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Constipation in children

CKS Constipation in children

NICE patient information: Constipation in children and young people


Definition

Constipation is a decrease in the frequency of bowel movements (<3 stools weekly since birth)
characterised by the passing of hardened stools which may be large and associated with straining and pain.

Constipation affects 5–30% of the child population, depending on the criteria used for diagnosis


Normal physiology

Stool frequency:
4 per day in the first week of life
2 per day at 1 year of age.

Frequency of stool ranges from  3 per week TO 3 stools per day ; this range is usually attained by 4 years of age.


Diagnosis

Constipation is termed idiopathic (functional) if it cannot be explained by any anatomical or physiological abnormality.

Faecal impaction:

  • A history of severe symptoms of constipation

  • Overflow soiling

  • A faecal mass palpable on abdominal examination

Constipation:

  • Infrequent bowel activity (<3/week) unless exclusively breastfed

  • Hard, large stool

  • 'Rabbit droppings' stool

  • Overflow soiling very loose, smelly stools, passed without sensation

Risk factors

  • Pain (such as painful defecation)

  • Fever

  • Inadequate fluid intake

  • Reduced dietary fibre intake

  • Toilet training issues

  • Drug side-effects

  • Psychosocial issues

  • Family history of constipation

  • Cerebral palsy

  • Down's syndrome

  • Autism


Red flags: refer the child urgently, do not initiate treatment for constipation in primary care

  1. Timing of onset of constipation and potential precipitating factors: reported from birth or first few weeks of life

  2. Failure to pass meconium/delay (>48h after birth in term baby)

  3. 'Ribbon stools' (more likely in a child younger than 1 year)

  4. Faltering growth and/or weight loss

  5. Previously unknown or undiagnosed weakness in legs, locomotor delay

  6. Abdominal distension with vomiting

  7. Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal wink

  8. Gross abdominal distension

  9. Abnormal: asymmetry or flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi or sinus, hairy patch, lipoma, central pit (dimple that you can't see the bottom of), scoliosis

  10. Deformity in lower limbs such as talipes

  11. Abnormal neuromuscular signs unexplained by any existing condition, such as cerebral palsy

  12. Lower limb neuromuscular examination: abnormal reflexes

Amber flags- also require specialist referral for assessment, but treatment for constipation may be initiated in primary care whilst awaiting specialist assessment

  1. Evidence of faltering growth, developmental delay, or concerns about wellbeing.

  2. Constipation triggered by the introduction of cows' milk.

  3. Concern of possible child maltreatment.


Investigations

If requested by specialist services, consider testing for

  • coeliac disease

  • hypothyroidism

  • cystic fibrosis

  • electrolyte disturbance

  • cows' milk protein allergy

Digital rectal examination

  1. A digital rectal examination should be undertaken only by healthcare professionals competent to interpret features of anatomical abnormalities or Hirschsprung's disease.

  2. If a child younger than 1 year has a diagnosis of idiopathic constipation that does not respond to optimum treatment within 4 weeks, refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung's disease.

  3. Do not perform a digital rectal examination in children or young people older than 1 year with a 'red flag' —> refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung's disease


Management of idiopathic constipation (red and amber flags excluded)

Paediatric formula: 
Oral powder: macrogol 3350 (polyethylene glycol 3350) 6.563 g; sodium bicarbonate 89.3 mg; sodium chloride 175.4 mg; potassium chloride 25.1 mg/sachet (unflavoured)

Maintenance laxatives if impaction is not present or has been successfully treated.

  • Child under 1 year: ½–1 sachet daily

  • Child 1–6 years: 1 sachet daily;(maximum 4 sachets daily)

  • Child 6–12 years: 2 sachets daily; (maximum 4 sachets daily)

Faecal impaction —> disimpaction laxative regimen

  • Child under 1 year: ½–1 sachet daily

  • Child 1–5 years: 2 sachets on 1st day, then 4 sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily

  • Child 5–12 years: 4 sachets on 1st day, then increased in steps of 2 sachets daily to maximum of 12 sachets daily

Add a stimulant laxative (sodium picosulfate, bisacodyl, Senna, docusate sodium) if macrogol 3350 does not work.

Add another laxative such as (osmotic laxative) lactulose or (stimulant laxative) docusate if stools are hard.

Diet

  • Adequate fluid intake

  • Adequate fibre. Recommend including foods with a high fibre content (such as fruit, vegetables, high-fibre bread, baked beans and wholegrain breakfast cereals)
    Do not recommend unprocessed bran, which can cause bloating and flatulence and reduce the absorption of micronutrients.

Behavioural interventions
Scheduled toileting, use of a bowel habit diary, and reward systems.

Specialist referral

Considering the need for specialist referral if symptoms do not respond to optimal treatment in primary care, or if there is faecal impaction and the child is very distressed.

Refer children and young people with idiopathic constipation who do not respond to initial treatment within 3 months to a practitioner with expertise in the problem

Referral for specialist assessment by a paediatrician is indicated in constipation when:

  • An underlying cause is suspected

  • There are 'red flags' such as failure to thrive, distended abdomen, blood and/or mucus in the stools

  • Treatment is unsuccessful

  • Management is complex (and requires more than the advice, support, and prescription of laxatives that can be provided in primary care because there are major psychological causes or consequences)

Referral to a paediatric continence adviser/specialist nurse should be considered when there is soiling and/or faecal loading requiring disimpaction. It is also important to be alert to the rare possibility of child abuse.


Rectal medications

Do not use rectal medications for disimpaction unless all oral medications have failed and only if the child or young person and their family consent.

Administer sodium citrate enemas only if all oral medications for disimpaction have failed.