This Guidelines summary covers diagnosing and managing constipation in children and young people up to 18. It provides strategies to support the early identification and timely, effective treatment of constipation which will help improve outcomes for patients. It does not cover constipation caused by a specific condition.
History-taking and Physical Examination
- Establish during history-taking whether the child or young person has constipation. Two or more findings from table 1 (below) indicate constipation
Table 1: Key Components of History-taking to Diagnose Constipation
| Key Components | Potential Findings in a Child Younger than 1 Year | Potential Findings in a Child/Young Person Older than 1 Year |
|---|---|---|
| Stool patterns |
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| Symptoms associated with defecation |
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| History |
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- If the child or young person has constipation take a history using table 2 (below) to establish a positive diagnosis of idiopathic constipation by excluding underlying causes. If a child or young person has any ‘red flag’ symptoms, do not treat them for constipation. Instead, refer them urgently to a healthcare professional with experience in the specific aspect of child health that is causing concern
Table 2: Key Components of History-taking to Diagnose Idiopathic Constipation
| Key Components | Findings and Diagnostic Clues That Indicate Idiopathic Constipation | ‘Red Flag’ Findings and Diagnostic Clues That Indicate an Underlying Disorder or Condition: Not Idiopathic Constipation |
|---|---|---|
| Timing of onset of constipation and potential precipitating factors |
| Reported from birth or first few weeks of life |
| Passage of meconium |
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| Stool patterns |
| |
| Growth and general wellbeing |
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| Symptoms in legs/locomotor development |
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| Abdomen |
| |
| Diet and fluid intake |
| |
| Amber flag’: possible idiopathic constipationGrowth and general wellbeing: Faltering growth Personal/familial/social factors: Disclosure or evidence that raises concerns over possibility of child maltreatment. | ||
- Do a physical examination. Use table 3 (below) to establish a positive diagnosis of idiopathic constipation by excluding underlying causes. If a child or young person has any ‘red flag’ symptoms do not treat them for constipation. Instead, refer them urgently to a healthcare professional with experience in the specific aspect of child health that is causing concern
Table 3: Key Components of Physical Examination to Diagnose Idiopathic Constipation
| Key Components | Findings and Diagnostic Clues that Indicate Idiopathic Constipation | ‘Red Flag’ Findings and Diagnostic Clues That Indicate an Underlying Disorder or Condition: Not Idiopathic Constipation |
|---|---|---|
| Inspection of perianal area: appearance, position, patency, etc |
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| Abdominal examination |
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| Spine/lumbosacral region/gluteal examination |
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| Lower limb neuromuscular examination including tone and strength |
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| Lower limb neuromuscular examination: reflexes (perform only if ‘red flags’ in history or physical examination suggest new onset neurological impairment) |
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- If the history-taking and/or physical examination show evidence of faltering growth treat for constipation and test for coeliac disease (see also the NICE guideline on coeliac disease: recognition, assessment and management) and hypothyroidism
- If either the history-taking or the physical examination show evidence of possible maltreatment treat for constipation and refer to the NICE guideline on child maltreatment: when to suspect maltreatment in under 18s
- If the physical examination shows evidence of perianal streptococcal infection, treat for constipation and also treat the infection
- Inform the child or young person and his or her parents or carers of a positive diagnosis of idiopathic constipation and also that underlying causes have been excluded by the history and/or physical examination. Reassure them that there is a suitable treatment for idiopathic constipation but that it may take several months for the condition to be resolved
Digital Rectal Examination
- A digital rectal examination should be undertaken only by healthcare professionals competent to interpret features of anatomical abnormalities or Hirschsprung’s disease
- 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
- Do not perform a digital rectal examination in children or young people older than 1 year with a ‘red flag’ (see tables 2 and 3) in the history-taking and/or physical examination that might indicate an underlying disorder. Instead, refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung’s disease
- For a digital rectal examination ensure:
- privacy
- informed consent is given by the child or young person, or the parent or legal guardian if the child is not able to give it, and is documented
- a chaperone is present
- the child or young person’s individual preferences about degree of body exposure and gender of the examiner are taken into account
- all findings are documented
Clinical Management
Disimpaction
- Assess all children and young people with idiopathic constipation for faecal impaction, including children and young people who were originally referred to the relevant services because of ‘red flags’ but in whom there were no significant findings following further investigations (see tables 2 and 3). Use a combination of history-taking and physical examination to diagnose faecal impaction – look for overflow soiling and/or faecal mass palpable abdominally and/or rectally if indicated
- Start maintenance therapy if the child or young person is not faecally impacted
- Offer the following oral medication regimen for disimpaction if indicated:
- polyethylene glycol 3350 + electrolytes, using an escalating dose regimen (see table 4, below), as the first-line treatment[A]
- polyethylene glycol 3350 + electrolytes may be mixed with a cold drink
- add a stimulant laxative (see table 4, below) if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks
- substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose (see table 4, below) if polyethylene glycol 3350 + electrolytes is not tolerated
- inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
Table 4: Laxatives: Recommended Doses
| Laxatives | Recommended Doses |
|---|---|
| Macrogols | |
| Polyethylene glycol 3350 + electrolytes | Paediatric formula: Oral powder: macrogol 3350 (polyethylene glycol 3350)[A] 6.563 g; sodium bicarbonate 89.3 mg; sodium chloride 175.4 mg; potassium chloride 25.1 mg/sachet (unflavoured)Disimpaction
Disimpaction
Ongoing maintenance (chronic constipation, prevention of faecal impaction)
|
| Osmotic laxatives | |
| Lactulose |
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| Stimulant laxatives | |
| Sodium picosulfate[B] | Non-BNFC recommended dosesElixir (5 mg/5 ml)
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| Non-BNFC recommended dose Perles[C] (1 tablet =2.5mg)
| |
| Bisacodyl | Non-BNFC recommended doses By mouth
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| Senna[D] | Senna syrup (7.5 mg/5 ml)
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Senna (non-proprietary) (1 tablet = 7.5 mg)
| |
| Docusate sodium[E] |
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| All drugs listed above are given by mouth unless stated otherwise Unless stated otherwise, doses are those recommended by the British National Formulary for Children (BNFC) 2009. Informed consent should be obtained and documented whenever medications/doses are prescribed that are different from those recommended by the BNFC [A] A range of paediatric plains are available, but not all are licensed for childen under 12 [B] Elixir, licensed for use in children (age range not specified by manufacturer). Perles not licensed for use in children under 4 years. Informed consent should be obtained and documented [C] Perles produced by Sanofi should not be confused with Dulcolax tablets which contain bisacodyl as the active ingredient [D] Syrup not licensed for use in children under 2 years. Informed consent should be obtained and documented [E] Adult oral solution and capsules not licensed for use in children under 12 years. Informed consent should be obtained and documented. | |
- 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
- Do not administer phosphate enemas for disimpaction unless under specialist supervision in hospital/health centre/clinic, and only if all oral medications and sodium citrate enemas have failed
- Do not perform manual evacuation of the bowel under anaesthesia unless optimum treatment with oral and rectal medications has failed
- Review children and young people undergoing disimpaction within 1 week
Maintenance Therapy
- Start maintenance therapy as soon as the child or young person’s bowel is disimpacted
- Reassess children frequently during maintenance treatment to ensure they do not become reimpacted and assess issues in maintaining treatment such as taking medicine and toileting. Tailor the frequency of assessment to the individual needs of the child and their families (this could range from daily contact to contact every few weeks). Where possible, reassessment should be provided by the same person/team
- Offer the following regimen for ongoing treatment or maintenance therapy:
- polyethylene glycol 3350 + electrolytes as the first-line treatment[A]
- adjust the dose of polyethylene glycol 3350 + electrolytes according to symptoms and response. As a guide for children and young people who have had disimpaction the starting maintenance dose might be half the disimpaction dose (see table 4)
- add a stimulant laxative (see table 4) if polyethylene glycol 3350 + electrolytes does not work
- substitute a stimulant laxative if polyethylene glycol 3350 + electrolytes is not tolerated by the child or young person. Add another laxative such as lactulose or docusate (see table 4) if stools are hard
- continue medication at maintenance dose for several weeks after regular bowel habit is established—this may take several months. Children who are toilet training should remain on laxatives until toilet training is well established. Do not stop medication abruptly: gradually reduce the dose over a period of months in response to stool consistency and frequency. Some children may require laxative therapy for several years. A minority may require ongoing laxative therapy
Diet and Lifestyle
- Do not use dietary interventions alone as first-line treatment for idiopathic constipation
- Treat constipation with laxatives and a combination of:
- negotiated and non-punitive behavioural interventions suited to the child or young person’s stage of development. These could include scheduled toileting and support to establish a regular bowel habit, maintenance and discussion of a bowel diary, information on constipation, and use of encouragement and rewards systems
- dietary modifications to ensure a balanced diet and sufficient fluids are consumed
- Advise parents and children and young people (if appropriate) that a balanced diet should include:
- 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) (not applicable to exclusively breastfed infants). Do not recommend unprocessed bran, which can cause bloating and flatulence and reduce the absorption of micronutrients
- Provide children and young people with idiopathic constipation and their families with written information about diet and fluid intake
- In children with idiopathic constipation, start a cows’ milk exclusion diet only on the advice of the relevant specialist services
- Advise daily physical activity that is tailored to the child or young person’s stage of development and individual ability as part of ongoing maintenance in children and young people with idiopathic constipation
Information and Support
- Provide tailored follow-up to children and young people and their parents or carers according to the child or young person’s response to treatment, measured by frequency, amount and consistency of stools. Use the Bristol Stool Form Scale to assess this (see appendix B in NICE CG99 full guideline). This could include:
- telephoning or face-to-face talks
- giving detailed evidence-based information about their condition and its management, using, for example, NICE’s information for the public for this guideline
- giving verbal information supported by (but not replaced by) written or website information in several formats about how the bowels work, symptoms that might indicate a serious underlying problem, how to take their medication, what to expect when taking laxatives, how to poo, origins of constipation, criteria to recognise risk situations for relapse (such as worsening of any symptoms, soiling etc.) and the importance of continuing treatment until advised otherwise by the healthcare professional
- Offer children and young people with idiopathic constipation and their families a point of contact with specialist healthcare professionals, including school nurses, who can give ongoing support
- Healthcare professionals should liaise with school nurses to provide information and support, and to help school nurses raise awareness of the issues surrounding constipation with children and young people and school staff
- 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
Footnote
[A] At the time of publication (May 2010), Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that includes electrolytes. It does not have UK marketing authorisation for use in faecal impaction in children under 5 years, or for chronic constipation in children under 2 years. Informed consent should be obtained and documented. Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that is also unflavoured.
References
References