Health Professional Section
(Guidelines for GPs)
Introduction
Constipation is a common presentation that is rarely due to an underlying medical problem. There needs to be an active management plan to quickly reverse painful bowel actions. Reassurance and diet advice alone is ineffective and leads to chronic constipation and its complications.
- Constipation means passage of infrequent painful bowel actions
- Dyschezia in infants means distress when passing normal bowel actions. This is temporary and will improve by 4-6 months as long as stools remain soft.
- There is little role for abdominal xrays in assessment and management of childhood constipation
Background
Introduction
Painful infrequent bowel actions can occur at any age, and requires a stool softener and management of any underlying precipitating factors. For instance the infant may need a formula adjustment and lactulose, whereas the older child will require regular toilet sitting and osmotic laxative such as osmolax.
Functional Constipation (extremely common)
- 95% of constipation is functional
- Symptoms are painful infrequent, hard bowel actions. Frequency is not a factor if stools are comfortable and soft.
- It can be mild, moderate or severe leading to encopresis (passage of involuntary stools)
- A painful bowel action, triggered by an illness or change in diet will result in the child refusing to use bowels due to pain. Particularly if there is an anal fissure. Other common triggers include
- Infant – transitioning to formula or solids
- Toddler – transitioning to cow’s milk
- Toilet training period
- Child too ‘busy’ to use toilet
- New kindy/school resulting in fear of using ‘other’ toilets
- Functional constipation results in recurrent abdominal pains, poor appetite, and is a risk factor for UTIs/enuresis/ and can lead to encopresis
- Some infants have dyschezia, a symptom whereby infants appear distressed and uncomfortable passing normal soft bowel actions.
Red Flags indicating organic Constipation – rare in general practice
- Infant < 6 weeks consider Hirschsprungs ( Failure to pass mec <48hrs, ribbon like stools, constipation since birth, family history)
- Other surgical causes include anal malformations, spinal cord abnormalites. (Abnormal position of anus)
- Medical causes include coeliac disease, Cow’s milk protein intolerance, Hypercalcaemia, Hypothyroidism ( Failure to thrive, abdominal distension, Vomiting)
Assessment
Assessment
History – ask about
- Stooling – How often, how painful, and how hard – Show Bristol Chart
- Soiling if present, how often, where and when.
- Perianal bleeding or history of anal fissures
- Chronicity and any precipitating factors – ie what was the trigger.
- May be innocuous such as illness or one off passage of painful bowel action.
- Infant – formula or introduction of solids or illness
- Toddler – diet or toilet training concerns
- Early childhood – toileting issues at kindergarten/prep/school
- Medications – Iron supplements/ADHD meds/PPIs/antihistamine
- Treatment to date
- Diet advice and specifically dairy intake.
- Voiding issues – (constipation can be a cause of enuresis)
Examination
- Measure ht/wt, to ensure no failure to thrive
- Palpate abdomen for faecal impaction. (No bowel action for days/weeks and large compacted mass of faeces palpated. )
- Check for spinal dysraphism (tuft of hair covering dimple, or subcutaneous lipoma suggesting possible cord tethering)
- If abnormal gait consider neurological exam
- Anal inspection for infection (strep), chronic fissure or sentinel pile, and position. (Rectal examination is not recommended)
Targeted Investigations
- AXR is not contributory. MRI or US if concerned about spinal dysraphism
- Blood tests if considering coeliac or IBD. Serum ferritin for Fe def (excessive cows milk)
Management
Management of Functional Constipation
The goal is painless comfortable bowel actions. This involves education, softening of the stools and age appropriate management of precipitating factors. Simply reassuring and some casual diet advice is ineffective in childhood constipation and leads to chronic problems. This is a condition that needs a careful management plan and also eliminating misheld beliefs and myths such as lazy bowels due to laxatives. Aggressive treatment to reverse the constipation and educating parents that treatment maybe required for months is imperative for successful resolution.
Education and Demystification – What to tell the parent
Educating the parent so they understand the underlying issue will dymystify constipation.
- passing a painful hard bowel action will result in stool withholding behaviour. This is particularly so if there has been an anal fissure/tear. This failure to pass stool results in dry harder stool, leading to this self perpetuating situation. So the goal is painless soft bowel actions
- It is not until the age of 5-6 years that children start to understand their bowel movements and realise they will feel better with a bowel action
- Older children with poorly managed chronic constipation lose the sensation of ‘fullness’ and this leads to encopresis. These children only are aware of needing to toilet when they feel faeces in their underwear.
Next the following is required for each age group
- Soften the stools acutely with age appropriate medication using Polyethyline glycol 3350 (PEG 3350)
- Eliminate ongoing triggers if present (Too much cow’s milk/toilet training stress)
- Diet advice ( Though diet should never be the sole treatment)
- Appropriate follow up
-Infant
Infant Management Guidelines – functional constipation
A careful history and examination is part of the management to reassure yourself and the parent this is non organic functional constipation. In a distressed acutely constipated infant consider use of microlax enema. Can be given in the surgery and works within a few minutes. If the infant passes a large hard painful bowel action this helps rules out organic cause and is a satisfying outcome.
Under 6 month
- Stool softeners – consider coloxyl drops as a start. Review for growth and general health frequently. If under 6 months it is safe to use PEG 3350 1/2 to 1 junior movicol sachet or osmolax 1/2 to 1 junior scoop (osmolax) per day
- Unresponsive or moderate to severe –
- Ensure no organic cause with careful history and examination (see assessment) – If concerned refer for urgent paediatric assessment
- Consider period of cow’s milk protein elimination – for breast fed infants Mother eliminates dairy from her diet, for formula fed infants consider trial of Hypoallergenic hydrolysed formula such as Aptamil Allerpro
Management over 6 months
- If solids the main trigger consider replacing rice cereal with oat cereal.
- PEG 3350 1/2 – 1 junior movicol sachet or 1/2 – 1 osmolax junor scoop per day.
- If cow’s milk formula is a trigger and severe consider trial of soy based formula.
- If ongoing significant constipation despite these measures refer for paediatric review.
- Toddler
Management of Toddler Constipation 12-36 months
Education
- Help the parents understand the stool with-holding behaviour is a self perpetuating problem. Often the toddler may hide or appear distressed as he or she fights the urge to pass a motion
- Unless more than 3-4 bottles of cow’s milk per day, there is little role in dietary manipulation
- Do not attempt to toilet train until constipation has been fixed
- Softening the stools to ensure twice per day soft bowel actions will ‘reset’ the toddler’s memory but this may take several weeks.
Stool Softeners
- Polyethyline glycol (PEG 3350) (osmolax, movicol) is safe, effective and usually palatable.
- initially give 3 movicol junior sachets or osmolax 3 small scoops daily
- Maintenance dose of 1-2 movicol junior sachets or osmolax 1-2 small scoops daily
- Titrate depending on sensitivity to treatment
- Toilet Training Constipation
Education
Discuss that the child’s reluctance to use the toilet has resulted in stool with-holding behaviour which has contributed to constipation. It is important to fix constipation first. Relax any toilet training regimes and sometimes it is necessary to return to nappies or pull ups.
Soften bowel actions
- Provide stool softeners if necessary –
- Commence PEG 3350 Movicol junior 2-3 sachets per day or Osmolax small scoops 2-3 per day
- Titrate up or down based on result
- When bowel actions have softened and bowels returned to normal review toilet training technique. Consider OT advice or online resources such as raisingchildren.net.au toilet training section.
- Older Child With Constipation
Management
Background
In this age group constipation can sometimes be triggered by starting school (March Constipation). Some children are anxious about using toilets away from home and will ‘hold on’. Some kindagartens do not have doors on the toilets and this leads to stool withholding. Asking children about this is important, as sometimes the parents can help by encouraging toilet use away from home. For example
- Visit the toilets after hours
- Engage the school/teacher to encourage toilet use
- Provide positive feedback when the toilet away from home is used.
Soften the stools
- Provide stool softeners if necessary –
- Day 1-3 Movicol 2-3 sachets or Osmolax 2-3 scoops
- Titrate up or down based on result
- If unsuccessful add 10-15 SP dulcolax drops for several days
Management of Functional Constipation
The goal of management is painless comfortable bowel actions. This involves education, softening of the stools and age appropriate management of precipitating factors. Simply reassuring and some casual diet advice is ineffective in childhood constipation and leads to chronic problems. This is a condition that needs a careful management plan and also eliminating misheld beliefs and myths such as lazy bowels due to laxatives. Aggressive treatment to reverse the constipation and educating parents that treatment maybe required for months is imperative for successful resolution.
Education and Demystification – What to tell the parent
Educating the parent so they understand the underlying issue will dymystify constipation.
- passing a painful hard bowel action will result in stool withholding behaviour. This is particularly so if there has been an anal fissure/tear. This failure to pass stool results in dry harder stool, leading to this self perpetuating situation. So the goal is painless soft bowel actions
- It is not until the age of 5-6 years that children start to understand their bowel movements and realise they will feel better with a bowel action
- Older children with poorly managed chronic constipation lose the sensation of ‘fullness’ and this leads to encopresis. These children only are aware of needing to toilet when they feel faeces in their underwear.
Next the following is required for each age group
- Soften the stools acutely with age appropriate medication
- Eliminate ongoing triggers if present (Too much cow’s milk/toilet training stress)
- Diet advice ( Though diet should never be the sole treatment)
- Appropriate follow up
Infant
The usual situation is moving to formula or recently introducing solids.
General measures
Establish regular toileting
Laxatives
Consider disimpaction
Anal fissures
Dr Scott Parsons
The author, has worked as a general practitioner with a special interest in paediatrics for the last 20 years. He has developed this website in order to help parents with the task of raising children. He currently works in Adelaide at Total GP Care Norwood and Priorty Paediatrics
Affiliations
The website content is based on evidenced based guidelines. There are no commercial affiliations.