Constipation in children and young people: diagnosis and management

National Institute for Health and Care Excellence


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History-taking and physical examination

History-taking and physical examination

Clinical management

Clinical management

Investigate possible underlying causes

Red flags found

Do not treat for constipation. Refer urgently for tests to a healthcare professional experienced in the specific aspect of child health that is causing concern

Faltering growth (amber flag)

If the history-taking or physical examination shows evidence of faltering growth, treat for constipation and test for coeliac disease and hypothyroidism. See ‘Coeliac disease’, NICE clinical guideline 86

Possible maltreatment (amber flag)

If the history-taking or physical examination shows evidence of possible child maltreatment, treat for constipation and refer to ‘When to suspect child maltreatment’, NICE clinical guideline 89

Digital rectal examination

  • Refer urgently, to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung’s disease, children younger than 1 year with idiopathic constipation that does not respond to optimum treatment within 4 weeks
  • Do not perform digital rectal examination in children or young people older than 1 year with a ‘red flag’. Refer urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung’s disease (see tables 2 and 3)
  • Digital rectal examination should be undertaken only by healthcare professionals competent to interpret features of anatomical abnormalities or Hirschsprung’s disease
Table 1: Key components of history-taking to diagnose constipation
Key components Potential findings in a child younger than 1 year Potential findings in a child/young person older than 1 year
Stool patterns Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks of age)
Hard large stool
‘Rabbit droppings’ (type 1, see Bristol Stool Form Scale)
Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale)
Overflow soiling (commonly very loose [no form], very smelly [smells more unpleasant than normal stools], stool passed without sensation. Can also be thick and sticky or dry and flaky.)
‘Rabbit droppings’ (type 1, see Bristol Stool Form Scale)
Large, infrequent stools that can block the toilet
Symptoms associated with defecation Distress on stooling
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
Table 2: Key components of history-taking to diagnose idiopathic constipation
Key components Findings and diagnostic clues that indicate idiopathic constipation ‘Red flag’ findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation
Timing of onset of constipation and potential precipitating factors In a child younger than 1 year:
  • Starts after a few weeks of life
  • Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, infections

In a child/young person older than 1 year:

  • Starts after a few weeks of life
  • Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking medicines
Reported from birth or first few weeks of life
Passage of meconium Normal (within 48 hours after birth, in term baby) Failure to pass meconium/delay (more than 48 hours after birth, in term baby)
Stool patterns ‘Ribbon stools’ (more likely in a child younger than 1 year)
Growth and general wellbeing In a child younger than 1 year:
  • Generally well, weight and height within normal limits
In a child/young person older than 1 year:
  • Generally well, weight and height within normal limits, fit and active
No ‘red flag’, but see ‘amber flag’ below
Symptoms in legs/locomotor development No neurological problems in legs (such as falling over in a child/young person older than 1 year), normal locomotor development Previously unknown or undiagnosed weakness in legs, locomotor delay
Abdomen Abdominal distension with vomiting
Diet and fluid intake In a child younger than 1 year:
  • Changes in infant formula, weaning, insufficient fluid intake
In a child/young person older than 1 year:
  • History of poor diet and/or insufficient fluid intake
‘Amber flag’: possible idiopathic constipation (see ‘Investigate possible underlying causes’) Growth and general wellbeing:
  • Faltering growth (see ‘Investigate possible underlying causes’)
Personal/familial/social factors:
  • Disclosure or evidence that raises concerns over possibility of child maltreatment
Table 3: Key components of physical examination to diagnose idiopathic constipation
Key components Findings and diagnostic clues that indicate idiopathic constipation ‘Red flag’ findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation
Inspection of perianal area: appearance, position, patency, etc Normal appearance of anus and surrounding area Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal wink
Abdominal examination Soft abdomen. Flat or distension that can be explained because of age or excess weight Gross abdominal distension
Spine/lumbosacral region/gluteal examination Normal appearance of the skin and anatomical structures of lumbosacral/gluteal regions Abnormal: asymmetry or flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi or sinus, hairy patch, lipoma, central pit (dimple that you can’t see the bottom of), scoliosis
Lower limb neuromuscular examination including tone and strength Normal gait. Normal tone and strength in lower limbs Deformity in lower limbs such as talipes

Abnormal neuromuscular signs unexplained by any existing condition, such as cerebral palsy
Lower limb neuromuscular examination: reflexes (perform only if ‘red flags’ in history or physical examination suggest new onset neurological impairment) Reflexes present and of normal amplitude Abnormal reflexes

Diet and lifestyle

Do not use dietary interventions alone as first-line treatment

  • Treat constipation with laxatives and a combination of:
    • negotiated and non-punitive behavioural interventions suited to the child or young person’s stage of development. This could include scheduled toileting and support to establish a regular bowel habit, maintenance and discussion of a bowel diary, information on constipation, and use of encouragement and rewards systems
    • dietary modifications to ensure a balanced diet and sufficient fluids are consumed
  • Advise parents and children or young people (if appropriate) that a balanced diet should include:
    • adequate fluid intake
    • adequate fibre. Recommend including foods with a high fibre content (such as fruit, vegetables, high–fibre bread, baked beans and wholegrain breakfast cereals) (not applicable to exclusively breastfed infants). Do not recommend unprocessed bran, which can cause bloating and flatulence and reduce the absorption of micronutrients
  • Give written information about diet and fluid intake to children and young people and their families
  • Start a cows’ milk exclusion diet only on the advice of the relevant specialist services
  • Advise daily physical activity that is tailored to the child or young person’s stage of development and individual ability as part of ongoing maintenance

Information and support

  • Provide tailored follow-up to children and young people and their parents or carers according to the child or young person’s response to treatment, measured by frequency, amount and consistency of stools (use the Bristol Stool Form Scale to assess this)
    • telephoning or face-to-face talks
    • giving detailed evidence-based information about their condition and its management, this might include for example the ‘Understanding NICE guidance’ leaflet for this guideline
    • giving verbal information supported by (but not replaced by) written or website information in several formats about how the bowels work, symptoms that might indicate a serious underlying problem, how to take their medication, what to expect when taking laxatives, how to poo, origins of constipation, criteria to recognise risk situations for relapse (such as worsening of any symptoms, soiling etc.), and the importance of continuing treatment until advised otherwise by the healthcare professional
  • Offer children and young people with idiopathic constipation and their families a point of contact with specialist healthcare professionals, including school nurses, who can give ongoing support
  • Liaise with school nurses to provide information and support, and to help them raise awareness of the issues surrounding constipation with pupils and school staff
  • Refer children and young people with idiopathic constipation that does not respond to initial treatment within 3 months to a practitioner with expertise in the problem

References

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG99

National Institute for Health and Care Excellence. Constipation in children and young people: diagnosis and management. May 2010
First included: May 2010.


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