Clinical Practice Guidelines

Constipation

  • This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

    See also: Abdominal pain

    Background to condition:

    • Constipation is common, occurring in up to 30% of children.
    • Most children defecate at least every 2-3 days. Breastfed babies may defecate as infrequently as once a week.
    • Features include infrequent stool passage, large stools, painful defecation, or new onset faecal incontinence.
    • Constipation is particularly common during the introduction of solid foods to the diet, during toilet training, and at school entry. It may be precipitated by episodes of dehydration / intercurrent illness.
    • Healthy infants (<6mo) can strain and cry before passing soft stools (dyschezia). This is caused by inability to co-ordinate the increase in intra-abdominal pressure with pelvic floor relaxation. Unless the stools are also hard, this is not constipation and will self-resolve.

    Causes:

    When constipation presents early in life (<6 weeks), be alert for organic disease. Neonates presenting with constipation should be discussed with a senior doctor.

    Functional constipation is the most common cause of constipation in childhood. Painful defaecation leads to apprehension, retention, passage of hard stool and a cycle of withholding and passage of hard stool. Young children may ignore the urge to defaecate, causing a build-up of large hard bowel actions.

    Less common causes:

    Medical

    Surgical

    Cow milk allergy
    Coeliac disease
    Hypercalcaemia, hypothyroidism

     

    Hirschsprung disease
    Meconium ileus
    Anatomic malformations of anus  
    Spinal cord abnormalities

    History:

    • Timing of meconium passage – most infants pass meconium in the first 24hrs of life
    • Painful/ frightening precipitant  
    • Straining
    • Toilet refusal, hiding while defaecating, crossing legs or other withholding behaviour
    • Faecal or urinary incontinence, day or night
    • Weight loss, vomiting or PR blood loss – suggests possible organic disease
    • Stool description

    Examination:

    • Height and weight – failure to thrive
    • Abdomen - palpable faeces
    • Spine – deep sacral cleft or tuft of hair
    • Neurology - assessment of lower limbs.
    • Anal area – visually examine for fissures. Internal examination not required.

    Investigations:

    Abdominal x-ray rarely changes management and is not recommended.
    If constipation persists despite adequate behaviour modification and laxative therapy, consider investigating for less common conditions listed above.

    Management:

    Behaviour modifications

    • Position – footstool to ensure knees are higher than hips. Lean forward and put elbows on knees. A toilet ring should be placed over the toilet seat if needed.
    • Toilet sits –5 minutes three times a day, preferably after meals. A timer in the bathroom can help. Encourage child to bulge out their abdomen. Praise child for sitting on toilet, keep toileting a positive experience.
    • Chart or diary – to reinforce positive behaviour and record frequency of bowel actions. 
    • Delay toilet training attempts until child is painlessly passing soft stool. 

    Diet

    • Increasing dietary fibre is not an adequate treatment for constipation, but can potentially help prevent future episodes.
    • A healthy diet and adequate fluid intake is important for children’s general health and wellbeing.
    • Excessive cow milk intake may exacerbate constipation in some children.  

    Medications

    • A common cause of treatment failure is stopping laxatives too early. Osmotic and lubricant laxatives can be used safely on a long term basis (months to years).
    • Titrate medication aiming for one soft, easy to pass bowel action per day.

    First line options- oral laxatives
    Children: Stool softener (paraffin oil) or iso-osmotic laxative (Movicol™ or Osmolax™)
    Infants 6-12mo: Coloxyl™ drops or Lactulose
    Infants <6months: Coloxyl™ drops

    Trade name

    Active ingredient/class

    Dosage

    Tips

    Parachoc™
    (chocolate)
    Agarol™ (vanilla)
    Plain paraffin oil

    Paraffin oil
    Stool softener

    1-6yo 10-15mL/day
    6-12yo 15-20mL/day
    >12yo up to 40mL/day

    Can cause orange oil seepage in underwear
    Can mix in foods, mixes well in ice-cream
    Avoid in children with swallowing problems due to aspiration risk.

    Osmolax™
    Clearlax™

    Macrogol 3350
    Iso-osmotic laxative

    4-5yo 1 large scoop/day
    6-12yo 1.5 large scoops/day
    >12yo 2 large scoops/day

    Tin with double ended scoop - large (17g) and small (8.5g).
    Mix 17g scoop with 1 cup of hot or cold liquid.
    Same active ingredient as Movicol without electrolytes (no salty taste).
    PBS listed (authority not required).

    Movicol™

    Macrogol 3350 + electrolytes
    Iso-osmotic laxative

    2-5yo: 1 sachet Movicol™ Half/ day
    6-11yo  1 full strength/day
    >12yo 1-3 full strength/day

    Movicol™ full strength 13g (lemon-lime/ choc/ flavour free)
    Movicol™ Half 6.9g (lemon-lime)
    Movicol™  Junior 6.9g (flavour free)
    Dissolve full strength sachet in ½ cup liquid.
    PBS listed (authority not required).

    Actilax™

    Lactulose
    Osmotic laxative

    6mo -1yo 3-5mL/day
    1-6yo 5-10mL/day
    7-14yo 10-15mL/day

    Can mix with water, milk or juice
    Can cause bloating/ abdominal discomfort

    Coloxyl™ drops

    Poloxamer
    Stool softener

    <6 mo 0.3mL tds
    6-18mo 0.5mL tds
    18mo-3yo 0.8mL tds

    Can mix in formula or juice (for Coloxyl+Senna, Senna is the stimulant component and should be avoided unless stools are soft)

    Dulcolax™ drops or tablets

    Sodium picosulfate/ bisacodyl
    Stimulant

    4-10yo  5-10 drops nocte
    >10yo  10 drops nocte or 1-2 tablets nocte

    Useful for patients who cannot tolerate large volumes of liquid. Avoid if impacted.
    Can cause abdominal cramps. Do not use long term.

    Disimpaction

    Children with severe constipation benefit from a disimpaction regimen before maintenance treatment begins. Oral medication as an outpatient is preferred. Stop once rectal effluent is clear, and switch to maintenance therapy.

    Outpatient management - oral

    Suitable for >2yo. Sachets can be mixed in liquid and kept in the fridge to be consumed across the day.

    Movicol™ - disimpaction regime using full strength/ adult Movicol™ sachets


    Age

    Day 1

    2

    3

    4

    5

    6

    7

    2-5yo

    1

    2

    2

    3

    3

    4

    4

    5-11yo

    2

    3

    4

    5

    6

    6

    6

    12+

    8

    8

    8

    8

    8

    8

    8

    1 Movicol™  sachet = 2 Movicol™ Junior or Half sachets

    Rectal medications

    Rectal treatment with suppositories or enemas should be avoided when possible, and used only in cases of acute severe rectal pain or distress related to faecal impaction. If using rectal medications in the emergency setting, sedation with N2O or midazolam should be strongly considered. Sodium citrate 5ml enemas (Microlax") can be used. Anal fissures can be treated with topical Petroleum Jelly to provide pain relief.

    Inpatient management

    Macrogol/ electrolyte solutions (Colonlytely™, Glycoprep™) 1-3L/day, via NGT at a rate of 25mL/kg/hr (maximum rate 400mL/hr, or less depending on pump used). Normal maintenance oral fluids should be given in addition to maintain hydration. These solutions provide no net fluid input and there is a risk of dehydration.

    Follow up:

    • Arrange follow up with GP, in General Medicine clinic or with a General Paediatrician
    • Refer to Continence Clinic or Encopresis Clinic for faecal/urinary incontinence, suspected organic cause, complex or difficult cases.   

    Links:

    • Constipation is common, occurring in up to 30% of children.
    • Constipation – home management sheet (toilet trained children)
    • Parent information sheet
    • Encopresis diary