Constipation in Children

Background/Epidemiology

• Prevalence ranges from 1-30%; majority (90-95%) is functional (i.e. no organic cause)

History and Examination

• In a child <1 year
  • NB normal stool frequency averages around 4/day in the first week of life to 2/day at 1 year.  ‘Normal’ stool frequency (i.e. for that person- can be between 3/day and 3/week) is usually established by age 4.
  • Diagnosing constipation
    • < 3 stools/week (typically type 3/4 on BSC– i.e. hard, larger stool to rabbit dropping stool)
    • There may also be
      • Distress on passing stool
      • Bleeding associated with hard stools
      • Straining
    • Ask about past history of constipation and previous/current anal fissure
  • Determining idiopathic vs serious causes
    • Idiopathic
      • Meconium passed within 48 hours; onset of constipation at least several weeks after birth
      • Precipitating factors e.g. dietary change (e.g. formula change, weaning); insufficient fluid intake
      • Normal appearance of the anus/anal region (DRE rarely required)
      • Soft, flat (distension only consistent with age/size etc) abdomen
      • Normal well-being and growth/development
    • Red-flags
      • Onset within first few weeks of life; delay in passing meconium (full-term)
      • Ribbon stool pattern
      • Abdominal distension and vomiting
      • Weakness of legs/locomotor delay
      • Abnormal anal appearance e.g. fistula, fissure, bruising, anteriorly placed anus, tight anus, absent ‘anal wink’ (reflex of anal contraction with close sensation)
        • Abnormal lumbosacral/gluteal regions e.g. asymmetry
      • Failure to thrive/poor growth; poor well-being
      • Concern over child-abuse
  • A history of constipation followed by loose soiling suggests impaction
• In a child >1 year
  • Stool pattern (as above- < 3/week; 3/4 on BSC)
  • There may also be
    • Poor appetite that may be relieved by passage of stool
    • Abdominal pain that may be relieved by passage of stool
    • Evidence of ‘retentive posturing’ (i.e. straight legged, tiptoes, arched back)
    • Straining, painful bowel movement and bleeding with hard stools
    • Anal pain
    • Past history of constipation or previous/current anal fissure
  • Idiopathic constipation is suggested by features described above plus
    • Poor diet/insufficient fluid intake
    • Acute infections
    • Domestic stress e.g. moving house, starting school, change in home circumstances
    • Timing of potty/toilet training
    • Fears/phobias
    • Medications
    • Anal fissure
  • Red flags are as above

Management

• If there are red flags, consider urgent referral.  If children <1 year does not respond to 4 weeks of treatment, consider urgent referral (DRE usually required).  If >1 year and does not respond to 3 months of treatment, consider referral.
• The use of laxatives early on should be considered
  • Prior to laxative use, exclude (or treat) any impaction
    • Polyethylene glycol + electrolytes (Movicol) (escalating dose for disimpaction; half the dose for maintenance once impaction has resolved)
      • If this fails use stimulant laxative e.g. sodium picosulfate or senna
      • Do not use enemas in children unless under specialist care
• Make sure to educate/advise about adequate fluid intake, good diet, ensure good toilet routine/behaviour- these will often aid symptoms
  • Aim for fluid intake of
    • 700ml (0-6 months); 800ml (7-12 months); 1300ml (1-3 years; around 900ml from drinks); 1700ml (4-8 years; around 1200ml from drinks)
    • 9-13 years
      • 2400ml boys (1800ml from drinks)
      • 2100ml girls (1600ml from drinks)
    • 14-18 years
      • 3300ml boys (2600ml from drinks)
      • 2300ml girls (1800ml from drinks)