Constipation in a child

Question 1

Define constipation with overflow

Explain the aetiology / risk factors of constipation with overflow

Summarise the epidemiology of constipation with overflow

Recognise the presenting symptoms of constipation with overflow

Recognise the signs of constipation with overflow on physical examination

Identify appropriate investigations for constipation with overflow and interpret the results

Generate a management plan for constipation with overflow

Identify the possible complications of constipation with overflow and its management

Summarise the prognosis for patients with constipation with overflow

Question 2

Why might you do an AXR in suspected constipation? What would you see?

Answer 2

Check the degree of impaction

Will see air bubbles throughout (ruling out obstruction, where there would be a cut off in air pattern), widening of the descending colon and faeces stored within the rectum and throughout the colon

Question 3

What is the mechanism of action of Movicol/macrogol?

Answer 3

Osmotically acting laxative/inert substance that passes through the gut without being absorbed into the body.

Causes water to be retained in the bowel instead of being absorbed into the body so stools are softer and easier to pass

Question 4

How do you manage faecal impaction?

Answer 4

1. Movicol Paediatric Plain - escalating dose regimen, warn of increased symptoms of pain and soiling at first (or lactulose if Movicol is not tolerated)
2. After 2 weeks add stimulant laxative if Movicol is not effective

Question 5

How do you manage normal constipation in a child?

Answer 5

1. Movicol Paediatric Plain/stimulant laxative if Movicol is not tolerated
2. Add lactulose or docusate if stools are still hard

This is continued for several weeks until a regular bowel habit is established, then slowly reduce dose

Question 6

Can dietary interventions alone be used as first-line treatment for childhood constipation?

Answer 6

Generally no although you should ensure the child is having adequate fluid and fibre intake

Question 7

What toileting advice can be given to help with constipation?

Answer 7

Question 8

How do you manage constipation in <6 month olds?

Answer 8

If bottle fed: give extra water between feeds; abdominal massage; bicycling legs

If breast fed: constipation uncommon and should be investigated

If being weaned: give extra water, fruits or juice; consider lactulose

Question 9

What 3 categories must you consider when diagnosing constipation?

Answer 9

1. Stool pattern - frequency <3 stools per week
2. Symptoms associated with defecation e.g. straining, anal pain, poor appetite that improves with stool passage, waxing/waning abdominal pain
3. History - previous episodes of constipation, anal fissurs or hard stools with bleeding

Question 10

What red flags suggest an underlying disorder as cause for constipation in a child?

Answer 10

1. Timing - from birth or first few weeks of life
2. Passage of meconium - >48 hours
3. Stool pattern - “ribbon” stools
4. Growth - faltering growth is an amber flag
5. Neuro/locomotor - weakness in legs/locomotor delay
6. Abdomen - distension
7. Diet - -
8. Other - amber flag if concerns raised over child maltreatment

Question 11

Which features suggest that constipation is idiopathic?

Answer 11

1. Timing - after a few weeks of life, precipitating factors present (e.g. fissure, change of diet, potty/toilet training, infections, house move, school start, fears and phobias, change in family, medicines)
2. Passage of meconium - <48 hours
3. Stool pattern - -
4. Growth - generally well
5. Neuro/locomotor - normal
6. Abdomen - -
7. Diet - changes in infant formula, feeding, poor diet or fluid intake

Question 12

Which factors suggest faecal impaction?

Answer 12

1. Severe constipation symptoms
2. Overflow soilinng
3. Faceal mass palpable in abdomen (DRE only done by a specialist)

Question 13

List 5 identifiable causes of constipation in children.

Answer 13

• dehydration, low-fibre diet
• medications: e.g. Opiates
• anal fissure
• over-enthusiastic potty training
• hypothyroidism
• Hirschsprung’s disease
• hypercalcaemia
• learning disabilities

Question 14

What types of stool patterns are suggestive of constipation in children <1 year and children >1 year old?

Answer 14

Children <1 year old - <3 complete stools per week* (type 3/4), ‘rabbit droppings’ (type 1), hard large stools

Children >1 year old - as above and overflow soiling (smelly, loose stools passed without sensation), large infrequent stools that block the toilet

*does not apply to exclusively breastfed babies >6 weeks old.