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Constipation in children

This common presentation can be quite distressing for parents. An extensive review of constipation in children is presented on A4Medicine. Causes including the red flags have been shown to help with history taking and examination. Management including the role of laxatives as Movicol is discussed. Management of faecal impaction has been shown. Referral criteria to pediatrics have also been cited. Undoubtedly a large chart and the clinician can zoom and focus on the section which is relevant to them.

Definition-Decrease in frequency of bowel movements which may be associated with
▬ hard stools
▬ straining and pain
▬ soiling of clothes ( from overflow and faecal impaction )
 Normal stool frequency
▬ 4/ day 1st week of life
▬ 2/ day at 1 year 
▬ By 4 years of age →Normal adult rate -between 3 stools/day and 3 stools/ week
 Chronic constipation- constipation lasting > 8 weeks

Causes-Intestinal causes
 Hirschsprung disease Anorectal malformation 
( imperforate anus & anal fissure ) Neuronal intestinal dysplasia Cystic fibrosis Cow’s milk intolerance Metabolic / Endocrine
 Hypothyroidism Diabetes melitus Hypercalcemia Hypokalaemia Vit D intoxication Other contributing factors
 Pain Fever Inadequate fluid intake Reduced dietary fibre Toilet training issues Psychosocial issues Family h/o constipation Drugs
 Opioids Anticholinergics Antidepressants Sedating antihistamines More common in children who are physically inactive or with impaired mobility ( eg cerebral palsy , spina bifida ) or a neurodevelopmental disorder ( eg Down’s or ASD )

Majority of
children will have Functional or Idiopathic constipation ie 
no organic pathology

Painful defecation – commonest factor for constipation

History-What do parents mean by constipation Frequency , consistency and size of stools Age of onset Pain or bleeding with passing stools Abdominal pain First bowel movement after birth ( consider Hirschsprung if lack of bowel movement within 48 hrs ) Faecal incontinence ( impaction , overflow ) Diet and fluid intake Withholding behavior Systemic symptoms Social history ( eg toilet training ) Any treatment tried and response

Diagnosis –Stool patterns
○ Fewer than 3 complete stools / week 
( unless exclusively breast fed)
○ Hard , large stool
○ Rabbit droppings stool
○ Overflow soiling > 1 yr age ( very loose , smelly stools passed without sensation or awareness , may also be thick and sticky , or dry and flaky )
 Symptoms associated with defecation ( any age )
○ Distress or pain on passing stool
○ Bleeding associated with hard stool
○ Straining
 Symptoms associated with defecation child > 1 year
○ Poor appetite that improves with passage of large stool
○ Waxing and waning of abdominal pain with passage of stool
○ Retentive posturing → straight legged , on tiptoes with an arched back
○ Anal pain Past h/o constipation H/O or current anal fissure


Presence of a large faecal mass in either the rectum or the abdomen which is unlikely to be passed on demand
 History of severe symptoms of constipation Presence of overflow soiling Faecal mass palpable P/A



Examination-Physical growth ( eg cystic fibrosis , hypothyroidism→ stunted growth failure to thrive ) General examination Abdominal examination Perineal inspection- 
○ particularly infants to r/o anorectal abnormality
○ position of anus
○ fissures
○ tags ( clue to anal fissures )
○ inflammation Neurological examination -inspection of spine to exclude spina bifida or cerebral palsy

Red flags-Symptoms appear from birth or during the 1st few weeks of life 
( may indicate Hirschsprung’s disease- congenital aganglionic megacolon )
 Delayed meconium > 48 hrs after birth in a full term baby ( may indicate Hirschsprung’s disease or cystic fibrosis )
 Abdominal distension with vomiting- may indicate Hirschsprung’s disease or intestinal obstruction )
 Family h/o Hirschsprung’s disease
 Ribbon stool pattern -may indicate anal stenosis 
( ↑ likely if child < 1 yr )
 Leg weakness or motor delay ( neurological or spinal cord abnormality )
 Abnormal appearance of anus -
○ fistulae 
○ bruising 
○ fissure 
○ tight or patalous-widely patent 
○ anteriorly placed anus
○ absent anal wink→reflex contraction of the external anal sphincter when the skin around anus is stroked
 Abnormalities in lumbosacral and gluteal regions
○ asymmetry of gluteal muscles
○ evidence of sacral agenesis
○ scoliosis
○ discolored skin
○ naevi
○ hairy patch
○ sinus or central pit .Do not initiate treatment in Primary 
care- refer urgently

Amber flags-Evidence of faltering growth , developmental delay or indications of a systemic illness ( liaise with specialist to arrange testing for possible Coeliac disease , hypothyroidism ,cystic fibrosis and electrolyte disturbance ) Constipation triggered by the introduction of cow’s milk Child maltreatment concern Refer but these children may be 
treated while awaiting specialist 
opinion

Consider using 
Bristol Stool Form Scale 
to measure frequency , amount and consistency 
of stools

Movicol® Paediatric Plain or Movicol® Start at the 
lowest dose and ↑ the dose every few days until 1 or 2 formed stools/ day Education and 
Resources for Improving Childhood Continence 
www.eric.org.uk 
has excellent supporting leaflets.Laxative 
treatment should not be stopped abruptly

NICE does not recommend use of suppositories or 
enemas in 
primary care

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