See also:      

Appendix: Medication Information
Abdominal pain

Key Points

1. Constipation is a common condition, with functional constipation being the most common cause. Reassure parents where appropriate.
2. A diagnosis can be made clinically and an X-ray is not recommended. Internal examination is not required.
3. Titrate medications aiming for one, soft, easy to pass bowel action per day.
4. Treatment is usually required for several months. A common cause of recurrence is stopping laxatives too early.

Background

• Constipation is common, occurring in up to 30% of children. Most children defaecate at least every 2-3 days.
• Breastfed babies may defaecate as infrequently as once a week.  
• Healthy infants ( <6mo) can strain and cry before passing soft stools (dyschezia). Unless the stools are also hard, this is not constipation and will self-resolve.
• Young children may ignore the urge to defaecate, causing a build-up of large hard bowel actions. Painful defaecation leads to apprehension, retention, passage of hard stool and a cycle of withholding and passage of hard stool.
• Constipation is particularly common during the introduction of solid foods to the diet, during toilet training and at school entry.

Assessment

History:

The Rome IV criteria is a useful diagnostic tool for the diagnosis of functional constipation.

Be mindful of less common, organic causes in the history and examination:

Medical	Surgical
Cow milk allergy Coeliac disease Hypercalcaemia Hypothyroidism	Hirschsprung disease Meconium ileus Anatomic malformations of anus   Spinal cord abnormalities

Rome IV criteria - Diagnostic criteria for Functional Constipation

Must include ≥ 2 criteria for at least 1 month

1. ≤2 stools/week

2. History of retentive posturing or excessive volitional stool retention (i.e. withholding or incomplete evacuation)

3. History of painful or hard bowel movements

4. History of large-diameter stools

5. Presence of a large faecal mass in the rectum

In toilet-trained children, the following additional criteria may be used:

6. At least 1 episode per week of soiling/incontinence after the acquisition of toileting skills 

After appropriate evaluation, the symptoms cannot be fully explained by another medical condition.

Further History:

• Stool consistency (see Bristol Stool Chart )
• Straining, blood on wiping and/or in the nappy.
• Past medication use and effectiveness.
• Painful or frightening precipitant prior to onset of constipation.
• Toilet refusal or withholding behaviours (e.g. crossing legs).
• Faecal or urinary incontinence, day or night.
• For children with faecal incontinence (soiling); onset, frequency of soiling episodes and relationship to bowel actions.
• Family history of coeliac disease
  

Red Flags

• Infants presenting <6 weeks age - should be discussed with a senior doctor or consider referral to a paediatrician.
• Delayed passage of meconium – most infants pass meconium in the first 24 hours of life (consider Hirschsprung disease or anorectal malformation).
• Ribbon like stools - consider anorectal malformation.
• Weight loss/poor growth, persistent vomiting or PR blood loss
• Abdominal mass (not consistent with large faecal mass)

Examination:

• Abdomen - palpable faeces.
• Lower Back/Spine – consider occult spinal dysraphism/tethered cord
• Neurology - assessment of lower limbs, observation of gait.
• Perianal area –fissures, placement of anus, anal wink / tone, or other abnormalities.
• Internal examination generally not required.

Impaction:

Use a combination of history-taking and physical examination to determine whether faecal impaction is present. This may include a hard mass in the lower abdomen and overflow soiling.

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 – up to 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. 
  

Dietary modification

• Increasing dietary fibre is not an adequate treatment for constipation.
• Excessive cow milk intake may exacerbate constipation in some children. 

Medications

• Osmotic and lubricant laxatives are usually required on a long term basis (months to years). Reassure parents that this is safe and doesn’t produce a ‘lazy bowel’.
• Titrate medication aiming for one soft, easy to pass bowel action per day.
• A common cause of recurrence is stopping laxatives too early.

First line options- oral laxatives

• Infants < 1 month: Coloxyl drops
• Infants 1-12 months: Iso-osmotic laxative or Lactulose
• Children: Iso-osmotic laxative (Movicol™ or Osmolax™) or lubricant (paraffin oil).

Rectal medications

Rectal treatment with suppositories or enemas should be avoided. Anal fissures can be treated with topical Petroleum Jelly to provide pain relief.

Disimpaction

• Children with severe constipation benefit from a disimpaction regimen before maintenance treatment begins.
• Oral medication as an outpatient is effective and preferred. Switch to maintenance therapy immediately post disimpaction.
• Only consider the use of glycerine suppository or Microlax™ enema as a one off treatment. Sedation should be strongly considered.

Outpatient Disimpaction Management - oral

The number of sachets or scoops to be taken daily for disimpaction are listed below. They can be mixed in liquid and kept in the fridge to be taken across the day.

Movicol™ - using full strength / adult Movicol™ sachets

Age	Day 1	2	3	4	5	6	7
1-6 yo	1	2	2	3	3	4	4
6-12 yo	2	3	4	5	6	6	6
12+	8	8	8	-	-	-	-

 

Note:  Double the dose if using Movicol™ Junior sachets (i.e. 1 Movicol™ sachet = 2 Movicol™ Junior or Half sachets).

Stop once a reasonable volume of faeces and/or faecaloma eliminated. It is recommended to review ongoing need for disimpaction on day 4 of treatment.

OsmoLax™ using small scoops (8.5g)

Age	Day 1	2	3	4	5	6	7
1-6 yo	2	3	3	4	5	6	6
6-12 yo	3	4	6	8	9	9	9

Inpatient Disimpaction 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.

For older children who refuse a nasogastric tube or prefer oral treatment, fixed dose sodium picosulphate preparations can be used (Picolax™/Picoprep™)

4-9 years: 1 sachet - first dose / ½ sachet - second dose

(=15mg sodium picosulphate/day)

Children >9years:1 sachet BD

(= 20mg sodium picosulphate/day) 

• Ensure adequate hydration to reduce the risk of dehydration and electrolyte disturbance (over 1 L recommended after a full sachet). Drink to thirst, liquids should include a variety of fruit juice, soft drinks, sport drinks etc.
• Oral medication taken during or within the hour before administration of a bowel washout may be flushed from the GIT without absorption.
• Do not use if signs of obstruction or in renal impairment.
  

Follow up:

Arrange follow up with GP or with a General Paediatrician within 4 weeks.

Refer to a Continence Clinic or Encopresis Clinic for faecal/urinary incontinence, complex or difficult cases.

Consider consultation with local paediatric team when:

• Presence of red flags or concern regarding underlying organic pathology.
• Non-resolution despite optimising management over 6 months (outpatient).
• Failure of outpatient disimpaction, requiring inpatient management.

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

Parent information sheet

• Constipation (Kids Health Info)
• Constipation (Raising Children Network)
• Faecal incontinence(Raising Children Network)
• Encopresis diary (RCH)

Additional notes

Health Pathways                                            

Last revised December 2017

Appendix: Medication Information (maintenance phase)

Trade name	Active ingredient/class	Dosage	Tips
Actilax™	Lactulose Osmotic laxative	1-12 months 3-5mL/day 1-5yo 5-10mL/day 5-14yo 10-40mL/day	Split larger doses BD. 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, >2yo.
Movicol™	Macrogol 3350 + electrolytes Iso-osmotic laxative	Movicol™ Half/Junior 1-12mo ½-1 sachet 1-6yo 1 sachet  (max 4/day) 6-12yo  2 sachet (max 4/day) Movicol™ full strength >12yo 1-4/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, more palatable if cold. May cause cramps or diarrhoea. PBS listed (authority not required).
OsmoLax™ ClearLax™	Macrogol 3350 Iso-osmotic laxative	Starting doses: 2-6yo 1 sm all scoop/day 6-12yo 1 large scoop/day >12yo 1-2 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). May cause cramps or diarrhoea. PBS listed (authority not required).
Parachoc™(chocolate) Agarol™ (vanilla) Plain paraffin oil	Paraffin oil Stool softener/ Lubricant	1-6yo 10-15mL/day 6-12yo 15-20mL/day >12yo up to 40mL/day	Can cause orange oil seepage in underwear (reduce dosage). Can mix in foods, mixes well in ice-cream, floats on liquids. Avoid in children with swallowing problems due to aspiration risk, particularly those < 6 months age.
Dulcolax™ drops or tablets	Sodium picosulfate drops (1 drop = 0.5mg) OR Bisacodyl tablets Stimulant	6mo-4yrs, 0.25mg/kg (max 5mg = 10 drops) 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.