Constipation in Children

Question 1

how often (on average) does an infant under 6 months poo per day?

Answer 1

3 times

Question 2

how often (on average) does a child after 3 years old poo per day?

Answer 2

once

Question 3

what factors should be considered when reviewing a child with constipation?

Answer 3

• stool pattern
• symptoms associated with defecation
• history

diagnosis of constipation is suggested by 2 or more of these symptoms

Question 4

what stool pattern suggests a diagnosis of constipation in a child <1 year old?

Answer 4

• <3 stools per week
• hard large stool
• ‘rabbit droppings’

3 complete stools per week does NOT apply to exclusively breastfed babies after 6 weeks of age

Question 5

what stool pattern suggests a diagnosis of constipation in a child >1 year old?

Answer 5

• <3 complete stools per week
• overflow soiling
• ‘rabbit droppings’
• large, infrequent stools that can block the toilet

Question 6

what are the characteristics of overflow soiling?

Answer 6

commonly very loose, very smelly, stool passed without sensation

Question 7

what symptoms associated wtih defecation suggests a diagnosis of constipation in a child <1 year old?

Answer 7

• distress on passing stool
• bleeding associated with hard stool
• straining

Question 8

what symptoms associated wtih defecation suggests a diagnosis of constipation in a child >1 year old?

Answer 8

• poor appetite that improves with passage of large stool
• waxing and waning of abdo pain with passage of stool
• evidence of retentive posturing
• straining
• anal pain

Question 9

what is retentive posturing?

Answer 9

typically straight-legged, tiptoed, back arching posture

e.g. trying to hold in a poo

Question 10

what history suggests a diagnosis of constipation in a child <1 year old?

Answer 10

• previous episodes of constipation
• previous or current anal fissure

Question 11

what history suggests a diagnosis of constipation in a child >1 year old?

Answer 11

• previous episodes of constipation
• previous or current anal fissure
• painful bowel movements and bleeding associated with hard stools

Question 12

what is the most common cause of constipation in children?

Answer 12

idiopathic

Question 13

name some causes of constipation in children?

Answer 13

• idiopathic
• dehydration
• low-fibre diet
• medications (e.g. opiates)
• anal fissure
• over-enthusiastic potty training
• hypothyroidism
• hirschsprung’s disease
• learning difficulties

Question 14

what timing suggests a diagnosis of idiopathic constipation?

Answer 14

• starts after a few weeks of life
• obvious precipitating factors coinciding with the start of symptoms

Question 15

what ‘red flag’ timing suggests an underlying disorder?

Answer 15

reported from birth or first few weeks of life

Question 16

what timing of the passage of meconium suggests a diagnosis of idiopathic constipation?

Answer 16

<48 hours

Question 17

what ‘red flag’ timing for the passage of meconium suggests an underlying disorder?

Answer 17

> 48 hours

Question 18

what ‘red flag’ stool pattern suggests an underlying disorder?

Answer 18

‘ribbon’ stools

Question 19

what ‘amber flag’ for growth suggests an underlying disorder?

Answer 19

faltering growth

Question 20

what ‘red flag’ for neuro/locomotor suggests an underlying disorder?

Answer 20

• previously unknown or undiagnosed weakness in legs
• locomotor delay

Question 21

what ‘red flag’ abdominal symptom suggests an underlying disorder?

Answer 21

distension

Question 22

what diet characteristics suggests a diagnosis of idiopathic constipation?

Answer 22

• changes in infant formula
• weaning
• insufficient fluid intake
• poor diet

Question 23

what factors suggest faecal impaction?

Answer 23

• symptoms of severe constipation
• overflow soiling
• faecal mass palpable in the abdomen

Question 24

what is the 1st line management of faecal impaction?

Answer 24

polyethylene glycol 3350 + electrolytes (movicol paediatric plain)

Question 25

what is the treatment plan for faecal impaction?

Answer 25

1. polyethylene glycol 3350 + electrolytes 2. + stimulant laxative if no disimpaction **after 2 weeks** 3. laxative --> osmotic laxative (lactulose) if electrolytes not tolerated

Question 26

what are the risks for disimpaction treatment?

Answer 26

can initially increase symptoms of soiling and abdominal pain

Question 27

what is the 1st line maintenance therapy for constipation?

Answer 27

**movicol paediatric plain (e.g. electrolytes)**

Question 28

what is the maintenance regimen for constipation?

Answer 28

1. movicol paediatric plain 2. + stimulant laxative 3. laxative --> osmotic laxative if movicol not tolerated continue medication at maintenance dose for several weeks after regular bowel habit established, then reduce the dose gradully

Question 29

what lifestyle measures can help in constipation?

Answer 29

* ensuring adequate fluid and fibre intake * regular toileting and non-punitive behavourial interventions

Question 30

what is the management in an infant who has not yet weaned who has constipation?

Answer 30

* bottle-fed = extra water between feeds, abdo massage and bicycling legs * breast-fed = constipation unusual --> organic cause

Question 31

what is the management in an infant who have been weaned/being weaned who have constipation?

Answer 31

* offer extra water, diluted fruit juice and fruit * + lactulose if not effective