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NICE Clinical Guidelines, No. 99
This guideline serves as the foundation for QS62.
Red flags for constipation in children include:
- Blood in stool
- Severe abdominal pain
- Unexplained weight loss
- Persistent vomiting
- Difficulty passing stool
Introduction
In childhood, constipation is a common issue, affecting approximately 5–30% of children. In over one third of cases, it can become a chronic condition. Various factors contribute to constipation, such as pain, dehydration, dietary issues, psychological factors, and medications. Symptoms of constipation, including infrequent bowel movements, abdominal pain, and soiling, may often go unnoticed. Early detection and proper treatment are crucial to prevent complications and enhance outcomes.
Terms used in this guideline
Criteria for constipation lasting more than 8 weeks, unresponsive to medical management, requiring a specialist healthcare professional, and specialized services for constipation management, including the exclusion of underlying causes and accurate diagnosis of idiopathic constipation.
Additional Information
It is important to encourage children to drink plenty of water and eat a diet high in fiber to prevent constipation. Regular physical activity can also help promote regular bowel movements. Parents should be aware of any changes in their child’s bowel habits and seek medical advice if they suspect constipation. Treatment may include dietary changes, laxatives, and behavior modification techniques.
Patient-centred care
This guideline offers best practice advice for children and young individuals with idiopathic constipation, prioritizing patient-centered care and informed decision-making. Effective communication, culturally sensitive care, involvement of families and caregivers, and transition planning for adolescents moving to adult services are key aspects of care.
Key priorities for implementation
History-taking and physical examination
Evaluating constipation during patient history, conducting a physical examination to confirm idiopathic constipation, ruling out underlying causes, informing the patient and family of the diagnosis, and discussing treatment options and expectations.
NCBI Bookshelf. Providing services through the National Library of Medicine, National Institutes of Health.
Accessed from: StatPearls Publishing; January 11, 2024.
StatPearls [Internet].
Authors: Paul Allen; Aniruddh Setya; Veronica N. Lawrence.
Affiliations
Last updated on: January 11, 2024.
Continuing Education Activity
Functional constipation is a prevalent condition in children, characterized by infrequent, painful bowel movements. Diagnosis involves excluding organic causes and adopting a holistic approach considering factors like diet, stress, and social support. Early identification, diagnosis, and management are essential to deliver effective care and prevent complications.
Differentiating pediatric gastrointestinal disorders requires understanding clinical presentations, diagnostic criteria, and excluding organic causes.
Implementing evidence-based interventions for managing functional constipation in children involves dietary adjustments, behavioral strategies, and pharmacological options.
Collaboration with an interprofessional team is crucial for optimal care of children with functional constipation.
Functional constipation is frequently seen in childhood, primarily affecting healthy children aged 1 year and older, especially preschoolers.
Manifesting as difficult or infrequent bowel movements, painful defecation, passing hard stools, and a feeling of incomplete evacuation.
Triggers for functional constipation may include painful or frightening defecation, dietary changes resulting in hard stools, and stress related to toilet training.
The progression of stool retention, water extraction from stool, and stretching of intestinal muscles lead to the formation of large, hard, painful stools.
Diagnosis of functional constipation necessitates a thorough history and physical examination, evaluating stool frequency, consistency, and other associated symptoms.
A comprehensive physical assessment should include growth assessment, vital signs, signs of thyroid issues, abdominal abnormalities, and neurologic causes.
Functional constipation can be diagnosed in infants and children over 4 years based on Rome IV criteria.
Pediatric visits commonly involve constipation issues, with bowel movement frequency and consistency varying based on age, diet, and individual characteristics.
Organic causes of constipation may stem from structural, neurologic, metabolic, or intestinal disorders, while functional constipation is attributed to non-organic reasons.
Factors like diet, stress, control issues, and past abuse can contribute to functional constipation in children.
Anus abnormalities
Endocrine/metabolic disorders
Relief of excessive crying by consuming water
Check of urine and serum osmolality
Assessment of antidiuretic hormone levels
Consideration of water deprivation test in specific cases
Symptoms like anorexia, weight loss
History associated with growth failure
Possible use of specific medications in history
Presentation of large fontanelles and hypotonia in newborns
Observation of symptoms like cold intolerance, dry skin, fatigue, prolonged jaundice
Thyroid-stimulating hormone (TSH) testing
Spinal cord abnormalities
Visually detectable spinal lesion at birth
Presence of decreased lower-extremity reflexes or muscle tone
Lack of anal wink reflex
X-ray examination of the lumbosacral spine
Possible signs of sacral hair tuft or pit
Complaints of pain or weakness in lower limbs
Possibility of spinal cord tumor or infection
Onset of symptoms after consuming wheat
Issues related to growth and weight (previously known as failure to thrive)
Frequent presentation of abdominal pain
Experiencing either diarrhea or constipation
Complete blood count testing
Screening for celiac disease through serologic tests (IgA antibody to tissue transglutaminase)
Endoscopy to perform a duodenal biopsy
Potential diagnosis of cow’s milk protein intolerance
Observation of diarrhea or constipation symptoms
Identifying growth and weight problems with symptom improvement after eliminating cow’s milk protein
Occasional need for endoscopy or colonoscopy
Delay in passing meconium or presence of meconium ileus in newborns
Possible recurrence of small-bowel obstruction in older children
Symptoms of growth and weight issues
Frequent episodes of recurrent pneumonia or wheezing
Delayed passage of meconium
Detection of tight anal canal during digital examination
Confirmation of diagnosis through anorectal manometry and rectal biopsy
Presentation of chronic recurrent abdominal pain
Occasional diarrhea and constipation alternation
Sensation of incomplete emptying and passing of mucus
Absence of appetite loss
Medical history involving abdominal pain and distention
Assessment of colonic transit time
Observation of abdominal pain and/or distention along with a palpable abdominal mass
Presence of cerebral palsy and other severe neurological deficits
Indications of hypotonia and motor paralysis
Utilization of tube feedings with low-fiber formulas
Conducting physical examination and assessing medical history
Adverse reactions to drugs
Usage of specific medications as part of the history
Encountering new onset of feeding difficulties, anorexia, weakness
Observation of hypotonia and weakness in descending or global forms
Potential ingestion of honey before 12 months of age
Stool test for Botulinum toxin
Commonly asymptomatic, but may present abdominal issues, sporadic vomiting, fatigue, and irritability
Noticeable loss of previously acquired developmental milestones
Testing of blood lead levels
* Calculating Anal Position Index (API) for evaluation of constipation in children
Assessment of constipation should primarily focus on distinguishing between functional constipation and that with an organic cause.
Past medical history should specifically inquire about meconium passage in newborns and a history of delayed meconium passage in older infants and children. Important details to gather include onset, duration, stool characteristics, frequency, timing of symptoms.
Review of systems must explore symptoms indicating potential organic causes. Past medical history should seek information on conditions contributing to constipation or exposure to constipating factors.
The physical examination should encompass a general evaluation, measurement of height and weight, inspection of the abdomen and anus, and a neurologic assessment.
Key findings of concern include delayed meconium passage, hypotonia, abnormal gait, and weak reflexes.
In neonates, organic cause detection includes constipation present since birth, while in older children, constitutional symptoms and poor growth signal a potential organic cause.
Testing for organic causes of constipation should align with history and physical exam findings, potentially involving barium enemas, rectal manometry, MRI scans, among other diagnostic procedures.
While specific organic causes of constipation require targeted treatment, functional constipation can initially be managed through conservative approaches.
Dietary requirements should be adjusted based on the child’s age. Infants may benefit from prune juice starting at 3 to 6 months of age. For older children, recommendations include increased water intake, consumption of fruits, vegetables, and fiber, while reducing constipating foods like milk and cheese.
Encouraging behavioral changes in older children involves promoting regular bowel movements after meals for those who are toilet trained, as well as providing positive reinforcement. Consider halting toilet training for children experiencing constipation.
For persistent constipation, interventions focus on clearing the bowels and establishing a consistent diet and toilet schedule. Options include oral or rectal agents, with oral agents requiring ample water intake. Rectal preparations may pose challenges. Severe cases may warrant hospitalization. Infants often respond well to glycerin suppositories, while some children may need fiber supplements along with adequate hydration.