Clinical Notes : Paediatrics

28. Constipation in children

Diagnosis of idiopathic constipation is reached by :

  • typical findings

  • excluding red flags

 

Typical findings

  • Any 2 or more of the following :

    • <3 complete stools/week

    • Large hard stools or ‘rabbit droppings’

    • Pain or straining on passing stool

    • Bleeding associated with hard stools

    • Previous constipation

    • Previous or current anal fissure

    • If > 1 year

      • Overflow soiling

      • Poor appetite

      • Waxing and waning abdominal pain that improves on passing a large stool

      • Evidence of retentive posturing (typically straight legged, tiptoed, back arching)

 

Red flags

  • Constipation from birth or first few weeks of life, or failure or delay in passing meconium (> 48hours)

  • Ribbon stools

  • Gross abdominal distention or distention with vomiting

  • Abnormalities on examination of lumbosacral region or found on lower limb musculoskeletal or neurological examinations

  • Faltering growth (Amber flag)

 

Management

  • Do not use dietary or lifestyle advice alone

  • Assess for and treat faecal impaction

  • Diagnose on basis of history, overflow soiling and/or palpable faecal mass abdominally

  • PR is not indicated in primary care

  • Use escalating regime of macrogol and advise family about initial soiling and pain

    • i.e. Escalate normal dose gradually to double normal

  • A stimulant can be added or substituted if not effective

    • e.g. senokot

 

Maintenance treatment – aiming for regular passage of soft stools

  • Macrogols first line

    • e.g. Movicol pediatric

    • 2-6 yrs : 1 sachet daily in ¼ cup water

    • 7-11 yrs : 2 sachets daily in ¼ cup water

  • Stimulant laxative second line (as addition or alternative to macrogol)

    • e.g. senokot

    • 2-6 yrs : 2,5-5 ml nocte

    • 6-12 yrs : 1-2 tabs or 5-10 ml nocte

  • Use osmotic laxative such as docusate or lactulose if stools are hard

    • e.g. lactulose

    • 1/12-1yr : 2,5ml BD

    • 1-2 yrs : 2,5-5ml BD

    • 2-5 yrs : 5ml BD

    • 5-10 yrs : 10ml BD

  • Continue treatment for several weeks after regular bowel habit is established, or if toilet training until this is complete

 

Timely review

  • Advise to see own GP

    • In 1 week if laxatives clearing a blockage/ impaction

    • Within 6 weeks for maintenance treatment

 

Provide clear information

  • On how to take medication

  • What to expect

  • How bowels work and

  • How to recognize symptoms of constipation

  • For a patient information leaflet click here

  • 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

  • Withdraw gradually over months.

  • Some children may need treatment for significantly longer.

  • No evidence that prolonged treatment leads to ‘lazy bowel’

 
 
 
 
 
 
 
 
 
NASPGHAN.jpg

Constipation in children and young people: diagnosis and management

NICE Clinical guideline CG99. May 2010

Access

 

Constipation: A Global Perspective

World Gastroenterology Organisation Global Guidelines.

November 2010

Access

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

Access

Tabbers MM, Boluyt N, Berger MY, et al.

Clinical practice: diagnosisand treatment of functional constipation.

Eur J Pediatr2011;170:955–63.

Access

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