with thanks to Dr Edward Dallas, paediatric registrar.
Constipation is <3 stools per week, often hard and large or rabbit droppings, often painful, possibly with overflow. Its prevalence is around 5-30%!
Most is idiopathic/functional, but the clinician must rule out red flag symptoms such as:
- Constipation from birth
- Delay in passing meconium <48 hours from birth, could suggest Hirschsprung’s or Cystic Fibrosis
- Abdominal distension with vomiting, could suggest obstruction
- Leg weakness or motor delay, could suggest neurological or spinal cord problem
- Ribbon stool pattern, could suggest anal stenosis (usually presents <1 yr)
- Faltering growth, could suggest coeliac disease or hypothyroidism
Remember that breast fed babies can have long periods between stooling. The introduction of cow’s milk based formulas can lead to constipation. Constipation often plays a big part in bedwetting and daytime continence issues. Examine the abdomen and spine in a child with enuresis.
The aetiology of constipation is multifactorial and includes: pain, fever, inadequate fluid intake, reduced dietary fibre intake, toilet training issues, the effects of drugs, psychosocial issues, and a family history of constipation. Primary school children who can’t quite organise themselves to empty their bowels before going to school and then won’t use the toilets at school often get bunged up quite quickly after starting school.
Management of idiopathic/functional constipation:
The management of functional constipation has 6 main components:
1– Education (demystification)
2- Fluids and diet
3- Regular toilet habit (behavioural) and exercise (re-training)
4- Disimpaction (if in doubt, disimpact!)
5- Maintenance laxatives
6- Regular follow up and support
Diet and Lifestyle advice e.g., regular toilet breaks with praise, star chart etc.
Reassurance, with sources of information & support:
- NHS: https://www.nhs.uk/conditions/baby/health/constipation-in-children/
- ERIC: https://www.eric.org.uk/what-is-constipation
- The Poo in You – Constipation and Encopresis Educational Video from Children’s Hospital Colorado
Longstanding constipation is unlikely to get better without medication. If left, it gets worse so please ensure you start the child on treatment before considering referral.
Usually start with a “Dis-impaction regime” which includes increasing doses of Paediatric Movicol, often adding Senna after a few days if the child still seems to not be passing the lumps. See https://pathways.nice.org.uk/pathways/constipation.
(A parent’s guide to dis-impaction can be found here: https://www.eric.org.uk/pdf-a-parents-guide-to-disimpaction)
If Movicol is not tolerated, try:
Bisacodyl tablets e/c 5mg (swallow whole)
OR Sodium picosulfate liquid 5mg/5mL
See NHS Lothian formulary for age-appropriate dosing at https://www.ljf.scot.nhs.uk/LothianJointFormularies/Child/1.0/1.6/Pages/default.aspx
Once dis-impacted, the child should be switched to a Maintenance regime to allow muscles and nerves to return to normal. This will take at least 6 months. Don’t stop medications too early!
Paediatric Movicol 1-4 sachets/day
If over 12 years old, use adult Movicol / cosmocol 1-2 sachets per day
Lactulose and Senna – see BNFc or the NHS Lothian formulary for suitable doses. Lactulose is bad for teeth. All laxatives can be diluted with squash, fruit juice, water or milk.
Regular follow-up and support. Aim to wean off once the child has had soft stools for at least 6 months.