11/14/24, 10\:52 AM Paediatric Constipation

Paediatric Constipation

Table of contents
Key points ⚡
Succinct notes to superpower your revision
Constipation\: subjective complaint of abnormally delayed, infrequent, dry, hardened faeces with straining/pain.
Common in childhood\: signi
Aetiology\: multifactorial; triggered by changes in routine, diet, illness, toilet training, emotional upset, withholding. Peaks at
weaning, toilet training, starting school.
Organic causes\: less common, include Hirschsprung’s disease (delayed meconium, abdominal distension, family history),
spinal cord problems (leg weakness, sacral dimple), anorectal malformations (imperforate anus, mislocated anus),
metabolic conditions (hypothyroidism, coeliac disease, cystic
Risk factors\: low
Symptoms\: infrequent hard stools, soiling, pain/bleeding when passing stool, straining, abdominal distension,
nausea/vomiting.
Examination\: assess growth, abdominal examination, perianal inspection, lumbosacral region examination, lower limb
neuromuscular examination.
Investigations\: rarely required; plain X-rays for faecal loading, referral for organic causes if standard therapy fails.
Diagnosis\: based on Rome IV criteria (di
Management\:
Non-pharmacological\: dietary changes (increase
bowel diaries), education.
Pharmacological\:
Disimpaction\: escalating dose of oral laxatives (Movicol
Maintenance\: continue therapy to establish regular bowel movements (Movicol
Complications\: faecal impaction, anal
Article 🔍
A comprehensive topic overview

Introduction

Constipation is a term used to describe the subjective complaint of the passage of abnormally delayed or infrequent dry,
hardened faeces often accompanied by straining and/or pain.
1
Constipation is a common problem in childhood and symptoms of constipation can be a source of considerable distress
to patients and families.
1

Aetiology

‘Normal’ bowel frequency varies widely from child to child and can be especially variable between breast- and bottle-fed
babies.
In most cases, paediatric constipation is thought to be multifactorial and can be precipitated by factors such as changes in
routine or diet, illness, toilet training, emotional upset or intentionally delayed defaecation (withholding).
https\://app.geekymedics.com/notebook/2688/ 1/611/14/24, 10\:52 AM Paediatric Constipation
Constipation frequently presents at three common stages in childhood\:
2
Weaning in infants
Toilet training in toddlers
Starting school
In most cases, no functional or anatomical cause is identi
is de

Organic causes of paediatric constipation

Constipation less commonly may be the presenting feature of a serious underlying disease arising in infants \< 1 year of
3
age.
Constipation is termed organic when there is an identi
Careful history-taking and physical examination can identify the ‘red
Hirschsprung’s disease
Hirschsprung's disease is de
extension, resulting in failure of the internal anal sphincter and distal colonic muscles to relax in response to rectal
distension.
Clinical features of Hirschsprung's disease include\:
Delayed passage of meconium >48 hours after birth (in a term baby)
Chronic abdominal distention and vomiting since
Family history of Hirschsprung’s disease
Spinal cord problems
Spinal cord problems including spinal cord compression and spina bi
include\:
Leg weakness or abnormal re
Gluteal muscle asymmetry
Sacral dimple/tuft of hair
Anorectal malformations
Anorectal malformations include imperforate anus, anal stenosis or mislocated anus. These can occur with or without

Lack of an anal opening
Abnormally sited anus
Meconium or gas in the urine
Metabolic conditions
constipation.
Metabolic conditions including hypothyroidism, coeliac disease, cystic
Clinical features will vary depending on the underlying condition, but may include\:
Faltering growth
Sensitivity to cold, fatigue, dry skin, pallor
Blood/mucus mixed with stool

Risk factors

Risk factors for paediatric constipation include\:
Diet low in
Low
Intercurrent illness
Postoperative bed rest or analgesia (e.g. opioids)
https\://app.geekymedics.com/notebook/2688/ 2/611/14/24, 10\:52 AM Paediatric Constipation
Psychological di

Clinical features

History

For more information on history taking, see the Geeky Medics guide to paediatric history taking.
Typical symptoms of constipation include\:
Infrequent passage of hard stools, typically Bristol stool type one or two (Figure 1)
Soiling\: the involuntary passage of
bowel
Pain or bleeding when passing stool
Straining
Abdominal distention, nausea and/or vomiting
Straining
Signs of straining in children less than one-year-old do not usually suggest constipation provided they pass soft
stool and are otherwise healthy. This is because children develop the pelvic muscles to assist bowel movements
gradually.
2.
Other important areas to cover in the history to cover include\:
Age at onset of symptoms
Timing of meconium passage
Dietary history, including
Success or failure of toilet training and withholding behaviour
Past medical/surgical history, current medications and any previous treatment of constipation
Figure 1. The Bristol Stool Chart

Clinical examination

In cases of paediatric constipation, a clinical examination should include\:
3
Growth parameters
Abdominal examination\: muscle tone, distension, faecal mass
Inspection of the perianal region\: anal position, stool present around the anus or in underwear, skin tags, excoriations
Examination of the lumbosacral region\: dimples, hair tuft, gluteal cleft deviation,
Lower limb neuromuscular examination
Digital rectal examination is not routinely necessary, although it may provide some useful information such as the
presence of a rectal faecal mass, anatomical abnormalities, anal
or lax in chronic idiopathic constipation).
1,4
If the urge to defecate is suppressed for too long (such as in withholding behaviour) stool in the rectum becomes harder
and di
https\://app.geekymedics.com/notebook/2688/ 3/611/14/24, 10\:52 AM Paediatric Constipation
As stool accumulates, dilatation of the smooth musculature reduces its contractility and desensitisation occurs. Eventually,

(‘stooling’).
4,5

Investigations

Investigations are rarely required for the diagnosis of paediatric constipation.
3,8
Occasionally, plain X-rays are used to assess the extent of faecal loading but should not be used for diagnosis.
3
The presence of red
specialist services for investigation, especially if standard diet and laxative therapy has failed.
1

Diagnosis

The most widely accepted criteria for the diagnosis of childhood idiopathic constipation are the Rome criteria.
The Rome IV criteria are divided by the age of the patient\:
6,7
Infants and toddlers up to 4 years old
Children and adolescents (developmental age ≥4 years)

Management

Non-pharmacological

Non-pharmacological management of paediatric constipation includes\:
Dietary changes\: increase
at the expense of water or juice, as well as suppresses appetite for other foods).
4
Behavioural training\: encourage regular, unhurried toileting (especially after meals), bowel diaries which link to the use
of reward systems.
9
Education\: addressing the anxiety of parent and child, explanation of the involuntary nature of soiling which helps to
address attitudes of guilt or blame.

Pharmacological

Pharmacological management is divided into disimpaction and maintenance.
Disimpaction
If a clinical assessment suggests faecal impaction of the rectum/colon, then an oral disimpaction regime should be
commenced. An escalating dose of oral laxatives are given over a few days to clear the impaction\:
1
First line\: Movicol (polyethylene glycol 3350 + electrolytes)
Second line\: Lactulose (if Movicol is not tolerated)
Movicol and Lactulose are both osmotic laxatives that work by drawing water into the colon and softening the stool.
5
A stimulant laxative (e.g. Senna) is added if disimpaction is not achieved within two weeks.
1
An increase in soiling/diarrhoea is common after the initiation of laxatives due to spurious over
treatment should not be reduced or stopped.
1
Maintenance
Maintenance therapy should be initiated straight away, or after disimpaction is completed, to encourage regular soft bowel
motions and should be continued for at least several weeks alongside conservative measures until a healthy bowel habit is
established\:
1,5,10
First-line\: Movicol (polyethylene glycol 3350 + electrolytes)\: started at half the disimpaction dose
Second-line\: stimulant (e.g. Senna) if tolerance is an issue or therapy isn’t working
https\://app.geekymedics.com/notebook/2688/ 4/611/14/24, 10\:52 AM Paediatric Constipation

Complications

Complications of paediatric constipation include\:
4
Faecal impaction\: chronic constipation may lead to a mass of stool unable to be evacuated from the rectum. Pain,
distention, nausea, vomiting and obstruction may ensue.
Anal
withholding behaviour.
Rectal prolapse\: straining against a hard stool can cause prolapse of the rectum. The prolapse may reduce
spontaneously or may need to be reduced manually.

References

NICE. Constipation i n c h i l d r e n a n d y o u n g p e o p l e \: d i a g n o s i s a n d m a n a g e m e n t . 2010 Available from\: [LINK]
NHSGGC Paediatric Clinical Guidelines. C o n s t i p a t i o n i n c h i l d r e n . 2019. Available from\: [LINK]
Tabers WW et al. E v a l u a t i o n a n d t r e a t m e n t o f f u n c t i o n a l c o n s t i p a t i o n i n i n f a n t s a n d c h i l d r e n \: E v i d e n c e-b a s e d
r e c o m m e n d a t i o n s f r o m E S P G H A N a n d N A S P G H A N . JPGN 2014. Available from\: [LINK]
Jones’ clinical paediatric surgery 6 th
edition. 2008. Blackwell publishing. ISBN\: 978-1-4051-6267-8
Zeshan Qureshi. T h e u n o st
2017. ISBN 978-0957 149953
Hyams JS et al. F u n c t i o n a l D i s o r d e r s \: C h i l d r e n a n d A d o l e s c e n t s . Gastroenterology 2016. Available from\: [LINK]
Benninga MA et al. C h i l d h o o d f u n c t i o n a l g a s t r o i n t e s t i n a l d i s o r d e r s \: n e o n a t e / t o d d l e r . Gastroenterology 2016. [LINK]
Available from\:
Koppen IJN et al. C h i l d h o o d c o n s t i p a t i o n \:
2016 Available from\: [LINK]
Patient.info C o n s t i p a t i o n i n c h i l d r e n . 2016. [LINK]
Afzal et al. C o n s t i p a t i o n i n c h i l d r e n . Italian Journal of Pediatrics 2011 Available from\: [LINK]

Reviewer

Professor Ramnath Subramaniam
Consultant Paediatric Urologist

Related notes

Attention De
Autism Spectrum Disorder (ASD)
Biliary Atresia
Bronchiolitis
Cerebral Palsy

Test yourself

Contents

Introduction
https\://app.geekymedics.com/notebook/2688/ 5/611/14/24, 10\:52 AM Paediatric Constipation
Aetiology
Risk factors
Clinical features
Investigations
Source\: geekymedics.com
https\://app.geekymedics.com/notebook/2688/ 6/6