ORIGINAL ARTICLE

Acute Constipation in Children Receiving Chemotherapy

for Cancer
Farzana D. Pashankar, MD,* J. Hale Season, BS,w Joseph McNamara, MD,*
and Dinesh S. Pashankar, MDz

Background: Constipation occurs in children receiving chemotherapy for cancer but there are no data about prevalence, risk factors,
and severity of constipation in this group of children.
Methods: We prospectively studied 61 children receiving chemotherapy for cancer. We administered questionnaires to children
and parents and collected data on demographics, chemotherapy,
and bowel movement pattern during chemotherapy. We used
North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition criteria for the diagnosis of constipation.
Parental perception of constipation as a problem and impact on
lifestyle during chemotherapy were assessed on a 0 to 3 scale with 0
being no problem, 1 minor, 2 signicant, and 3 being a major
problem.
Results: Thirty-ve children (57%) had acute constipation lasting
for 2 or more weeks during chemotherapy. Several risk factors were
analyzed and only combined use of vincristine and opiates emerged
as signicant risk factor for the development of constipation. In
children with constipation, 15 of 35 parents (43%) perceived
constipation as a major/signicant problem and 8 children and
their parents (23%) perceived constipation having a major/signicant impact on lifestyle during chemotherapy.
Conclusions: Acute constipation was diagnosed in 57% of children
receiving chemotherapy for cancer. Combined use of vincristine
and opiates was associated with the development of constipation.
Constipation can be a signicant problem with a negative impact
on lifestyle during chemotherapy and needs aggressive management.
Key Words: constipation, cancer, chemotherapy, children

(J Pediatr Hematol Oncol 2011;33:e300e303)

ancer chemotherapy is associated with multiple adverse

eects in children, including gastrointestinal symptoms
such as nausea, vomiting, and constipation. Nausea and
vomiting are common adverse eects and there are many
well-designed studies on prophylaxis and treatment of these
complications.1,2 However, there are no studies addressing
the issue of constipation in children on chemotherapy. A
recent systematic review of treatments for constipation in
Received for publication August 20, 2010; accepted February 6, 2011.
From the *Section of Pediatric Hematology-Oncology; zSection of
Pediatric Gastroenterology; and wDepartment of Pediatrics, Yale
University School of Medicine, New Haven, CT.
This study was supported by Takeda Pharmaceuticals North America,
Inc, Deereld, IL.
The authors declare no conict of interest.
Reprints: Dinesh S. Pashankar, MD, Division of Pediatric Gastroenterology, Department of Pediatrics, Yale University School of
Medicine, 333 Cedar Street, FMP 408, New Haven, CT 06520-8064
(e-mail: Dinesh.Pashankar@yale.edu).
Copyright r 2011 by Lippincott Williams & Wilkins

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children and young adults on chemotherapy failed to nd a

single suitable study in the literature on this topic.3
Constipation is a commonly recognized complication
in adult patients with cancer on chemotherapy and has been
the subject of many studies and reviews.46 Our clinical observation suggests that acute constipation is very common
in children receiving chemotherapy for cancer. In a survey
of 12 pediatric oncology units from the United Kingdom,
all units reported constipation as a problem for patients.7
However, this study did not have any interaction with
patients and did not have any data about the prevalence of
constipation. To the best of our knowledge, there are no
reports or prospective studies on constipation in children
with cancer.
We planned a prospective study to assess the prevalence of constipation in children on chemotherapy for cancer.
We investigated various risk factors for the development of
constipation on chemotherapy and also attempted to assess
the severity of the problem as perceived by children and
their parents.

METHODS
Children (up to 21 y of age) who received chemotherapy for cancer at Yale New Haven Childrens Hospital
were eligible for the study. We approached 62 children who
were seen consecutively between June 2008 and February
2009 in pediatric oncology clinics. Only 1 child declined the
study. Sixty-one children and their parents were interviewed
in person and a questionnaire was administered. The demographic data including age, sex, weight, and height were
obtained. Body mass index was calculated and obesity was
dened as body mass index above the 95th percentile for
age and sex. Detailed information about the diagnosis and
type of cancer and use of various medications including
chemotherapy was collected from the children/parents and
hospital charts.
Children and parents were asked about various bowel
movement parameters during chemotherapy period to
assess for constipation. Constipation was dened by using
the North American Society of Pediatric Gastroenterology,
Hepatology, and Nutrition (NASPGHAN) criteria.8 The
NASPGHAN criteria dene constipation as a delay or
diculty in defecation for 2 or more weeks and sucient to
cause signicant distress to the patient.8 We also evaluated
bowel movement parameters such as 2 or fewer defecations
in the toilet per week, episodes of fecal incontinence (in
children above 4 y of age), retentive posturing or stool retention, painful or hard bowel movements, and large stools
that obstruct the toilet. These criteria have been used in
Rome III criteria for constipation.9 Parents were also asked

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Volume 33, Number 7, October 2011

Constipation in Children Receiving Chemotherapy

about temporal relationship between constipation and

medications including chemotherapy.
Details about any specic visits for constipation to
physician and use of prophylactic or therapeutic laxatives
during chemotherapy period were noted. We asked children
and parents whether they perceived constipation as a problem during chemotherapy on a scale of 0 to 3, with 0 being
no problem, 1 minor, 2 signicant, and 3 being a major
problem. Similarly, impact of constipation on lifestyle during chemotherapy was assessed on a same scale of 0 to 3
with 0 being no impact, 1 minor, 2 signicant, and 3 major.
We explained the scale to children and their parents and
asked for their response.

from 2 to 6 weeks (mean 2.4 wk). Seventeen children were

on prophylactic laxative during chemotherapy cycles and
11 developed constipation on laxative therapy. Twentythree of 35 constipated children (66%) had repeated episodes of constipation during chemotherapy. Twenty-eight
of 35 patients reported temporal association of constipation with chemotherapy cycles and 11 of them reported
constipation within days after receiving vincristine.
Therapy with a laxative was started in most children
and was changed if there was no good response. Commonly
used medications were polyethylene glycol (22 patients),
colace (16 patients), and senna (9 patients).

Statistical Analysis
The statistical analysis included the Fisher exact test
using a 2  2 contingency table, with signicance accepted
at P value less than 0.05. Results were expressed as mean or
percent.
This study was approved by the Human Investigation
Committee of Yale University School of Medicine. Informed consent was obtained from parents of patients and
assent was obtained from children above 7 years of age.

RESULTS
Sixty-one children participated in the study. The
demographic data, details of underlying malignancy,
commonly used chemotherapeutic agents, and opiates are
shown in Table 1. None of the children had malignancy in
the gastrointestinal tract. Two children received abdominal
radiation along with chemotherapy. Besides chemotherapy
and opiates, other commonly used medications in children
were ondansetron (n=33), diphenhydramine (n=11), and
acid suppression therapy (n=23) including famotidine,
ranitidine, and lansoprazole.
Table 2 shows bowel movement parameters of children
on chemotherapy. Thirty-ve children (57%) had delayed
and dicult defection for 2 or more weeks and satised the
NASPGHAN diagnostic criteria of constipation. Bowel
movement parameters according to Rome III criteria are
shown in Table 2. The duration of constipation ranged

Male: female
Obese children
Diagnosis (%)

Chemotherapy (%)

Mean duration of chemotherapy (mo)

Intermittent use of opiates

Thirty-ve children who satised the NASPGHAN

criteria were assessed for risk factors for constipation.
Seven of 8 children with previous history of constipation
developed constipation on chemotherapy. Several risk
factors including age group (below or above 10 y), sex, previous history of constipation, obesity, abdominal radiation,
as well as isolated and combined use of medications
including vincristine, methotrexate, 6-mercaptopurine, cytosine arabinoside, and opiates were assessed. Use of other
medications besides chemotherapy and opiates, and underlying diagnosis of malignancy were also assessed for risk of
developing constipation. Only combined use of vincristine
and opiates (P<0.03) in children was signicantly related
to development of constipation whereas other risk factors
were not signicant.

Impact of constipation
Fourteen of 35 constipated children (20%) sought
physician care for constipation as a presenting problem in
the oce (9), emergency room (3), and 2 patients required
hospitalization. They all had abdominal pain as a result of
constipation. Parental/childs perception of problem and
impact on lifestyle during chemotherapy on 0 to 3 scale are
shown in Figures 1 and 2. In children with constipation, 15
children/parents (43%) perceived constipation as a signicant or major problem during chemotherapy whereas 8
children(23%) perceived constipation having a signicant
or major impact on lifestyle during chemotherapy.

DISCUSSION

TABLE 1. Demographic Data

Patients
Age (y)

Risk Factors for Constipation

61
Mean 10.6 (range: 1.1 to 20.4)
Children <10-29
Children >10-32
34:27
12 (20%)
Acute lymphoid leukemia 33 (54)
Lymphomas 10 (16)
Brain neoplasm 3 (5)
Myeloid leukemia 3 (5)
Other solid tumors 12 (20)
Vincristine 47 (77)
Methotrexate 33 (54)
6-mercaptopurine 28 (46)
Cytosine arabinoside 12 (20)
13 (range: 1-48)
17 children (28%)
Codeine 14
Morphine 5
Oxycodone 5
Hydromorphone 2

2011 Lippincott Williams & Wilkins

In this study, we found acute constipation in 57% of

children on chemotherapy for cancer. Six children in our
study were on prophylactic laxatives before chemotherapy
and in the absence of these medications the frequency of
constipation could have been higher than what we observed. Children receiving both vincristine and opiates were
at high risk for development of constipation. Constipation
was perceived as a signicant/major problem in 43% of
children and had a signicant/major impact on lifestyle in
23% of children during chemotherapy. To the best of our
knowledge, this is the rst study reporting high prevalence
and severity of constipation in children on chemotherapy
for cancer.
Constipation is a common problem in children, but
there are no universally accepted diagnostic criteria for
childhood constipation.10 We elected to use the NASPGHAN criteria because of the short duration of constipation. Recently reported Rome III criteria are widely used in
children and we assessed these criteria in our patients. The
constipation by Rome III criteria is dened as presence of
2 or more criteria for at least 2 months.9 Therefore, we
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Pashankar et al

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TABLE 2. Bowel Movement Parameters of Children on Cancer Chemotherapy

Bowel Movement Parameters

Delayed or dicult defecation for 2 wk (NASPGHAN denition of constipation)
Painful or hard stools
Two or fewer defecations per week
Large stools
Retentive posturing
>1 episodes of fecal incontinence per week (assessed in children>4 y only)

Numbers

Percentage

35/61
46/61
26/61
19/61
10/61
4/54

57
75
43
31
16
7.4

NASPGHAN indicates North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition.

50
45
40
35
30
25
20
15
10
5
0

abdominal pain, and distension because of constipation

could be confused with presentation of neutropenic enterocolitis. In our study, 20% of constipated children sought
physician care only for the purpose of constipation. These
ndings are in agreement with a recent study that reported
higher costs and resource utilization such as inpatient
admissions, emergency, and oce visits for adult patients
with cancer and constipation.16 In children, functional
constipation is reported to aect quality of life scores
negatively even worse than inammatory bowel disease.17
Although we did not use a detailed standardized questionnaire, 23% of constipated children and their parents
reported that constipation led to negative impact on
lifestyle while on chemotherapy. This indicates that constipation is perceived as a signicant problem for children and
parents and needs to be addressed appropriately during
chemotherapy.
There are some limitations of the study. First, the
temporal association of constipation and vincristine described by parents could have been because of physicians
explanation of the anticipated side-eects of vincristine to
the parents. Second, children are usually sick with multiple
symptoms because of side eects while on chemotherapy. It
is possible that constipation occurred along with other side
eects and parents attributed negative impact of overall
chemotherapy to constipation despite our specic questions
of constipation aecting lifestyle. Finally, dierent laxatives
were used for prophylaxis and treatment of constipation in
dierent doses depending on the choice of attending
physicians. Polyethylene glycol has been shown to be a
very eective therapy for constipation in children18 and was
commonly used in our patients. However, we can not draw
any specic conclusions about eective therapy from our
study.

45
40
35
Percentage

Percentage

elected not to use Rome III criteria for the diagnosis as

constipation was acute in our patients.
The prevalence rate of 57% of acute constipation in
children on chemotherapy is much higher than the prevalence reported in the general population of children. A
recent systematic review of 18 pediatric studies reported the
prevalence of childhood constipation from 0.7% to
29.6%.10 In a study from Iowa, the prevalence of acute constipation (lasting less than 8 wk) in children of 4 to 17 years
of age was estimated to be 4.6% in a primary care clinic.11
In Turkey, 12.4% of school children (5 to 9 y) had constipation diagnosed by the NASPGHAN criteria.12 Compared with these studies, children on chemotherapy in our
study had much higher prevalence of acute constipation.
Our results are in agreement with studies in adults that
report constipation in 30% to 50% of patients with cancer
on chemotherapy.6
We assessed several risk factors for constipation in
children. None of the children in the study had gastrointestinal cancer or any other obvious organic cause such as
anorectal anomalies or obstruction. We also ruled out obesity as a contributing factor in children as obesity was
related to childhood constipation in a recent study.13
Children who received both vincristine and opiates were
at signicant risk of developing constipation. Both vincristine and opiates can decrease colonic motility and can lead
to constipation.4,5,14
The problem of constipation in children on chemotherapy is far from trivial. Forty-three percent of
children and parents in our study reported constipation as
a signicant or major problem (2 or 3 on a scale of 0 to 3).
Constipation is reported to be the most common cause of
acute abdominal pain in children15 and can also cause
abdominal distension. In a child with neutropenia, acute

30
25
20
15
10
5

FIGURE 1. Perception of 35 children/parents perceiving constipation as a problem on a scale of 0 to 3 (0no problem, 1

minor, 2significant, and 3major problem).

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FIGURE 2. Impact of constipation on lifestyle of 35 children on a

scale of 0 to 3 (0no impact, 1minor, 2significant, and 3
major impact).
r

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Constipation in Children Receiving Chemotherapy

In summary, children on cancer chemotherapy are at high

risk of developing acute constipation. Constipation is most
often related to the use of vincristine and opiates, and
aggressive prophylactic laxative therapy should be considered when both medications are used. As constipation is
perceived to be a signicant and distressing problem in a
high proportion of children, a prompt laxative treatment is
recommended to alleviate symptoms. Further studies are
needed to nd an appropriate therapeutic approach for
these children.

8. Baker SS, Liptak GS, Colletti RB, et al. Constipation in infants

and children: evaluation and treatment. J Pediatr Gastroenterol
Nutr. 1999;29:612626.
9. Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood
functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130:15271537.
10. van den Berg MM, Benninga MA, Di Lorenzo C. Epidemiology of childhood constipation: a systematic review. Am J
Gastroenterol. 2006;101:24012409.
11. Loening-Baucke V. Prevalence rates for constipation and
faecal and urinary incontinence. Arch Dis Child. 2007;92:
486489.
12. Uguralp S, Karaoglu L, Karaman A, et al. Frequency of
enuresis, constipation, and enuresis associated with constipation in a group of school children aged 5-9 years in Malatya,
Turkey. Turk J Med Sci. 2003;33:315320.
13. Pashankar DS, Loening-Baucke V. Increased prevalence of
obesity in children with functional constipation evaluated in an
academic medical center. Pediatrics. 2005;116:e377e380.
14. OBrien SH, Fan L, Kelleher KJ. Inpatient use of laxatives
during opioid administration in children with sickle cell
disease. Pediatr Blood Cancer. 2010;54:559562.
15. Loening-Baucke V. Constipation as cause of acute abdominal
pain in children. J Pediatr. 2007;151:666669.
16. Candrilli SD, Davis KL, Iyer S. Impact of constipation on
opioid use patterns, health care resource utilization, and cost in
cancer patients on opioid therapy. J Pain Palliat Care
Pharmacother. 2009;23:231241.
17. Youssef NN, Langseder AL, Verga BJ, et al. Chronic
childhood constipation is associated with impaired quality of
life: a case-controlled study. J Pediatr Gastroenterol Nutr.
2005;41:5660.
18. Pashankar D, Bishop WP. Ecacy and optimal dose of daily
polyethylene glycol 3350 for treatment of constipation and
encopresis in children. J Pediatr. 2001;139:428432.

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