NICE clinical guidelines
Issued: May 2010
CG99

Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg99

Introduction

Constipation is common in childhood. It is prevalent in around 5–30% of the child population, depending on the criteria used for diagnosis. Symptoms become chronic in more than one third of patients and constipation is a common reason for referral to secondary care. Morbidity may be under-reported because people may not seek advice because they are embarrassed.

The exact cause of constipation is not fully understood but factors that may contribute include pain, fever, dehydration, dietary and fluid intake, psychological issues, toilet training, medicines and familial history of constipation. Constipation is referred to as 'idiopathic' if it cannot be explained by anatomical or physiological abnormalities.

Many people don't recognise the signs and symptoms of constipation and few relate the presence of soiling to constipation. The signs and symptoms of childhood idiopathic constipation include: infrequent bowel activity, foul smelling wind and stools, excessive flatulence, irregular stool texture, passing occasional enormous stools or frequent small pellets, withholding or straining to stop passage of stools, soiling or overflow, abdominal pain, distension or discomfort, poor appetite, lack of energy, an unhappy, angry or irritable mood and general malaise.

Painful defecation is an important factor in constipation but it is not always recognised; withholding behaviours to prevent passage of painful stools are often confused with straining to pass stools. Families may delay seeking help for fear of a negative response from healthcare professionals. It has been suggested that some healthcare professionals underestimate the impact of constipation on the child or young person and their family. This may contribute to the poor clinical outcomes often seen in children and young people with constipation.

Soiling is debilitating but rarely life threatening so it might be expected to have little impact on healthcare provision. But many children and young people experience social, psychological and educational consequences that require prolonged support.

Some children and young people with physical disabilities, such as cerebral palsy, are more prone to idiopathic constipation as a result of impaired mobility. Children and young people with Down's syndrome or autism are also more prone to the condition. It is important that assessment and ongoing management for these children and young people happen in the same way as is recommended for all children and young people.

Without early diagnosis and treatment, an acute episode of constipation can lead to anal fissure and become chronic. By the time the child or young person is seen they may be in a vicious cycle. Children and young people and their families are often given conflicting advice and practice is inconsistent, making treatment potentially less effective and frustrating for all concerned. Early identification of constipation and effective treatment can improve outcomes for children and young people. This guideline provides strategies based on the best available evidence to support early identification, positive diagnosis and timely, effective management. Implementation of this guideline will provide a consistent, coordinated approach and will improve outcomes for children and young people.

Definitions of terms used in this guideline

Chronic constipation

Constipation lasting longer than 8 weeks.

Digital rectal examination

Examination of the lower rectum using a gloved, lubricated finger to check for abnormalities.

Idiopathic constipation

Constipation that cannot (currently) be explained by any anatomical, physiological, radiological or histological abnormalities.

Intractable constipation

Constipation that does not respond to sustained, optimum medical management.

Optimum management

Management as set out in this guideline.

Specialist

Healthcare professional with either interest, experience and/or training in the diagnosis and treatment of constipation in children and young people. Examples: specialist continence nurse, community paediatrician with an interest in the diagnosis and treatment of constipation.

Specialist services

Services for children and young people that include constipation management.

A larger glossary of terms can be found in the full guideline.