Clinical Notes : Paediatrics
28. Constipation in children

Diagnosis of idiopathic constipation is reached by :
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typical findings
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excluding red flags
Typical findings
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Any 2 or more of the following :
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<3 complete stools/week
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Large hard stools or ‘rabbit droppings’
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Pain or straining on passing stool
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Bleeding associated with hard stools
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Previous constipation
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Previous or current anal fissure
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If > 1 year
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Overflow soiling
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Poor appetite
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Waxing and waning abdominal pain that improves on passing a large stool
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Evidence of retentive posturing (typically straight legged, tiptoed, back arching)
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Red flags
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Constipation from birth or first few weeks of life, or failure or delay in passing meconium (> 48hours)
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Ribbon stools
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Gross abdominal distention or distention with vomiting
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Abnormalities on examination of lumbosacral region or found on lower limb musculoskeletal or neurological examinations
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Faltering growth (Amber flag)
Management
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Do not use dietary or lifestyle advice alone
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Assess for and treat faecal impaction
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Diagnose on basis of history, overflow soiling and/or palpable faecal mass abdominally
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PR is not indicated in primary care
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Use escalating regime of macrogol and advise family about initial soiling and pain
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i.e. Escalate normal dose gradually to double normal
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A stimulant can be added or substituted if not effective
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e.g. senokot
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Maintenance treatment – aiming for regular passage of soft stools
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Macrogols first line
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e.g. Movicol pediatric
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2-6 yrs : 1 sachet daily in ¼ cup water
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7-11 yrs : 2 sachets daily in ¼ cup water
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Stimulant laxative second line (as addition or alternative to macrogol)
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e.g. senokot
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2-6 yrs : 2,5-5 ml nocte
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6-12 yrs : 1-2 tabs or 5-10 ml nocte
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Use osmotic laxative such as docusate or lactulose if stools are hard
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e.g. lactulose
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1/12-1yr : 2,5ml BD
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1-2 yrs : 2,5-5ml BD
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2-5 yrs : 5ml BD
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5-10 yrs : 10ml BD
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Continue treatment for several weeks after regular bowel habit is established, or if toilet training until this is complete
Timely review
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Advise to see own GP
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In 1 week if laxatives clearing a blockage/ impaction
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Within 6 weeks for maintenance treatment
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Provide clear information
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On how to take medication
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What to expect
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How bowels work and
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How to recognize symptoms of constipation
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For a patient information leaflet click here
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Use of dietary and behavioural interventions once regular toileting is established
Either provide own written info sheet or direct parents to online info sheet at
http://patient.info/health/constipation-in-children-leaflet
Withdrawing treatment
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Withdraw gradually over months.
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Some children may need treatment for significantly longer.
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No evidence that prolonged treatment leads to ‘lazy bowel’

Constipation in children and young people: diagnosis and management
NICE Clinical guideline CG99. May 2010
Constipation: A Global Perspective
World Gastroenterology Organisation Global Guidelines.
November 2010
Evaluation and Treatment of Functional Constipation inInfants and Children: Evidence-Based RecommendationsFrom ESPGHAN and NASPGHAN
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
JPGN2014;58: 258–274
Tabbers MM, Boluyt N, Berger MY, et al.
Clinical practice: diagnosisand treatment of functional constipation.
Eur J Pediatr2011;170:955–63.

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