Based on Evaluation and Treatment of Constipation in Infants and Children by NASPGHAN (2006).
HPI: 3 yo M here for WCC. Mother reports pt. stools only 2 times per week. BMs described as hard, brown, and round. Has noticed this infrequent stooling pattern since began potty training at 2.5 yo. Pt. often cries and strains when trying to pass bowel movement. Pt. a "picky" eater who avoids fruits and vegetables. Mother has not tried any treatments and is unsure what makes better or worse.
PMH: No hospitalizations or surgeries. Passed meconium within first day of life.
Allergies: NKDA and No known food allergies or intolerances
FH: Mother has hx of constipation.
SH: Lives with mother, father, and two siblings. In daycare during days.
ROS: Negative for bloody stools, weight loss, N/V/D, fevers, ulcers in the mouth, jaundice, and enuresis.
General: Well appearing, well nourished child in no acute distress. VSS.
Abd: Bowel sounds present x4. Abd soft, non-distended, and non-tender. No HSM. No palpable masses or stool. Rectal opening mid line with no anal fissures.
Neuro: Cranial nerves intact. DTRs +2. No sacral dimple.
Rx: polyethylene glycol (Miralax) 1g / kg / day (max dose = 17g / day)
Increase water intake.
Encourage balanced diet, when possible.
Take Miralax daily.
Mix dose of Miralax in glass of water or juice.
If stools become too loose, reduce Miralax dose. Titrate as needed to achieve soft (peanut butter consistency) stools.
Implement regular, un-rushed toilet time.
1 month, follow-up
Detailed HPI should include onset of symptoms, duration of symptoms, stooling frequency, stool characteristics, diet information, treatments tried, and aggravating / relieving factors.
Reduce suspicion of Hirschsprung Disease.
Some medications can be constipating.
Lactose intolerance and other food allergies can present with constipation.
Negatives reduce suspicion of an organic cause such as IBD, milk protein allergy, or neurologic disease.
No Failure to thrive (rarely seen in functional / diet-based constipation but often seen if organic cause).
Abd exam grossly normal. No signs of fecal impaction.
Reduces suspicion of a neurological cause.
Absence of red flag symptoms coupled with infrequent stooling pattern (2 or fewer BMs / week), hard stool consistency, and low fiber diet.
Osmotic laxative. Non-addicting. Well tolerated.
S/Sx should improve by now. If not, (re)assess for fecal impaction (if present, treat with bowel clean-out regimen), medication adherence, provide additional pt. education, and possibly try different medications and/or doses.
Photo used under Creative Commons from Jim Bahn