Constipation


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

  • See also 

    Appendix: Medication Information 
    Abdominal pain 
    Bowel and bladder dysfunction
    Urinary Incontinence
    Urinary Tract Infections

    Key Points

    1. Constipation is a common condition and functional constipation is the most common cause.
    2. The diagnosis is made clinically. Internal examination and X-ray are not required.
    3. Symptoms of constipation are underreported
    4. Medications are often required and should be titrated to achieve one, soft, easy to pass bowel action per day.
    5. Treatment is usually required for several months and if stopped early may lead to recurrence.

    Background

    • Constipation affects 1/3 children and frequently occurs during the introduction of solid foods, toilet training and school.
    • Most children defaecate at least every 2-3 days however breastfed babies may defaecate as infrequently as once per 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. When this leads to painful defaecation it may cause apprehension, stool retention and passage of further hard stool - a cycle of withholding and constipation.

    Assessment

    History

    • Duration of symptoms
    • Stool frequency and consistency (see Bristol Stool Chart )
    • Blood on wiping and/or in the nappy (may indicate anal fissure or organic cause)
    • Mucus in the stool
    • Painful or frightening precipitant prior to the onset of constipation. This is different from infant dyschezia
    • Toilet refusal or withholding behaviours (e.g. crossing legs)
    • Past medication use and effectiveness
    • Feeding history (e.g. food avoidance or force feeding, daily fluid consumption, excessive cow milk consumption)
    • Faecal (soiling) or urinary incontinence; onset, frequency of episodes and relationship to bowel actions
    • Family history of coeliac disease or hypothyroidism

    *Note that children with Autism Spectrum Disorders and Attention Deficit / Hyperactive Disorder have an increased risk of functional constipation.

    Rome IV criteria - Diagnostic criteria for Functional Constipation

    Must include ≥ 2 criteria for at least 1 month in infants or 2 months in older children

    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  

    Red Flags

    • Infants presenting <6 weeks of age - should be discussed with a senior doctor
    • 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
    • Abdominal mass (not consistent with large faecal mass)

    Organic causes of constipation

    Medical

    Surgical

    Cow milk allergy
    Coeliac disease 
    Hypothyroidism
    Hypercalcaemia 
    Slow-transit constipation
    Neurological disorders

    Hirschsprung disease 
    Meconium ileus 
    Anatomic malformations of anus
    Spinal cord abnormalities

     Examination

    • Abdomen - palpable faeces, often felt in the left lower quadrant but may extend across the right side of the abdomen
    • 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 should not be performed without first consulting a senior doctor
    • Impaction: hard mass in the lower abdomen and soiling from overflow

    Management

    Investigations

    Investigations are not routinely required. 
    If constipation persists despite adequate behaviour modification and laxative therapy, consider investigating for less common conditions as listed above.

    Treatment

    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. Ensure toileting remains a positive experience
    • Chart or diary – to reinforce positive behaviour and record frequency of bowel actions
    • Encourage children to exercise more
    • Review toilet access e.g. investigate barriers to using school toilets
    • 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. More information can be found here (Nutrition – babies & toddlers)
    • There is no need to increase fluid intake beyond daily maintenance fluid requirements as shown here

    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 treatment options (oral laxatives)

    • Infants < 1 month: Coloxyl drops
    • Infants 1-12 months: Iso-osmotic laxative (Movicol™ or Osmolax™) or Lactulose
    • Children: Iso-osmotic laxative or lubricant (paraffin oil)
    • Children with stool with-holding behaviours, pain while defecating or rectal bleeding or fissures may benefit from inpatient disimpaction management

    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. It is recommended to review ongoing need for disimpaction on day 4 of treatment.

    Number of Movicol™ sachets using full strength (adult Movicol™)



    Age

    Day 1

    2

    3

    4

    5

    6

    7

    1-6 yo

    1

    2

    3

    4

    4

    4

    4

    6-12 yo

    2

    3

    4

    5

    6

    6

    6

    12+

    8

    8

    8

    -

    -

    -

    -

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

    Number of OsmoLax
    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™)


    Children 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 gastrointestinal tract without absorption
    • Do not use if signs of obstruction or in renal impairment 
    • Consider ceasing if child begins passing clear fluid per rectum

    Follow up

    Arrange follow up with GP or Paediatrician within 4 weeks.
    Consider referral to a continence or encopresis service for faecal/urinary incontinence, complex or difficult cases.

    Consider consultation with local paediatric team when:

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

    Parent information

    Kids Health Info

    Constipation

    RCH constipation encopresis diary

    Raising Children Network

    Constipation
    Faecal incontinence

    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.
    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 daily
    1-6yo 1 sachet daily (max 4/day) 
    6-12yo  2 sachets daily (max 4/day) 
    Movicol™ full strength 
    >12yo 1-4 sachets/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 small 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) nocte
    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.

    Last updated March 2020