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Using NICE guidelines to manage childhood constipation


11 Oct 2011

Child constipation can be distressing for both the child and parents. Without early diagnosis and treatment an acute episode of constipation, which may only last a few days and then get better, could persist lead to anal fissures and become chronic. By the time the child or young person is seen they may be in a vicious cycle of fear and withholding going to the toilet to avoid pain caused by hard stools and anal fissures. This can exacerbate the problem. Children, young people and their families are often given conflicting advice and practice is inconsistent, making treatment potentially less effective.

Identifying constipation in young children can be difficult. Therefore understanding this common problem is important to reassure parents and assist them find a suitable solution. National guidelines for the diagnosis and management of childhood idiopathic constipation published by the National Institute for Health and Clinical Excellence are available to assist healthcare professionals.

Defining constipation in children
What is normal?
Breast-fed babies have an average of about three bowel movements daily, while formula-fed babies have about two. With age the frequency reduces to about one movement daily in children by the time they are four years old, by which age 98 per cent of children are toilet trained.

What is constipation?
Constipation generally occurs when, for whatever reason, the child does not have a bowel movement often enough. Then, when they do try to pass stools it can hurt as the stools have become hard and dry and may be impacted. However, there are some children who appear to be going to the toilet every day, but as they are not emptying their bowel properly and only passing small amounts of stool, they can also be suffering from constipation. Constipation is defined as:

    • Infrequent passing of stools (less than three times per week);
    • Excessive straining;
    • Excessive stool hardness;
    • Pain on passing stools.

Causes of constipation
Constipation can be present at three stages of childhood: in infants at weaning, in toddlers acquiring toilet skills and at school age due to lack of privacy or concerns about toilet cleanliness outside the home. Painful defecation is one of the most common triggers for faecal retention, caused by a build up of faecal mass that is painful to pass, leading to a cycle of fear and further retention. Other causes of constipation include:

    • Fever;
    • Dehydration;
    • Inadequate diet;
    • Too much milk;
    • Psychological issues;
    • Toilet training;
    • Medicines;
    • Family history of constipation.

 Some children and young people with physical disabilities, such as cerebral palsy, are more prone to idiopathic constipation as a result of impaired mobility.

Faecal impaction
Constipation can sometimes be confused with diarrhoea, as there may be some soiling of underclothes. When there is no adequate bowel movement for several days or weeks a large, compacted mass of faeces builds up in the rectum and/or colon which cannot be easily passed by the child. Liquid stools above the blockage flow around it and are passed out without the child knowing this is happening. Where faecal compaction is present the child will fail to pass a stool for several days followed by a large, often painful or distressing bowel movement.

Diagnosis of constipation in childhood
According to NICE guidelines two or more of the following findings indicate idiopathic constipation:
In a child younger than one year:

  • Fewer than three complete stools per week
  • Hard stool
  • Small hard rabbit dropping-like stool
  • Distress on stooling
  • Bleeding associated with passage of hard stool
  • Straining
  • Previous episode(s) of constipation
  • Previous or current anal fissure

In a child older than one year:

  • Fewer than three complete stools per week
  • Overflow soiling (commonly loose and smelly, passed without sensation. can be thick, dry and sticky or dry and flaky
  • Small hard rabbit dropping-like stool
  • Large infrequent stools that can block toilet.
  • Poor appetite, improves with passage of stool
  • Abdominal pain reduces with passing of stool
  • Evidence of retentive posturing: straight legged, tiptoed, back arching
  • Straining
  • Anal pain n Previous episode(s) of constipation
  • Previous or current anal fissure
  • Painful bowel movement and bleeding associated with stool passage

Underlying conditions
Any of the following symptoms could indicate an underlying disorder or condition, rather than idiopathic constipation:

  • Constipation reported since birth or first few weeks of life;
  • Babies failure to pass meconium or a delay of more than 48 hours after birth;
  • Ribbon type stools – more likely in children under one year;
  • Previous unknown or undiagnosed weakness in legs or locomotor delay;
  • Abdominal distension with vomiting.

In these cases the child should not be treated for constipation. Instead, they should be referred to their GP or specialist child healthcare professional. 

Treatment
The objectives of treatment are to clear any faecal impaction and establish a regular and effective pattern of defecation in which stools are soft and passed without discomfort, and to prevent recurrence.

Resolve underlying causes
Where possible any underlying causes should be resolved. For example: stopping constipation-causing medicines, treating painful anal conditions, and addressing possible psychological causes, ie if school age children refuse to use school toilets, parents might plan breakfast earlier, enabling the child to use the toilet at home before they leave for school.

Dietary improvement
Constipation can often be relieved by increasing dietary fluid and fibre. The child will need to see other family members eating the same sort of food or they will, understandably, view the enforcement of this type of diet as a punishment with predictably negative results. It is therefore important that the whole family is involved with any dietary improvements.

Laxatives
When dietary changes are not sufficient to produce softer and more frequent stools, starting a laxative may help. Treatment should start with a regular dose of a stool softener/osmotic or bulk-forming laxative to produce a soft, easily passed stool. If these interventions do not work, or if the child is withholding defaecation, a stimulant laxative may be tried. This type of laxative stimulates colonic propulsion, which quickens the filling of the rectum and intensifies rectal contractions. Defaecation is therefore more frequent and so the stool is smaller and softer. However, a combination of laxatives (ie osmotic and stimulant) may be particularly effective and should be considered if individual medicines fail.

Parents can be nervous about giving medicines to their children. But there are products available that are specifically developed for children and can also assist parents overcome problems with administration, such as liquid formulations that can be mixed with food and drink.

A holistic approach
NICE guidelines state that idiopathic constipation should not be treated alone with dietary intervention as first line, but with a combination of laxatives and negotiated and non-disciplinary behavioural interventions suited to the child or young person’s stage of development. These could include scheduled toileting and support to establish a regular bowel habit, with use of encouragement and a rewards system. Along with improved diet and laxatives, physical activity tailored to the child’s stage of development and individual ability is also recommended.

Maintenance
Laxatives should be continued as maintenance for several weeks after regular bowel habit is established, with the dose being reduced gradually to avoid the problem reoccurring. In some cases this may take several months. Children with constipation who are toilet training should remain on laxatives until toilet training is well established.

By Typharm Limited

References
1. Rubin G, Dale A. Chronic Constipation in children. BMJ Nov 18 2006; 333.
2. Constipation in children and young people – Diagnosis and management of idiopathic childhood constipation in primary and secondary care. NICE. May 2010.
3. www.childhoodconstipation.com.
4. Managing constipation in children. Drug and Therapeutics Bulletin Aug 2000; 38.


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