Constipation

Who to refer:

1. Any child with a ‘red’ or ‘amber’ flag according to the NHS Lothian constipation guidelines i.e: Guidelines-for-management-of-idiopathic-childhood-constipation.pdf

Screening bloods for children with suspected non-idiopathic constipation mentioned above:

• Full blood count
• Urea and electrolytes
• Liver function tests
• Glucose,
• Calcium, Magnesium, Phosphate,
• CRP
• Thyroid function tests
• Coeliac screen / IgA level (if gluten exposed)

2. Any child with chronic constipation not responding to recommended doses of laxatives (see Primary Care Management tab)

• Refer children < 1yr after 4 weeks optimal treatment.

• Refer children >1yr after 3 months optimal treatment.  

3. Any child with faecal impaction +/- overflow who fails to respond to disimpaction regimens (see Primary Care Management tab)

• These children should be discussed with on-call paediatric team (link to urgent telephone advice main page) regarding possible admission for supervised inpatient disimpaction. 

4. If you wish to refer a child who falls out with the above criteria, please state reason for referral. 

Useful additional information for GPs and families

Diet 

• Milk – too much milk can cause constipation, affect appetite, and cause iron deficiency anaemia.
  • Over 1 year: aim to reduce intake to 400ml maximum/day (plus dairy in diet).
  • Switching from a bottle to a sippy cup often leads to reduced intake, dilute milk if necessary.
• Fluid intake – aim for at least 5 drinks of water per day; more specific volume guide https://cks.nice.org.uk/topics/constipation-in-children/management/management/#recommended-fluid-intake
• Diet – increase fruit, vegetables, fibre.  

Laxatives 

Disimpaction (see Disimpaction-regimens.pdf for treatment regimen) 

• Any child being disimpacted should be reviewed 1 week after treatment to ensure disimpaction successful and taking adequate maintenance therapy.  
• Macrogol (Movicol/Laxido) can be difficult to get a child to take more than a few sachets per day due to high volumes required. Consider using Sodium Picosulphate (only needed for 2-3 days and easier to give). 
• Abdo cramps are a common side effect of disimpaction treatment – do mention to parents – can treat with paracetamol, if concerns/abdo pain severe/concerned about child seek medical advice. 
• If soiling, likely to be impacted – disimpact and start maintenance laxatives then review after 1 week. 

Maintenance treatment (see Maintenance-Laxative-Therapy.pdf for treatment regimen) 

• Always start on maintenance therapy immediately after disimpaction. 
• Aim for one or two soft stools (type 3-4) most days.
• Children may require many months of maintenance treatment. 
• Consider combination laxatives: 
  • If stool still too hard on one laxative, consider adding in a softener.  
  • If stool frequency too low on one laxative, consider adding in a stimulant.   
• Softener/stimulant: 
  • Macrogols are combined softener and stimulant laxatives.
  • Softeners: Lactulose, liquid Paraffin.  
  • Stimulants: Sodium Picosulphate; Senna; Bisacodyl; Docusate. 
• Lactulose – can cause tooth decay – make a note on script – give before brushing teeth.  
• Stopping laxatives – once stable for a period of time can trial off laxatives but wean off slowly (particularly if have been on for a long time), low threshold to restart / use on an as required basis.  
• Macrogol (Movicol/Laxido) more palatable when chilled in the fridge, can be mixed with any fluid the child will drink (milk, squash)

Toileting behaviour 

• Toileting – encourage sitting on the toilet/potty for short periods after meals e.g. to sit for 10 minutes shortly (5-10 minutes) after meals (at least once per day).
• Avoid punitive measures – constipation is not the child’s fault & punitive measures can make things worse
• Positive reinforcement – of good behaviours (rather than success which leads to despondency & disengagement) helps to establish regular bowel habit 

Information for GPs 

Constipation guideline NHS Lothian – https://apps.nhslothian.scot/files/sites/2/Guidelines-for-Management-of-Idiopathic-Childhood-Constipation.pdf  

Bristol stool chart https://eric.org.uk/poo-checker/ 

Lothian Joint Formulary Child chronic constipation; faecal impaction https://formulary.nhs.scot/east/gastro-intestinal-system/colonic-disorders/constipation/ 

Clinical knowledge summary The Managment of Idiopathic Constipation in Children https://cks.nice.org.uk/topics/constipation-in-children/management/management/#overview-of-management 

Information for Parents  

Videos for parents – eric (resources in constipation section) or youtube Constipation – YouTube 

ERIC – https://eric.org.uk/childrens-bowels/constipation-in-children/ on this link, click resources, there are several PILs that can be printed including ‘a parents’ guide to disimpaction’ and ‘how to use macrogol laxatives’ 

Eric – advice on toilet anxiety for parents – Toilet anxiety and toilet phobia in children – ERIC 

Poo diary – can print and give to take home prior to next review https://eric.org.uk/wp-content/uploads/2022/08/poodiary.pdf 

Constipation in children general information for parents which includes links to information on diet https://www.nhs.uk/conditions/baby/health/constipation-in-children/  

Info on fibre (link on above website page) https://www.nhs.uk/live-well/eat-well/digestive-health/how-to-get-more-fibre-into-your-diet/ 

Please see this helpful PIL for parents:  Dyschezia in babies v1.0.pdf