Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care continued

Clinical management

Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care continued

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

Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care continued

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

Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care continued

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

Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care continued

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

Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care continued

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

 

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG99

National Institute for Health and Clinical Excellence. Constipation in children and young people. May 2010