See also 

Abdominal pain 
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 under reported
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 of 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 (<6 months) 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 (eg crossing legs)
• Past medication use and effectiveness
• Feeding history (eg 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 (ie 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

 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 clinician 
• 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 eg investigate barriers to using school toilets
• Delay toilet training attempts until child is painlessly passing soft stool  

Dietary modification

• Excessive cow milk intake may result in inadequate dietary fibre; this may exacerbate constipation in some children. More information can be found here (Nutrition – babies & toddlers)
• Increasing dietary fibre is not an adequate treatment for constipation
• There is no need to increase fluid intake beyond daily maintenance fluid requirements as shown here

Medications (see also Appendix below)

• 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 (see Appendix for oral laxatives)

• Infants <1 month: Coloxyl drops
• Infants 1–12 months: Iso-osmotic laxative (Macrogol-3350 + electrolytes or Lactulose
• Children: Iso-osmotic laxative or lubricant (paraffin oil)
• Children with stool withholding 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 Macrogol-3350 + electrolytes sachets

 

Number of OsmoLax™small scoops (8.5 g)

Inpatient disimpaction management

Macrogol/ electrolyte solutions (Colonlytely™, Glycoprep™) 1–3 L/day, via NGT at a rate of 25 mL/kg/hr (maximum rate 400 mL/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 yo: 1 sachet — first dose / ½ sachet - second dose (=15 mg sodium picosulphate/day)
Children >9 yo: 1 sachet BD (= 20 mg 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

• Red flags present, or concerns of an underlying organic pathology
• Non-resolution occurs despite optimising management over 6 months (outpatient)
• Outpatient disimpaction fails, requiring inpatient management

Parent information

Kids Health Info

Constipation

RCH constipation encopresis diary

Raising Children Network

Constipation
Faecal incontinence

Appendix: Medication information (maintenance phase)

Last updated March 2020