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”
Leave feedback
You must be logged in to post a comment.