Constipation

Who to refer:

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

• Symptoms since birth or within 2 weeks of birth*
• Delayed passage of meconium (>48 hours in term infant)*
• Passage of ‘toothpaste stool’*
• Abdominal distension and vomiting*
• Abnormal appearance of anus* (e.g. fistulae, multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal wink)
• Abnormalities of lower spine or gluteal region* (e.g. discoloured or hairy patch, sinus or sacral pit, asymmetry of gluteal muscles, sacral agenesis)
• Unexplained weakness or deformity of lower limbs; history locomotor delay**
• Evidence of faltering growth ((treat constipation and consider screening bloods (FBC, UE, LFT, Glucose, bone profile, CRP, TFT, Coeliac Screen). Refer child if weight fails to improve with treatment of constipation))
• Child protection concerns

If red flag is present and child is well then

-Treat Constipation (see below under primary care management)

-Refer :

*Refer to Paediatric Surgical Outpatients

**to paediatric neurology or medical paediatrics

If red flag is present and child is unwell eg surgical abdomen, suspected obstruction:

-do not treat constipation

-discuss child with oncall paediatric surgeon and refer to A+E

2. Any child with chronic constipation not responding to recommended doses of laxatives.  

• 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.  

• 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 2 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.  

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).

Useful website for GPs 

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

Useful links for GPs while assessing/reviewing a child 

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/ 

Other useful information for GPs 

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

Useful 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’ 

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

nhs.uk constipation in children general information for parents 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/