HNY Policy and Pathway Repository - York

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The inability to pass stools regularly OR empty the bowels completely.

Paediatric Normal Values (adapted from APLS)
Age	Resp Rate	Heart Rate	Systolic BP
Neonate <4w	40-6	120-160	>60
Infant <1 y	30-40	110-160	70-90
Toddler 1-2 yrs	25-35	100-150	75-95
2-5 yrs	25-30	95-140	85-100

Exclude Red Flag Symptoms

• Constipation in neonates (48h in term infant)
• Abnormal appearance of anus (patency, anterior position, fistula, fissures, bruising)
• Ribbon like stools (with presence of blood or mucus)
• Abnormal neurological examination (lower limbs particularly)
• Deformity in the lower limbs (talipes, contractures)
• Abdominal distension with vomiting (urgent referral)
• Abnormal appearance of spine or sacral region (discoloured skin, hairy patch, sacral dimple, asymmetry of the gluteal muscles
• Previous necrotising enterocolitis in ex-preterm infants

High risk of chronicity

• ASD
• Cerebral palsy
• Down syndrome
• Impaired mobility
• Looked After Children

General Points

• The majority can be managed in primary care
• Can have a significant impact on health and wellbeing if not addressed and managed
• It is common and affects 5-30% of young children (most common in toddlers)
• It affects about 1% of adolescents
• Most are idiopathic
• 1 in 3 develop chronic symptoms
• Delays of >3d between stools may increase the likelihood of pain on passing hard stools leading to anal fissures, anal spasm and eventually a learned response to avoid defecation
   

Presenting Features

• Duration of symptoms and any ‘trigger events’
• Stool pattern (<3 stools/wk may indicate constipation)
• Stool consistency (using Bristol stool chart) - passage of firm or hard stools
• Faecal soiling – the passage of liquid or formed stool into the child’s underwear. This can be caused when stools have sat in the rectum for a long time.
• Straining or distress associated with opening bowels
• Poor appetite that resolves with opening of the bowels  
• Abdominal pain that resolves with opening of the bowels
• Urinary symptoms (incontinence, UTI, retention)

Background History

• Passage of meconium within 48h of birth in a term baby
• Previous episodes of constipation or anal fissure
• Measures already tried
• Medications that may cause constipation (e.g. iron, opiates)
• Diet and fluid intake
• Previous abdominal surgery
• Personal or family history of bowel disorders or connective tissue disorders (e.g. EhlerDanlos, hypermobility)

Examination

• Check growth
• Abdominal examination
• Check lumbosacral spine for swelling, tuft of hair suggesting spinal dysraphism
• Lower limb neurological examination including tone, power and reflexes
• Visual inspection of perineum
• DO NOT perform a digital rectal examination

Differential Diagnoses

Although laxatives can be used safely in even very young infants, have a low threshold for discussing these patients with paediatrics. Particular considerations include;

• Cystic fibrosis (can occur even if Newborn Heel-Spot is normal)
• Thyroid disorders (can occur even if Newborn Heel Spot is normal)
• Hirschsprungs disease
  • Delayed passage of meconium (>48h in term babies)
  • Constipation since first few weeks of life
  • Chronic abdominal distension plus vomiting
  • Family history of Hirschsprungs disease
  • Faltering growth
• Bowel malformation
• Incorrectly made formula feeds
• Cow’s milk protein allergy (constipation or loose stools)
• Medication (alginate antacids, Carobel, ‘hungry baby formula’, iron)

Investigations

Consider investigations if there is no response to optimum therapy within 3 months

• Bloods to look for causation: coeliac disease, thyroid function tests
• Bloods to consider if diet is poor: FBC, ferritin, vitamin D
   

Management

Do not use dietary interventions alone as first-line treatment

Diet

• Dietary interventions should be used alongside laxatives, rather than as first line treatment alone
• Increase fluid intake
• High fibre foods

Behavioural

• Adapted to stage of development
• Include encouragement and reward systems
• Keep a bowel diary
• Scheduled toileting to establish a regular bowel habit – utilise the gastro-colic reflex by visiting toilet after meals
  • Encourage child to sit on the toilet for 5-10 minutes
    • 20-30mins after breakfast
    • After lunch/when home from school
    • 20-30mins after dinner
    • Before bed
• Make toilet sitting fun – blow bubbles, games that make them laugh
• Place child’s feet on a step-stool, so their knees are above the hips, as this makes passing stool easier
• At least 60 mins of physical activity a day
• Massage the stomach in a clockwise direction

Medication

• Adjust dosages according to effect in order to establish a regular pattern of bowel movement in which stools are soft, well-formed and passed without discomfort
• Reassure about the safety of long-term laxative use
• The principle for medication in the treatment of constipation is a high enough dose, for a long enough period, which can be gradually weaned down.

First line laxative: oral macrogols, e.g. Laxido

 

Disimpaction Regime

Overflow soiling +/- palpable faecal mass are indications of impaction. If the child is impacted, a disimpaction regime should be commenced. If the child is not impacted, maintenance therapy should be commenced.

• The duration of treatment at the highest doses may vary and should be guided by response to treatment
• Disimpaction may initially increase symptoms of soiling and abdominal pain
• Disimpaction dose should be continued until there is a good response

Paediatric macrogols
Age: <1y*
Day	1	2+
Sachets	0.5-1	0.5-1
Age: 1-4y
Day	1	2	3	4	5	6+
Sachets	2	4	4	6	6	8
Age: 5-12y
Day	1	2	3	4	5+
Sachets	4	6	8	10	12
Adult macrogols
Age: 12-18y
Day	1	2	3+
Sachets	4	6	8
*Unlicenced dose

 

Maintenance Therapy

• It is useful to give a dose range for treatment so they can adjust medication within these limits over time
• Children who are toilet training should remain on laxatives until toilet training is well established
• Medication should not be stopped abruptly: reduce dose gradually over months in response to stool consistency and frequency
• Informed consent should be obtained and documented whenever medications/doses are prescribed that are different from those recommended by the BNFC.

Paediatric Macrogol

<1y: 0.5-1 sachet/d*

1-6y: 1 sachet/d (max 4/d)

6-12y: 2 sachets/d (max 4/d)

* Unlicensed dose

Adult Macrogol

12-18y: 1-3 sachets/d in divided doses; maintenance 1-2 sachets/d

 

Follow-up

• Child undergoing disimpaction regime: follow up to assess response within 1 week
• Child on maintenance regime: review response to treatment within 6 weeks and the dose titrated to produce a regular, soft stool
• If impaction recurs at any point during treatment, a disimpaction regime should be recommenced
• Maintenance therapy should be continued for several weeks after regular bowel habit is established  
• No response by 3 months despite compliance with treatment – reassess the patient for potential alternative diagnosis or complicating factors

Treatment Failure

The commonest reason for lack pf response is that they are not being administered correctly

• Check understanding of number of sachets/d
• Space out doses across the day (solution stores well in fridge for 24h)
• Mix with cordial • Mix with larger volume of liquid if texture not tolerated
• DO NOT mix with milk Second Line If oral macrogols are not effective but are being taken reliably: add stimulant laxative If oral macrogols are not tolerated: use a stimulant but a softener (e.g. lactulose) will also be required

Second Line

If oral macrogols are not effective but are being taken reliably: add stimulant laxative

If oral macrogols are not tolerated: use a stimulant but a softener (e.g. lactulose) will also be required

Indications for referral

• <1y who do not response to optimum therapy within 4 weeks – URGENT referral - consider Hirschsprungs
• Medical cause is suspected, e.g. dysmotility, suspected underlying primary bowel disorder, malabsorption
• Where optimum management has failed despite good compliance
• Complex cases, e.g. complex neurodisability, short gut
• Suspected Hirschsprungs disease
• Structural abnormality

Patient information leaflets/ PDAs

Healthier together Constipation - 1-4 years Constipation - 5-11 years Constipation - young person

Other resources

• https://www.eric.org.uk/Pages/Category/bowel-problems
• www.thepoonurses.uk
• Constipation leaflet
• Suppository leaflet for parents

References

• National Institute for Clinical Excellence [NICE] (2017) Constipation in children and young people: diagnosis and management [Viewed 20 Aug 2021] https://www.nice.org.uk/guidance/cg99 
• National Institute for Clinical Excellent [NICE] (2014) Constipation in children and young people: Quality Standard [Viewed 20 Aug 2021] https://www.nice.org.uk/guidance/qs62