databases for all studies on constipation in children published before December 2007. The researchers assessed the quality of the resulting studies using the Delphi list, a validated quality score tool. They found that only 10 studies were of high quality and concluded that there is no evidence to support the use of one particular method of treatment of constipation over another.4
The author’s search resulted in 33 pertinent references for this article. Of the limited number of quality studies available, even fewer pertain to diagnosis and management in the pediatric ED.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.*
Brandon C. Carr
February 1, 2012