Constipation in children, paediatrics (540)

Constipation is the subjective complaint of passing abnormally delayed or infrequent dry hardened faeces which is difficult and distressing. A diagnosis must include 2 or more of the following (using the Rome 111 criteria)

< 3 bowel movements per week
a history of painful or hard bowel movements
at least 1 episode of faecal incontinence per week
a history of excessive stool retention or retention posturing.
presence of large faecal mass in rectum
a history of stool so large that may obstruct the toilet

This must be present for 4 weeks in infants and children < 4 years and for 8 weeks in children over 4 years.

Soiling:- the involuntary passage of fluid or semi solid stool into clothing, usually as a result of overflow from a faecally loaded bowel. May be due to spurious diarrhoea or faecal incontinence and usually described by parents as staining in underwear.

Faecal Impaction:- this occurs when there has been no adequate bowel movement for several days/weeks and a large compacted mass of faeces builds up in the rectum and/or colon which cannot be passed easily by the child.

‘Normal’ bowel function:- The ‘normal’ frequency of bowel movements varies from child to child and varies widely.

Bowel motions in breast fed babies can be very variable. It is not common, but some babies can have infrequent motions sometimes once in 7 or even 10 days.

Most children have no underlying organic cause for constipation i.e. they have functional constipation. Organic causes are uncommon and found more frequently in infants < 1 yr.

Organic causes:

Hirschsprungs Disease
Cystic Fibrosis
Metabolic conditions eg hypothyroidism
Neurological disability eg cerebral palsy
Anorectal anomalies

Non-Organic causes/Risk factors:

Many drugs - Antihistamines/anticonvulsants/iron supplements and many more
Intolerance to cows milk
Inadequate fluid intake
Poor diet including excess milk
Low fiber diet
Lack of exercise
Obesity
[Remember: 1) Sexual abuse may precipitate constipation and if considered - refer appropriately 2) Streptococcal infection of the perineal area is common in infants - treat with antibiotics]

History:

• Delay of passage of meconium > 24 hrs after birth
• Duration
• Frequency, consistency and size of stool
• Pain or bleeding when passing stool
• Type of diet/milk
• Medication that can cause constipation
• Poor Appetite, nausea and vomiting
• Abdominal pain/distension
• Behavior – withholding/posturing
• Soiling
• Is child thriving?
• Rectal prolapse

• Any evidence of failure to thrive
• Abdominal tenderness/distension/faecal loading
• Position of anus/anal fissure/skin tags/sacral anomalies
• Check lower back/ neurological assessment of lower limbs if indicated
• Visual assessment of anus / no digital rectal examination necessary

Decide if Functional or Organic. If Organic investigate and refer appropriately. No investigation necessary if Functional.

Constipation can be difficult to treat and often requires prolonged support, explanation, encouragement and medical treatment.

• Aim to empty bowel, keep bowel empty and prevent recurrence.
• Clear any impaction.
• Restore a bowel habit so stools are soft and passed without discomfort.

Treatment starts with education of parents/carers and children (as appropriate for age).

Constipation may be Acute or Chronic.

Acute constipation 1-3 weeks (generally precipitated by transient illness eg viral or febrile illness) Ensure adequate fluid intake/good diet and may need lactulose or Movicol (Laxido, Cosmocol) for a short period of 1 week followed by GP review and reassessment thereafter. (NB not disimpaction regime if Movicol (Laxido, Cosmocol) used)

Chronic Constipation

(See below for laxative maintenance & disimpaction regimes)

Infants 1-6 months

• Problem from birth/neonatal period/not passed meconium first 24 hrs.
• Discuss with Senior, possible Hirschsprungs Disease – refer for Surgical opinion.
• Type of milk – If formula fed, maintain on 1st formula for age and not overfed.
• Ensure adequate fluid intake (150mls/kg).
• Lactulose Or Movicol (Laxido, Cosmocol)
• For Disimpaction – Movicol (Laxido, Cosmocol)
• If already on treatment by GP (invariably Lactulose), can increase Lactulose and/or add Senna or change to Movicol (Laxido, Cosmocol).

Infants 6 months - 1 year

• Ensure adequate fluid intake
• Ensure not overfeeding and no excess milk
• Lactulose Or Movicol (Laxido, Cosmocol)
• May benefit from dietetic referral/assessment/follow up, if diet is thought to be poor
• Abdominal pain with distension+/ - vomiting – discuss with Senior, possible referral for Surgical opinion
• Anal fissure Lactulose or Movicol (Laxido, Cosmocol)/Topical L.A. ointment.

Children > 1 year

• Ensure adequate fluid intake
• Ensure adequate diet/fibre -?refer to dietitian if necessary.
• Movicol (Laxido, Cosmocol) as per simple regime or lactulose
• Impaction – treat with disimpaction Movicol (Laxido, Cosmocol) regime, followed by maintenance Movicol (Laxido, Cosmocol)
• Adequate exercises – active lifestyle
• Regular toileting
• ? Behavior modification :- toilet training/rewarding/toilet diaries etc.

Laxative Maintenance Regime

Laxative Disimpaction Regime

Children over 12 years should be treated with the adult preparation – the macrogol is exactly the same but there is twice as much in the sachet

Enemas can be considered in cases undergoing disimpaction who do not have the required result from the medicine regime, if they are on maximum medication, and have been compliant with treatment. Discuss with Consultant, if considered.

(1) All children undergoing disimpaction should be reviewed by GP after 1 week.

(2) Patients with Organic causes should be referred to appropriate Departments- Surgical/ Medical/ Neurological/ Metabolic.

(3) Idiopathic constipation (Idiopathic constipation is described as constipation that cannot be explained by any anatomical or physiological abnormalities):

• Referral will be accepted for children 6/12 -16 years, from a general paediatrician, or emergency department doctor,  underlying pathology or ‘red flag’ symptoms  should have been excluded and a diagnosis of idiopathic constipation made, with parent / carer / child / young person consent.
• They should reside within the boundary area of NHS Greater Glasgow and Clyde.
• There should be no other diagnoses which impact on bowel function.
• ED referrals made by completing ‘pink’ slip and dictating a letter to Constipation Service.

See also:

• Referral pathway for Paediatric Continence Service
• Referral criteria for Paediatric Continence Service 

Macrogol Disimpaction Regime: Information for parents/carers/users (pdf)