constipation in children | Notion

Definition

NICE produced guidelines in 2010 on the diagnosis and management of constipation in children
A diagnosis of constipation is suggested by 2 or more of the following:

	Child < 1 year	Child > 1 year
Stool pattern	Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks
of age)
Hard large stool
'Rabbit droppings' (type 1)	Fewer than 3 complete stools per week (type 3 or 4)
Overflow soiling (commonly very loose, very smelly, stool passed without sensation)
'Rabbit droppings' (type 1)
Large, infrequent stools that can block the toilet
Symptoms associated with defecation	Distress on passing stool
Bleeding associated with hard stool
Straining	Poor appetite that improves with passage of large stool
Waxing and waning of abdominal pain with passage of stool
Evidence of retentive posturing: typical straight-legged, tiptoed, back arching
posture
Straining
Anal pain
History	Previous episode(s) of constipation
Previous or current anal fissure	Previous episode(s) of constipation
Previous or current anal fissure
Painful bowel movements and bleeding associated with hard stools

Aetiology

The vast majority of children have no identifiable cause (idiopathic constipation)
Other causes of constipation in children include:
- Dehydration
- Low-fibre diet
- Medications: e.g. opiates
- Anal fissure
- Over-enthusiastic potty training
- Hypothyroidism
- Hirschsprung's disease
- Hypercalcaemia
- Learning disabilities

Investigations

Red flags which may indicate a secondary cause

Onset reported from birth or first few weeks of life
Passage of meconium > 48 hours
'Ribbon' stools
Faltering growth (amber flag)
Previously unknown or undiagnosed weakness in legs, locomotor delay
Abdominal distension
Disclosure or evidence that raises concerns over possibility of child maltreatment (amber flag)

Assessing for faecal impaction

Prior to starting treatment, the child needs to be assessed for faecal impaction
Factors which suggest faecal impaction include:
- Symptoms of severe constipation
- Overflow soiling
- Faecal mass palpable in the abdomen (digital rectal examination should only be carried out by a specialist)

Management