Constipation Flashcards
Define constipation
Decrease in the frequency of bowel movements ± passing of large, hard stools ± straining ± pain
2 or more of the following features:
- Infrequent passage (<3 complete stools per week)
- Hard, large stool
- “Rabbit dropping” stool
- Overflow soiling
What is chronic constipation
constipation > 8 weeks
What is the normal frequency of defecation in children (breastfed, 1 year old, 4 year old)
Breastfed infants: ≥4x a day, but may not pass stool for several days
1yo: 2x a day
4yo: 3 stools per day - 3 stools per week (adult stool pattern)
What are the causes of acute constipation
Dehydration/fluid depletion (Following vomiting, hot weather, febrile illness)
Inadequate dietary fibre intake
Bowel obstruction
Side effect of medications e.g. sedating antihistamines, opioids
What are the causes of chronic constipation
Functional constipation
GI: Hirschsprung’s disease, coeliac disease
CMPA
Endo: Hypothyroidism
Rectoanal: Anal stenosis, Abnormal anorectal anatomy, Perianal Crohn’s disease
Neurological or spinal cord abnormality
Spina bifida occulta
Breast-fed babies (can be normal for the baby to pass only one stool in 7 days if exclusively breastfed)
Withholding of stool to avoid distraction from play
Problems with toilet training
Anxiety about opening bowels at schools or in unpleasant or unfamiliar toilets
What are the risk factors for constipation
FHx constipation
Immobility: physically inactive or impaired mobility e.g. CP, neurodevelopmental disorder
What is the epidemiology for constipation
Seen most often between 2-4 years of age
Prevalence is around 10-20%
What are the symptoms of constipation
Constipation (<3 stools a week (unless exclusively breastfed))
- Stools typically semi-soft (3 or 4 on Bristol Stool Form scale)
- Hard, large stool, may block the toilet
- Rabbit droppings-like stool
Soiling of clothes (loose, smelly, passed without awareness)
Difficulty defecating
- Distress or pain
- Bleeding with hard stool
- Straining
- Retentive posturing (straight-legged, tiptoes, arched back)
Poor appetite, improves with passage of stool
Abdominal pain (waxing and waning)
Anal pain
What are the signs of constipation on examination
Height and weight: ?failure to thrive (Hirschsprung’s, hypothyroidism, coeliac)
General
Precipitant dehydration: sunken eyes, poor skin turgor, dry mucous membranes, prolonged CRT
- “retentitive posturing”: straight-legged, tiptoes, arched back
Abdominal exam: abdominal mass, often LLQ
Anorectal: normal OR anal fissures, hard stools, ?signs of sexual abuse, perianal infection (erythema, local oedema)
What investigations should be done for constipation
Investigations are not usually required
AXR: may show faecal impaction
What are the red flags for constipation presentation
Constipation from birth on during the first few weeks of life
Delay in meconium passage
Abdominal distension with vomiting
Ribbon stool pattern
FHx Hirschsprung’s disease
Leg weakness or motor delay
Abnormal anal appearance (fistulae/bruising/fissures/tight/patulous)
Absent anal wink (fails to contract when the skin around is stroked)
Abnormalities in the lumbosacral and gluteal regions
What are the amber flags for constipation presentation
Faltering growth/developmental delay/wellbeing concerns
Symptom onset with cow’s milk
Concerns about child maltreatment
What is the management for constipation
- Reassurance: underlying causes have been excluded
- Advice on diet and oral fluids & toileting habits
- Pharmacological treatment: macrogol (movicol paediatric plain)
+ regular follow up
What advice should be given for diet and fluid intake in constipation
Eat food with high fibre content e.g. fruit, vegetables, high-fibre bread, baked beans, wholegrain breakfast cereals
Normal daily physical activity that is tailored to developmental stage and ability
3/4 of the daily fluid requirement is obtained from water in drinks, and higher intakes are required for those in hot environments or are obese
What is the recommended fluid intake for children 0-6 months, 7-12 months, 1-3 years, 4-8 years, 9-13 years, and 14-18 years
0-6 months: 700mL
7-12 months: 800mL
1-3 years: 900mL from drinks
4-8 years: 1200mL from drinks
9-13 years: Boys: 1800mL from drinks | Girls: 1600mL from drinks
14-18 years: Boys: 2600mL from drinks | Girls: 1800mL from drinks
What advice should be given about toileting habits in constipation
Scheduled toileting - encourages the child to try and open their bowels at pre-planned intervals or activities such as after each meal of five minutes
Bowel habit diary to track frequency and consistency e.g. ERIC Toilet Tool Wallchart
Use of Star charts
What is the pharmacological treatment for constipation
First line: Macrogol (Movicol® Paediatric Plain or Movicol®)
- Fruit squash may be added as it is not preferable to children
- Continue for at least several weeks after regular bowel movements are established (May take several months)
1-5yo: 1 sachet daily
>5yo: 2 sachets daily
Second line: Add Senna (stimulant laxative)
What is the management for faecal impaction
- Evacuate the overloaded rectum
Warn parents that treating impaction may increase symptoms of soiling and pain worse initially and to ensure there is easy access to a toilet
a. First line: Movicol Paediatric plain (Polyethylene glycol) - escalate dose over 1-2 weeks, once resolved gradually reduce over months
<1yo: 1 sachet daily
1-4: 2 sachet, increase in increments of 2 until 8 daily
>5: 4 sachets, increase until 12 daily
>12: 4 sachets, increase until 8 daily
i. Alternative: lactulose (osmotic laxative)
b. Second line (2 weeks: Senna, sodium picosulphate (stimulant laxatives) - Third line: NG large volume macrogol (Klean Prep)
- Enemas or manual evacuation under anaesthetic
What is the difference between osmotic and stimulant laxatives and give examples of each
Osmotic: increases the amount of fluid in the large bowel, softening the stool and stimulating peristalsis e.g. movicol, lactulose
Stimulant: stimualtes the colonic and rectal nerves to stimulate peristalsis e.g. senna, docusate, bisacodyl, sodium picosulphate
What are the complications of constipation
Overflow diarrhoea and soiling (long-standing complications lead to overdistension of the rectum → loss of feeling to need to defecate + inhibition of the internal sphincter
Anal fissures (pain → stool withholding → stool hardening → constipation)
Haemorrhoids
Rectal prolapse
Megarectum
Volvulus
Distress for child and family, physical discomfort, missed school, poor school performance, social isolation
What is the prognosis for constipation
More likely to become persistent if it develops in early infancy and the child has a FHx of constipation
Delay in treatment correlates with a longer duration of symptoms
Symptoms can become chronic in more than 1/3 of children
Around half of children recover with laxative use after 6-12 months
