Constipation in children
Gastro-intestinal causes:
– Meconium ileum in newborn
– Intestinal obstruction
– Hirschsprung’s disease
– Anal stenosis, fissure
– Abdominal tumour
– Coeliac disease
Other causes:
– Idiopathic (Low fibre diet, less exercise)
– Hypothyroidism
– Neuropathic bowels
– Medications (opiates, Baclofen, etc)
– Hypercalcemia
– Cystic Fibrosis
– Child Abuse
(Emotional/ Sexual/ Physical)
History:
– Duration of constipation symptoms
– Was meconium passed <24 hours
– Bowel frequency
– Stool consistency (Bristol type)
– Blocks the toilet?
– Straining/ Long time in toilet?
– Painful passage of stools?
– Soiling? Rectal bleeding?
– ‘Holding pattern’
– Any triggers at onset
e.g. starting nursery/ illness?
Enquire about:
– Abdominal pain?
– Urinary retention/ dribbling?
– Appetite affected?
– Usual food types & fluid amount
– Behavioural issues?
– Sensory issues (?Autism)
– Food intolerances?
– Known medical illnesses?
– Any regular medications?
Examination:
– Growth & Hydration status
– Evidence of chronic illness?
– Gait & LL neurology
– Examine lumbosacral spine
– Record HR, BP
– Abdo soft? distended?
any palpable faecal mass?
– Inspect anus- position, tone, fissures
– Rectal examination consider
(esp in young child, think chaperone)
Investigations (generally none required):
Consider if suspecting organic cause:
– Abdominal X-ray sometimes to confirm impaction
– Rectal biopsy for Hirschsprung
– Abdo USS if other mass suspected
– Sitz markers to demonstrate slow gut motility
– Blood tests TSH, Ca++, Coeliac screen
– MRI spine if neuropathic spine
– Anal manometry?
Management:
Lifestyle changes:
– Lots of Education+++
– Increase dietary fibre & adequate fluid intake
– Regular toileting habit & Improved ‘sitting posture’ while defecating
– Regular exercise
– Behavioural management i.e. star charts, etc
Manage any underlying cause:
– Treat if hypothyroid
– Amend medications if possible
– Gluten-free if Coeliac
Maintenance regimes
– Macrogols usually start at 1 to 2 sachets/ day for 4 weeks
– If no response, add Stimulant i.e. Senna/ Sodium Picosulphate
Appropriate clinic follow-up and support from specialist nurse
Consider weaning if good control for few months
Disimpaction regimes:
– High dose Macrogols +/- stimulant
– KleanPrep as inpatient
May need specialist input if:
– poorly controlled symptoms
– persistent soiling despite treatment
– severe constipation in infancy
M M Tabbers et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74.
Pijpers MA. Functional constipation in children: a systematic review on prognosis and predictive factors. Pediatr Gastroenterol Nutr. 2010 Mar;50(3):256-68
NICE guideline. Constipation in children and young people. 2010