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Tricky ten minutes - My child's constipated again

Dr Mandeep Baveja offers his advice on how to tackle this difficult presentation – plus a handy patient leaflet

 

Constipation is a common childhood problem presenting to primary care - affecting around 5-30% of children. In about one third of these cases symptoms become chronic.

The consultation can be challenging - the diagnosis needs to be established with an appropriate history and examination, and you need to exclude any underlying causes before diagnosing idiopathic constipation.

Then, a clear management plan covering lifestyle and medication should be agreed with the patient and family, keeping in mind possible need for further specialist opinion if initial management strategies are unsuccessful.

Although idiopathic constipation may seem to be one of the more trivial complaints presenting to primary care, the impact of the problem on both child and family cannot be underestimated and so an empathic and supportive approach is needed. An important part of this is providing parents with access to good information, and signposting to resources to improve education and self-management.

Establishing the diagnosis

There are two steps in this process – establishing that the problem is constipation and making a positive diagnosis of idiopathic constipation.  Symptoms of constipation are different in children younger than one and those older than one – see the box below. But essentially, the key symptoms are fewer than three complete stools per week, ‘rabbit droppings’, distress on stooling, straining, and a past history of constipation or anal fissure.

Diagnosing constipation

Children younger than one yearChildren older than one year

Stool pattern:

·         Fewer than three complete stools per week

·         Hard large stools

·         Rabbit droppings

Stool pattern:

·         Fewer than three complete stools per week

·         Overflow soiling (encopresis)

·         Rabbit droppings

Symptoms on defecation:

·         Distress on stooling

·         Bleeding associated with hard stool

·         Straining

Symptoms on defecation:

·         Poor appetite, improving after passage of large stool

·         Intermittent abdominal pain with passage of stool

·         ‘Retentitive posturing’- straight legged, tiptoed, back-arching posture

·         Straining

·         Anal pain

History:

·         Previous episode of constipation

·         Previous or current anal fissure

History:

·         Previous episode of constipation

·         Previous or current anal fissure

·         Painful bowel movements and bleeding associated with hard stool

 

The classic history of idiopathic constipation is one of a well-thriving child, with no developmental or neurological problems, who had a normal passage of meconium.  Onset of constipation will have occurred after the first few weeks of life possibly with an obvious precipitating factor such as a fissure, recent infection, potty or toilet training. In children there may be a clear history of poor diet or insufficient fluid intake. In infants there may be a history of recent weaning or change of formula.

Examination should include an abdominal examination, inspection of the anal area, and a lower limb and spinal examination - in idiopathic constipation this should all be normal. A rectal examination is not recommended in primary care and should only be undertaken in certain situations by specialists.

Red and amber flags

It is vital that you ask about, and examine for, red and amber flags to exclude an underlying cause for constipation. Red flags include:

  • constipation reported from birth
  • failure or delayed passage of meconium
  • ribbon stools in children younger than one (Hirschsprung’s disease must be excluded)
  • undiagnosed leg weakness or developmental delay
  • abdominal distension or vomiting
  • abnormal appearance or position of the anus
  • abnormal neuromuscular signs or lower-limb deformity.

Amber flags could indicate an underlying disorder but may occur in idiopathic constipation:

  • faltering growth - exclude hypothyroidism and coeliac disease
  • factors in the history suggesting possible child abuse

Management

Management should initially include both medication and lifestyle and behavioral methods in conjunction. Provision of high-quality information to support patients and their families is also important.

Medication

Medication regimens should include disimpaction and maintenance therapy to ensure resolution of constipation and prevention of recurrence.

The first step in disimpaction therapy is polyethylene glycol 3350 and electrolytes (PEG-3350) (Movicol Paediatric plain) in an escalating dose according to age, as per the box below. If this is not tolerated use a stimulant laxative with or without another alternative osmotic laxative - lactulose can be used as an alternative starting regimen.  A stimulant laxative such as senna should be added if there is no improvement within two weeks. Enemas can be used as a final step but further treatments such as phosphate enemas and manual evacuation should be performed by secondary care.

Disimpaction regimen with PEG-3350

Child < 1 yearHalf a sachet to one sachet daily
Child 1-5 years

two sachets on first day, then four sachets daily for two days, then six

sachets daily for two days, then eight sachets daily

Child 5-12 yearsfour sachets on first day, then increased in steps of two sachets daily to maximum of 12 sachets daily
Child 12-18 yearsAdult formula to be used - four sachets on first day, then increased in steps of two sachets daily to maximum of eight sachets daily

 

Once regular bowel habit is established, maintenance therapy is vital to prevent relapse. One useful analogy to help parents and children understand the value of maintenance therapy is to describe the bowel as having become lax and lazy as a result of distension from constipation - maintenance therapy gives the bowel the chance to recover its “squeezing’ activity. This should begin with PEG-3350 at half the disimpaction dose, with option to add a stimulant laxative if this does not work. Another laxative such as lactulose/docusate can be added if stool remains hard. Maintenance therapy should be continued for several weeks after regular bowel habit is established and treatment should be reduced down slowly according to stool frequency and consistency.

Diet, lifestyle and behavioral methods

Patients should have sufficient fluid and fibre intake, and daily physical activity should be encouraged. Scheduled toileting, bowel diary and encouragement/reward systems can be used depending on the child’s development, to actively engage them to manage the problem.

Referral

Referral within the primary care setting might include a health visitor or school nurse to help support the child and family. Urgent secondary care referral is required where red flags are identified, for example there is suspicion of Hirschsprung’s or of child abuse. Referral to secondary care is also indicated if there is no response to treatment within three months.

Patient resources

Perhaps one of the most useful things that we as GPs can do is signpost patients and their families to high quality information about childhood constipation. The website www.childhoodconstipation.com provides easy to understand information about constipation, including signs and symptoms, a constipation assessment tool and advice regarding prevention, along with several real life stories which will help parents and children feel they are not alone.

You can also go online to pulsetoday.co.uk/tools-and-resources to download a patient information leaflet to print off.

 

Dr Mandeep Baveja is a GP in Batley, West Yorkshire.

Competing interests: Dr Baveja was asked to write this article by ERIC (Education and Resources for Improving Childhood Continence) as part of their constipation campaign which is being supported by Norgine.

ERIC are running a national awareness campaign to increase early recognition of the signs and symptoms of constipation in children. As part of the campaign, posters will be put up in 6,000 GP surgeries across the country to alert parents to the link between a child soiling their pants and underlying constipation. The campaign posters are supported by resources that parents and children can use together with their healthcare professional, including a wall chart and a questionnaire.  The resources can be downloaded from the ERIC website.

 

Further reading

1. NICE quick reference guide. Constipation in children and young people. NICE May 2010. CG99.

2. Childhood constipation. Accessed 22/02/13.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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