Constipation Passmed

Question 1

Define constipation

Answer 1

Constipation is a common primary functional disorder of the bowel but may, of course, develop secondary to another condition. It may be defined as defecation that is unsatisfactory because of infrequent stools (< 3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation.

Question 2

Feature of constipation

Answer 2

Features
the passage of infrequent hard stools

Question 3

management

Answer 3

Management
_investigate and exclude any secondary causes, consider red flag symptoms
_exclude any faecal impaction
_advice on lifestyle measures
- increasing dietary fibre
- ensuring adequate fluid intake
- ensuring adequate activity levels
_first-line laxative: bulk-forming laxative first-line, such as ispaghula
_second-line: osmotic laxative, such as a macrogol

Question 4

what is the first line medication

Answer 4

first-line laxative: bulk-forming laxative first-line, such as ispaghula

Question 5

what is the second line medication

Answer 5

second-line: osmotic laxative, such as a macrogol

Question 6

what are the complications

Answer 6

overflow diarrhoea
acute urinary retention
haemorrhoids

Question 7

how frequently do children open their bowels

Answer 7

The frequency at which children open their bowels varies widely but generally decreases with age from a mean of 3 times per day for infants under 6 months old to once a day after 3 years of age.

Question 8

summarise the nice 2010 guidelines on the diagnosis and management of constipation in children.

Answer 8

NICE produced guidelines in 2010 on the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by 2 or more of the following:

Question 9

NICE criteria for stool pattern for children under 1

Answer 9

Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks
of age)
Hard large stool
‘Rabbit droppings’ (type 1)

Question 10

NICE criteria for stool pattern for children over 1

Answer 10

Fewer than 3 complete stools per week (type 3 or 4)
Overflow soiling (commonly very loose, very smelly, stool passed without sensation)
‘Rabbit droppings’ (type 1)
Large, infrequent stools that can block the toilet

Question 11

Symptoms associated with defecation in children under 1

Answer 11

Distress on passing stool
Bleeding associated with hard stool
Straining

Question 12

Symptoms associated with defecation in children over 1

Answer 12

Poor appetite that improves with passage of large stool
Waxing and waning of abdominal pain with passage of stool
Evidence of retentive posturing: typical straight-legged, tiptoed, back arching
posture
Straining
Anal pain

Question 13

history for children under 1

Answer 13

Previous episode(s) of constipation
Previous or current anal fissure

Question 14

history for children over 1

Answer 14

Previous episode(s) of constipation
Previous or current anal fissure
Painful bowel movements and bleeding associated with hard stools

Question 15

what is the most common cause of constipation in children

Answer 15

The vast majority of children have no identifiable cause - idiopathic constipation

Question 16

Other causes of constipation in children include:

Answer 16

Other causes of constipation in children include:
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung’s disease
hypercalcaemia
learning disabilities

Question 17

what do NICE suggest doing after making a diagnosis of consipation

Answer 17

After making a diagnosis of constipation NICE then suggesting excluding secondary causes. If no red or amber flags are present then a diagnosis of idiopathic constipation can be made:

Question 18

timing: idiopathic constipation vs ‘Red flag’ suggesting underlying disorder

Answer 18

idipathic

Starts after a few weeks of life
Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking medicines

‘Red flag’ suggesting underlying disorder

Reported from birth or first few weeks of life

Question 19

passage of meconium: idiopathic constipation vs ‘Red flag’ suggesting underlying disorder

Answer 19

idipathic

< 48 hours

Red flag’ suggesting underlying disorder
> 48 hours

Question 20

stool pattern: idiopathic constipation vs ‘Red flag’ suggesting underlying disorder

Answer 20

‘Ribbon’ stools in ‘Red flag’ suggesting underlying disorder

Question 21

growth: idiopathic constipation vs ‘Red flag’ suggesting underlying disorder

Answer 21

idiopathic

Generally well, weight and height within normal limits, fit and active

‘Red flag’ suggesting underlying disorder

Faltering growth is an amber flag

Question 22

Neuro/locomotor: idiopathic constipation vs ‘Red flag’ suggesting underlying disorder

Answer 22

idiopathic constipation
- No neurological problems in legs, normal locomotor development

‘Red flag’ suggesting underlying disorder
- Previously unknown or undiagnosed weakness in legs, locomotor delay

Question 23

abdomen: idiopathic constipation vs ‘Red flag’ suggesting underlying disorder

Answer 23

distension in ‘Red flag’ suggesting underlying disorder

Question 24

diet: idiopathic constipation vs ‘Red flag’ suggesting underlying disorder

Answer 24

idiopathic constipation
- Changes in infant formula, weaning, insufficient fluid intake or poor diet

Question 25

other: idiopathic constipation vs ‘Red flag’ suggesting underlying disorder

Answer 25

‘Red flag’ suggesting underlying disorder

Amber flag: Disclosure or evidence that raises concerns over possibility of child maltreatment

Question 26

what needs to be assessed prior to starting constipation treatment

Answer 26

Prior to starting treatment, the child needs to be assessed for faecal impaction.

Question 27

Factors which suggest faecal impaction include:

Answer 27

• symptoms of severe constipation
• overflow soiling
• faecal mass palpable in the abdomen (digital rectal examination should only be carried out by a specialist)

Question 28

NICE guidelines on management If faecal impaction is present

Answer 28

NICE guidelines on management

If faecal impaction is present
polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain

Question 29

Maintenance therapy for consipation

Answer 29

Maintenance therapy
very similar to the above regime, with obvious adjustments to the starting dose, i.e.
first-line: Movicol Paediatric Plain
add a stimulant laxative if no response
substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually

Question 30

general points regarding constipation management

Answer 30

General points
do not use dietary interventions alone as first-line treatment although ensure the child is having adequate fluid and fibre intake
consider regular toileting and non-punitive behavioural interventions
for all children consider asking the Health Visitor or Paediatric Continence Advisor to help support the parents.

Question 31

management for children who have not yet weaned

Answer 31

Infants not yet weaned (usually < 6 months)
bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant’s legs
breast-fed infants: constipation is unusual and organic causes should be considered

Question 32

management for Infants who have or are being weaned

Answer 32

Infants who have or are being weaned
offer extra water, diluted fruit juice and fruits
if not effective consider adding lactulose