Constipation in children
The frequency at which children open their bowels varies widely, but generally decreases with age from a mean of 3 times per day for infants under 6 months old to once a day after 3 years of age.
NICE produced guidelines in 2010 on the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by 2 or more of the following:
The vast majority of children have no identifiable cause - idiopathic constipation. Other causes of constipation in children include:
After making a diagnosis of constipation NICE then suggesting excluding secondary causes. If no red or amber flags are present then a diagnosis of idiopathic constipation can be made:
Prior to starting treatment the child needs to be assessed for faecal impaction. Factors which suggest faecal impaction include:
NICE guidelines on management
If faecal impaction is present
Maintenance therapy
General points
The NICE guidelines do not specifically discuss the management of very young child. The following recommendations are largely based on the old Clinical Knowledge Summaries recommendations.
Infants not yet weaned (usually < 6 months)
Infants who have or are being weaned
NICE produced guidelines in 2010 on the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by 2 or more of the following:
| Child < 1 year | Child > 1 year | |
|---|---|---|
| Stool pattern | Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks of age) Hard large stool 'Rabbit droppings' (type 1) | Fewer than 3 complete stools per week (type 3 or 4) Overflow soiling (commonly very loose, very smelly, stool passed without sensation) 'Rabbit droppings' (type 1) Large, infrequent stools that can block the toilet |
| Symptoms associated with defecation | Distress on passing stool Bleeding associated with hard stool Straining | Poor appetite that improves with passage of large stool Waxing and waning of abdominal pain with passage of stool Evidence of retentive posturing: typical straight legged, tiptoed, back arching posture Straining Anal pain |
| History | Previous episode(s) of constipation Previous or current anal fissure | Previous episode(s) of constipation Previous or current anal fissure Painful bowel movements and bleeding associated with hard stools |
The vast majority of children have no identifiable cause - idiopathic constipation. Other causes of constipation in children include:
- dehydration
- low-fibre diet
- medications: e.g. Opiates
- anal fissure
- over-enthusiastic potty training
- hypothyroidism
- Hirschsprung's disease
- hypercalcaemia
- learning disabilities
After making a diagnosis of constipation NICE then suggesting excluding secondary causes. If no red or amber flags are present then a diagnosis of idiopathic constipation can be made:
| Indicates idiopathic constipation | 'Red flag' suggesting underlying disorder | |
|---|---|---|
| Timing | Starts after a few weeks of life Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking medicines | Reported from birth or first few weeks of life |
| Passage of meconium | < 48 hours | > 48 hours |
| Stool pattern | 'Ribbon' stools | |
| Growth | Generally well, weight and height within normal limits, fit and active | Faltering growth is an amber flag |
| Neuro/locomotor | No neurological problems in legs, normal locomotor development | Previously unknown or undiagnosed weakness in legs, locomotor delay |
| Abdomen | Distension | |
| Diet | Changes in infant formula, weaning, insufficient fluid intake or poor diet | |
| Other | Amber flag: Disclosure or evidence that raises concerns over possibility of child maltreatment |
Prior to starting treatment the child needs to be assessed for faecal impaction. Factors which suggest faecal impaction include:
- symptoms of severe constipation
- overflow soiling
- faecal mass palpable in abdomen (digital rectal examination should only be carried out by a specialist)
NICE guidelines on management
If faecal impaction is present
- polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
- substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
- inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
Maintenance therapy
- very similar to the above regime, with obvious adjustments to the starting dose, i.e.
- first-line: Movicol Paediatric Plain
- add a stimulant laxative if no response
- substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
- continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce dose gradually
General points
- do not use dietary interventions alone as first-line treatment although ensure child is having adequate fluid and fibre intake
- consider regular toileting and non-punitive behavioural interventions
- for all children consider asking the Health Visitor or Paediatric Continence Advisor to help support the parents.
The NICE guidelines do not specifically discuss the management of very young child. The following recommendations are largely based on the old Clinical Knowledge Summaries recommendations.
Infants not yet weaned (usually < 6 months)
- bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant's legs
- breast-fed infants: constipation is unusual and organic causes should be considered
Infants who have or are being weaned
- offer extra water, diluted fruit juice and fruits
- if not effective consider adding lactulose