Constipation

Presentation

• Less than 3 formed stools a week.
• Pain, straining or bleeding with stooling (?fissure)
• Hard stools and/or ‘rabbit droppings’ – Type 1-2 on Bristol Stool Chart.
• History of irregular stooling with overflow soiling – suggests impaction.
• Withholding of stools – clenching buttocks/tiptoe/hiding/leaning over furniture.
• Recurrent abdominal pain often spending longer periods in the bathroom.
• Very large stools that are difficult to flush.

Red flags

• No meconium in first 48 hours of life, early onset symptoms within first month.
• Ribbon stools.
• Neuromuscular signs e.g. leg weakness, motor delay.
• Abdominal distension with vomiting/gross abdominal distension.
• Anal/sacral abnormality e.g. tuft, dimple, pit, asymmetrical gluteal muscles, talipes or abnormal reflexes.
• Disclosure or evidence raising concerns about child maltreatment.

Please refer to NICE guidelines for management of constipation

When to refer

• Red flag features present.
• If no improvement, consider compliance, under-dosing, understanding and appropriateness of advice to family settling. Re-treat for impaction with further support from health visitor/school nurse follow up within 1-2 weeks; refer on if needed thereafter.
• Faltering growth or developmental delay.
• Possible underlying systemic condition.
• Possible cow’s milk protein allergy (CMPA) – refer to Paediatric Dieticians once diagnosis of CMPA confirmed.

Please refer to the NHS England Bristol stool chart.

Referrals to Paediatrics should be made via the SCI Gateway.

Please note, these are vetted in a timely manner so the priority status of a referral may change upon review.

Lifestyle management

• Timed toileting after around 20 mins after mealtimes to sit for 5 minutes and do 5 good pushes into their bottom.
• Toileting position – knees above hips/feet on step if don’t touch ground/hands on lap.
• Adequate fluid intake
  • Age 4-8 years: 1000-1400mls (girls and boys)
  • Age 9-13 years: 1200-2100mls (girls), 1400-2300mls (boys)
  • Age 14-18 years: 1400-2500mls (girls), 2100-3200mls (boys)
• Healthy balanced diet with fruit and fibre.

Medical management

• If issues such as soiling and overflow, commence disimpaction with macrogol 3350.
• Prescribe maintenance dose if not impacted but still requires medication.
• If in doubt, disimpact.
• If early onset/during weaning - consider cow’s milk protein-free diet for 1 month.
• Access support from ERIC website, health visitor, school nurse or continence service.
• First line medication – macrogol 3350 eg Movicol or Laxido as per BNFc.
• Second line medication – add stimulant.

Practical advice

• Mix contents of each macrogol sachet in the suggested volume of water (differs for full and Paediatric strength sachets), then add diluting juice if needed.
• Ensure adequate fluid intake throughout the day.
• Once disimpaction achieved, reduce to maintenance dose.
• Do not reduce maintenance dose or discontinue medication until child is stooling frequently without distress or overflow for at least 4 weeks; 6-12months maintenance treatment, or longer term, may be required.

ERIC. Advice for children with constipation leaflet.

ERIC. A parent's guide to disimpaction leaflet.

ERIC. Chronic constipation and disimpaction podcast.

NHS Ayrshire & Arran app. Continence section - for parental support.

NICE. Constipation in children and young people: diagnosis and management.CG99. Last updated 13 July 2017.