Constipation in Children

Question 1

What are some causes of constipation in children?

Answer 1

• Idiopathic constipation (most common)
• Dehydration
• Low-fibre diet
• Medications: e.g. Opiates
• Anal fissure
• Over-enthusiastic potty training
• Hypothyroidism
• Hirschsprung’s disease
• Hypercalcaemia
• Learning disabilities

Question 2

How do you diagnose constipation in a child < 1 year old?

Answer 2

2 or more of the following:

1. Stool pattern -
   
   • Fewer than 3 complete stools per week.
   • Hard large stool.
   • “Rabbit droppings”
2. Symptoms -
   
   • Distress on passing stool.
   • Bleeding.
   • Associated with Hard Stool.
   • Straining.
3. History -
   
   • Previous episodes of constipation.
   • Previous or current anal fissure.

Question 3

How do you diagnose constipation in children > 1 year old?

Answer 3

2 or more of the following:

1. Stool pattern -Fewer than 3 stools per week.
   
   • Overflow soiling
   • Rabbit droppings.
   • Large, infrequent stools that can block the toilet.
2. Symptoms -Poor appetite but improves with passing stools.
   
   • Intermittent abdo pain with passing stool.
   • Retentive posturing - straight legged, tiptoed, back arching posture, straining, anal pain.
3. History - Previous constipation, anal fissure, painful bowel movements or bleeding with hard stools.

Question 4

After you make a diagnoses of constipation, you need to exclude amber or red flags in order to diagnose idiopathic constipation.

What are the “red flags” indicating an underlying disorder?

Answer 4

• Timing - from birth or first few weeks of life.
• Passage of meconium - >48 hours
• Stool pattern - “Ribbon stools”
• Neuro/locomotor - Undiagnosed weakness in legs or locomotor delay.
• Abdomen - distension

Question 5

What are some amber signs that would make idiopathic constipation less likely?

Answer 5

• Growth - faltering growth
• Other - disclosure or evidence that raises concerns over possibility of child maltreatment.

Question 6

Before starting treatment for idiopathic constipation, what should you do?

Answer 6

Assess for faecal impaction.

Question 7

What are some factors which suggest faecal impaction?

Answer 7

• Symptoms of severe constipation
• Overflow soiling
• Faecal mass palpable in abdomen

Question 8

As a GP should you do rectal examinations on children?

Answer 8

No, digital rectal examination should only be done by a specialist.

Question 9

How do you treat faecal impaction?

Answer 9

• First line - Movicol Paediatric Plain using an escalating dose regimen. (Polyethylene glycol 3350 + electrolytes)
  
  • Add Senna (stimulant laxative) if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
• If Movicol Paediatric Plain is not tolerated:
  
  • Substitute with Senna (stimulant laxative) +/- Lactulose (combination with an osmotic laxative)
• Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain.

Question 10

After the patient is disimpacted, how do you ensure maintenance of bowels?

Answer 10

• Similar to disimpaction regime
• First-line: Movicol Paediatric Plain
  
  • If no response - add Senna
• 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

Question 11

What are some general points to tell the parents?

Answer 11

• 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.

Question 12

How do you manage constipation in children < 6 months who are not yet weaned but bottle fed?

Answer 12

Give extra water in between feeds.

Try gentle abdominal massage and bicycling the infant’s legs.

Question 13

How do you manage constipation in children < 6 months who are not yet weaned but breast fed?

Answer 13

Constipation is unusual and organic causes should be considered

Question 14

How do you manage constipation in infants who are being weaned?

Answer 14

First line - Offer extra water, diluted fruit juice and fruits.

Second Line - consider adding lactulose.