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Constipation – Children

  

Constipation occurs when there is a reduction in the frequency of bowel movements characterized by the passage of hard stools and may be associated with straining and pain


Introduction

In the UK, normal stool frequency in children ranges from an average of 4/day in the first week of life to 2/day at 1 year of age.

A normal adult range of 3 stools per day to 3 stools per week is usually attained by 4 years of age.

Terminologies:

Chronic constipation: symptoms lasting longer than 8 weeks

Functional constipation: cause not explained by any functional and physiological abnormality

Organic Constipation: There is an established cause for constipation

Epidemiology:

The peak incidence of constipation follows the time of toilet training usually around 2-3 years

10-25% of paediatric gastroenterology referrals

90-95% constipation is functional

Aetiology:

Functional: Usually idiopathic

Organic causes: Usually present in the first week of life Eg:

  • Anorectal malformation
  • Hirschsprung disease
  • Spinal cord problems
  • Pelvic floor dyssynergia
  • Metabolic problems (Hypothyroidism, Cystic fibrosis, coeliac disease, CMPA)
History
  • Characterize with Bristol stool chart
  • Reduced dietary fibre (take a dietary history)
  • Contributing factors: pain, reduced fluid intake, witholding
  • On-going toilet training
  • Drugs: Opiates, sedating anti-histamines
  • Reduced physical activity
  • Psychosocial issues

 

Red Flag Amber flag
Commencing from birth or within a few weeks Evidence of faltering growth, or developmental delay may indicate systemic condition e.g. coeliac disease, hypothyroidism, cystic fibrosis, electrolyte imbalance
Failure or delay (>48hours at term) in the passage of meconium Constipation triggered by cow’s milk-CMPA
Ribbon stools may indicate anal stenosis A concern of possible child maltreatment
Abdominal  distension with vomiting
Family history of HD
Leg weakness of motor delay
Abnormality in the gluteal or sacral region

 

Management guidelines:

Red flags/Organic cause for constipation: Urgent referral to appropriate speciality. Do not initiate treatment

Amber flags: Also require specialist referral for assessment. Treatment can be commenced while awaiting specialist assessment

Functional Constipation: If faecal impaction present (Large mass in the rectum, overflow soiling, faecal mass palpable per abdomen) Use Disimpaction regimen-

  • Prescribe a Macrogol (paediatric plain movicol) as first-line in escalating dose, as per BNFc.
  • If failed disimpaction after 2 weeks – Add a stimulant laxative such as senna, picosulphate,
  • If macrogol is not tolerated, then substitute for stimulant laxative either alone or in combination with stool softener e.g. docusate, lactulose
  • If no successful treatment after this- discuss with a paediatrician

After disimpaction start maintenance therapy aiming for regular soft formed stool with treatment lasting several months

If disimpaction has been required, the maintenance dose will be half of the disimpaction dose.

Titrate according to Bristol stool chart

Disimpaction (If overflow soiling or palpable faecal mass):

  • Polyethylene glycol 3350 + electrolytes (Macrogol such as Movicol / Cosmocol paediatric)
  • As per BNF, with escalating dose regimen.
  • To be given until all hard stool passed and stool regular and soft.
  • Then should be switched to maintenance dosing.
  • Add in stimulant (eg senna) if movicol alone insufficient after 2 weeks

Dietary and lifestyle advice:

High fibre

Vegetables

Normal physical activity

Encourage fluid intake: As a guide –

  • 0-6 months: 700mls usually from milk
  • 7-12 months: 800mls from milk & 600ml from water and drinks
  • 1-3 years: 1300mls
  • 4-8 years: 1700mls
  • 9-13 years Boys: 2400mls, Girls: 2100mls
  • 14-18 years: Boys: 3300mls, Girl: 2300mls

Behavioural modification:

Encourage regular toileting (schedules toileting)

Reward system after successful toilet use

Other considerations:

  • Anxiety of parent and child
  • Attitudes of guilt and blame
  • In-appropriate coercive toilet training
  • Social consequences: e.g. incontinent in older children
  • Avoid prolonging the use of stimulant laxatives as they can cause atonic colon, reduced potassium
  • Consider involving health visitor / school nurse for additional support

Follow up:

Weekly follow up (can be telephone ) in children undergoing dis-impaction regime

Reinforce adherence to a maintenance regimen

Hints and Tips:

  • Movicol can be mixed with any cold drink, to improve intake
  • For issues with toilet use and potty training, ensure adequately treated prior to attempts. Suggest use of “Poo Goes to PooLand App”

 

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