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

1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 History-taking and physical examination

1.1.1 Establish during history-taking whether the child or young person has constipation. Two or more findings from table 1 indicate constipation.

Table 1 Key components of history-taking to diagnose constipation

Key components

Potential findings in a child younger than 1 year

Potential findings in a child/young person older than 1 year

Stool patterns

  • Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale – appendix D) (this does not apply to exclusively breastfed babies after 6 weeks of age)

  • Hard large stool

  • 'Rabbit droppings' (type 1, see Bristol Stool Form Scale – appendix D)

  • Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale – appendix D)

  • Overflow soiling (commonly very loose [no form], very smelly [smells more unpleasant than normal stools], stool passed without sensation. Can also be thick and sticky or dry and flaky.)

  • 'Rabbit droppings' (type 1, see Bristol Stool Form Scale – appendix D)

  • Large, infrequent stools that can block the toilet

Symptoms associated with defecation

  • Distress on stooling

  • Bleeding associated with hard stool

  • Straining

  • 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

History

  • Previous episode(s) of constipation

  • Previous or current anal fissure

  • Previous episode(s) of constipation

  • Previous or current anal fissure

  • Painful bowel movements and bleeding associated with hard stools

1.1.2 If the child or young person has constipation take a history using table 2 to establish a positive diagnosis of idiopathic constipation by excluding underlying causes. If a child or young person has any 'red flag' symptoms, do not treat them for constipation. Instead, refer them urgently to a healthcare professional with experience in the specific aspect of child health that is causing concern.

Table 2 Key components of history-taking to diagnose idiopathic constipation

Key components

Findings and diagnostic clues that indicate idiopathic constipation

'Red flag' findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation

Timing of onset of constipation and potential precipitating factors

  • In a child younger than 1 year:

    • Starts after a few weeks of life

    • Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, infections

    • In a child/young person older than 1 year:

    • 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

  • Reported from birth or first few weeks of life

Passage of meconium

  • Normal (within 48 hours after birth [in term baby])

  • Failure to pass meconium/delay (more than 48 hours after birth [in term baby])

Stool patterns

  • 'Ribbon stools' (more likely in a child younger than 1 year)

Growth and general wellbeing

  • In a child younger than 1 year:

    • Generally well, weight and height within normal limits

    • In a child/young person older than 1 year:

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

  • No 'red flag', but see 'amber flag' below.

Symptoms in legs/locomotor development

  • No neurological problems in legs (such as falling over in a child/young person older than 1 year), normal locomotor development

  • Previously unknown or undiagnosed weakness in legs, locomotor delay

Abdomen

  • Abdominal distension with vomiting

Diet and fluid intake

  • In a child younger than 1 year:

    • Changes in infant formula, weaning, insufficient fluid intake

    • In a child/young person older than 1 year:

    • History of poor diet and/or insufficient fluid intake

'Amber flag': possible idiopathic constipation

Growth and general wellbeing: Faltering growth (see recommendation 1.1.4)

Personal/familial/social factors: Disclosure or evidence that raises concerns over possibility of child maltreatment (see recommendation 1.1.5)

1.1.3 Do a physical examination. Use table 3 to establish a positive diagnosis of idiopathic constipation by excluding underlying causes. If a child or young person has any 'red flag' symptoms do not treat them for constipation. Instead, refer them urgently to a healthcare professional with experience in the specific aspect of child health that is causing concern.

Table 3 Key components of physical examination to diagnose idiopathic constipation

Key components

Findings and diagnostic clues that indicate idiopathic constipation

'Red flag' findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation

Inspection of perianal area: appearance, position, patency, etc

  • Normal appearance of anus and surrounding area

  • Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal wink

Abdominal examination

  • Soft abdomen. Flat or distension that can be explained because of age or excess weight

  • Gross abdominal distension

Spine/lumbosacral region/gluteal examination

  • Normal appearance of the skin and anatomical structures of lumbosacral/gluteal regions

  • Abnormal: asymmetry or flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi or sinus, hairy patch, lipoma, central pit (dimple that you can't see the bottom of), scoliosis

Lower limb neuromuscular examination including tone and strength

  • Normal gait. Normal tone and strength in lower limbs

  • Deformity in lower limbs such as talipes

  • Abnormal neuromuscular signs unexplained by any existing condition, such as cerebral palsy

Lower limb neuromuscular examination: reflexes (perform only if 'red flags' in history or physical examination suggest new onset neurological impairment)

  • Reflexes present and of normal amplitude

  • Abnormal reflexes

1.1.4 If the history-taking and/or physical examination show evidence of faltering growth treat for constipation and test for coeliac disease[2] and hypothyroidism.

1.1.5 If either the history-taking or the physical examination show evidence of possible maltreatment treat for constipation and refer to NICE guidance on 'When to suspect child maltreatment', NICE clinical guideline 89 (2009)[3].

1.1.6 If the physical examination shows evidence of perianal streptococcal infection, treat for constipation and also treat the infection.

1.1.7 Inform the child or young person and his or her parents or carers of a positive diagnosis of idiopathic constipation and also that underlying causes have been excluded by the history and/or physical examination. Reassure them that there is a suitable treatment for idiopathic constipation but that it may take several months for the condition to be resolved.

1.2 Digital rectal examination

1.2.1 A digital rectal examination should be undertaken only by healthcare professionals competent to interpret features of anatomical abnormalities or Hirschsprung's disease.

1.2.2 If a child younger than 1 year has a diagnosis of idiopathic constipation that does not respond to optimum treatment within 4 weeks, refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung's disease.

1.2.3 Do not perform a digital rectal examination in children or young people older than 1 year with a 'red flag' (see tables 2 and 3) in the history-taking and/or physical examination that might indicate an underlying disorder. Instead, refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung's disease.

1.2.4 For a digital rectal examination ensure:

  • privacy

  • informed consent is given by the child or young person, or the parent or legal guardian if the child is not able to give it, and is documented

  • a chaperone is present

  • the child or young person's individual preferences about degree of body exposure and gender of the examiner are taken into account

  • all findings are documented.

1.3 Clinical investigations

Endoscopy

1.3.1 Do not use gastrointestinal endoscopy to investigate idiopathic constipation.

Coeliac disease and hypothyroidism

1.3.2 Test for coeliac disease[2] and hypothyroidism in the ongoing management of intractable constipation in children and young people if requested by specialist services.

Manometry

1.3.3 Do not use anorectal manometry to exclude Hirschsprung's disease in children and young people with chronic constipation.

Radiography

1.3.4 Do not use a plain abdominal radiograph to make a diagnosis of idiopathic constipation.

1.3.5 Consider using a plain abdominal radiograph only if requested by specialist services in the ongoing management of intractable idiopathic constipation.

Rectal biopsy

1.3.6 Do not perform rectal biopsy unless any of the following clinical features of Hirschsprung's disease are or have been present:

  • delayed passage of meconium (more than 48 hours after birth in term babies)

  • constipation since first few weeks of life

  • chronic abdominal distension plus vomiting

  • family history of Hirschsprung's disease

  • faltering growth in addition to any of the previous features.

Transit studies

1.3.7 Do not use transit studies to make a diagnosis of idiopathic constipation.

1.3.8 Consider using transit studies in the ongoing management of intractable idiopathic constipation only if requested by specialist services.

Ultrasound

1.3.9 Do not use abdominal ultrasound to make a diagnosis of idiopathic constipation.

1.3.10 Consider using abdominal ultrasound in the ongoing management of intractable idiopathic constipation only if requested by specialist services.

1.4 Clinical management

Disimpaction

1.4.1 Assess all children and young people with idiopathic constipation for faecal impaction, including children and young people who were originally referred to the relevant services because of 'red flags' but in whom there were no significant findings following further investigations (see tables 2 and 3). Use a combination of history-taking and physical examination to diagnose faecal impaction – look for overflow soiling and/or faecal mass palpable abdominally and/or rectally if indicated.

1.4.2 Start maintenance therapy if the child or young person is not faecally impacted.

1.4.3 Offer the following oral medication regimen for disimpaction if indicated:

  • Polyethylene glycol 3350 + electrolytes, using an escalating dose regimen (see table 4), as the first-line treatment[4].

  • Polyethylene glycol 3350 + electrolytes may be mixed with a cold drink.

  • Add a stimulant laxative (see table 4) if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks.

  • Substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose (see table 4) if polyethylene glycol 3350 + electrolytes is not tolerated.

  • Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain.

Table 4 Laxatives: recommended doses

Laxatives

Recommended doses

Macrogols

Polyethylene glycol 3350 + electrolytes

Paediatric formula: Oral powder: macrogol 3350 (polyethylene glycol 3350)a 6.563 g; sodium bicarbonate 89.3 mg; sodium chloride 175.4 mg; potassium chloride 25.1 mg/sachet (unflavoured)

Disimpaction

  • Child under 1 year: ½–1 sachet daily (non-BNFC recommended dose)

  • Child 1–5 years: 2 sachets on 1st day, then 4 sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily (non-BNFC recommended dose)

  • Child 5–12 years: 4 sachets on 1st day, then increased in steps of 2 sachets daily to maximum of 12 sachets daily (non-BNFC recommended dose)

Ongoing maintenance (chronic constipation, prevention of faecal impaction)

  • Child under 1 year: ½–1 sachet daily (non-BNFC recommended dose)

  • Child 1–6 years: 1 sachet daily; adjust dose to produce regular soft stools (maximum 4 sachets daily) (for children under 2, non-BNFC recommended dose)

  • Child 6–12 years: 2 sachets daily; adjust dose to produce regular soft stools (maximum 4 sachets daily)

Adult formula: Oral powder: macrogol 3350 (polyethylene glycol 3350) 13.125 g; sodium bicarbonate 178.5 mg; sodium chloride 350.7 mg; potassium chloride 46.6 mg/sachet (unflavoured)

Disimpaction

  • Child/young person 12–18 years: 4 sachets on 1st day, then increased in steps of 2 sachets daily to maximum of 8 sachets daily (non-BNFC recommended dose)

Ongoing maintenance (chronic constipation, prevention of faecal impaction)

  • Child/young person 12–18 years: 1–3 sachets daily in divided doses adjusted according to response; maintenance, 1–2 sachets daily

Osmotic laxatives

Lactulose

  • Child 1 month to 1 year: 2.5 ml twice daily, adjusted according to response

  • Child 1–5 years: 2.5–10 ml twice daily, adjusted according to response (non-BNFC recommended dose)

  • Child/young person 5–18 years: 5–20 ml twice daily, adjusted according to response (non-BNFC recommended dose)

Stimulant laxatives

Sodium picosulfateb

Non-BNFC recommended doses

Elixir (5 mg/5 ml)

  • Child 1 month to 4 years: 2.5–10 mg once a day

  • Child/young person 4–18 years: 2.5–20 mg once a day

Non-BNFC recommended dose

Perlesc (1 tablet  = 2.5mg)

  • Child/young person 4–18 years: 2.5–20mg once a day

Bisacodyl

Non-BNFC recommended doses

By mouth

  • Child/young person 4–18 years: 5–20 mg once daily

By rectum (suppository)

  • Child/young person 2–18 years: 5–10 mg once daily

Sennad

Senna syrup (7.5 mg/5 ml)

  • Child 1 month to 4 years: 2.5–10 ml once daily

  • Child/young person 4–18 years: 2.5–20 ml once daily

Senna (non-proprietary) (1 tablet  = 7.5 mg)

  • Child 2–4 years: ½–2 tablets once daily

  • Child 4–6 years: ½–4 tablets once daily

  • Child/young person 6–18 years: 1–4 tablets once daily

Docusate sodiume

  • Child 6 months–2 years: 12.5 mg three times daily (use paediatric oral solution)

  • Child 2–12 years: 12.5–25 mg three times daily (use paediatric oral solution)

  • Child/young person 12–18 years: up to 500 mg daily in divided doses

All drugs listed above are given by mouth unless stated otherwise.

Unless stated otherwise, doses are those recommended by the British National Formulary for Children (BNFC) 2009. Informed consent should be obtained and documented whenever medications/doses are prescribed that are different from those recommended by the BNFC.

a At the time of publication (May 2010) Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that includes electrolytes. It does not have UK marketing authorisation for use in faecal impaction in children under 5 years, or for chronic constipation in children under 2 years. Informed consent should be obtained and documented. Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that is also unflavoured.

b Elixir, licensed for use in children (age range not specified by manufacturer). Perles not licensed for use in children under 4 years. Informed consent should be obtained and documented.

c Perles produced by Dulcolax should not be confused with Dulcolax tablets which contain bisacodyl as the active ingredient

d Syrup not licensed for use in children under 2 years. Informed consent should be obtained and documented.

e Adult oral solution and capsules not licensed for use in children under 12 years. Informed consent should be obtained and documented.

1.4.4 Do not use rectal medications for disimpaction unless all oral medications have failed and only if the child or young person and their family consent.

1.4.5 Administer sodium citrate enemas only if all oral medications for disimpaction have failed.

1.4.6 Do not administer phosphate enemas for disimpaction unless under specialist supervision in hospital/health centre/clinic, and only if all oral medications and sodium citrate enemas have failed.

1.4.7 Do not perform manual evacuation of the bowel under anaesthesia unless optimum treatment with oral and rectal medications has failed.

1.4.8 Review children and young people undergoing disimpaction within 1 week.

Maintenance therapy

1.4.9 Start maintenance therapy as soon as the child or young person's bowel is disimpacted.

1.4.10 Reassess children frequently during maintenance treatment to ensure they do not become reimpacted and assess issues in maintaining treatment such as taking medicine and toileting. Tailor the frequency of assessment to the individual needs of the child and their families (this could range from daily contact to contact every few weeks). Where possible, reassessment should be provided by the same person/team.

1.4.11 Offer the following regimen for ongoing treatment or maintenance therapy:

  • Polyethylene glycol 3350 + electrolytes as the first-line treatment[4].

  • Adjust the dose of polyethylene glycol 3350 + electrolytes according to symptoms and response. As a guide for children and young people who have had disimpaction the starting maintenance dose might be half the disimpaction dose (see table 4).

  • Add a stimulant laxative (see table 4) if polyethylene glycol 3350 + electrolytes does not work.

  • Substitute a stimulant laxative if polyethylene glycol 3350 + electrolytes is not tolerated by the child or young person. Add another laxative such as lactulose or docusate (see table 4) if stools are hard.

  • Continue medication at maintenance dose for several weeks after regular bowel habit is established – this may take several months. Children who are toilet training should remain on laxatives until toilet training is well established. Do not stop medication abruptly: gradually reduce the dose over a period of months in response to stool consistency and frequency. Some children may require laxative therapy for several years. A minority may require ongoing laxative therapy.

1.5 Diet and lifestyle

1.5.1 Do not use dietary interventions alone as first-line treatment for idiopathic constipation.

1.5.2 Treat constipation with laxatives and a combination of:

  • Negotiated and non-punitive 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, maintenance and discussion of a bowel diary, information on constipation, and use of encouragement and rewards systems.

  • Dietary modifications to ensure a balanced diet and sufficient fluids are consumed.

1.5.3 Advise parents and children and young people (if appropriate) that a balanced diet should include:

  • Adequate fluid intake (see table 5).

  • Adequate fibre. Recommend including foods with a high fibre content (such as fruit, vegetables, high-fibre bread, baked beans and wholegrain breakfast cereals) (not applicable to exclusively breastfed infants). Do not recommend unprocessed bran, which can cause bloating and flatulence and reduce the absorption of micronutrients.

Table 5 American dietary recommendations

(Institute of Medicine, 2005). Dietary reference intakes for water, potassium, sodium chloride and sulfate. Washington DC: The National Academies Press

Total water intake per day, including water contained in food

Water obtained from drinks per day

Infants 0–6 months

700 ml
assumed to be from breast milk

7–12 months

800 ml
from milk and complementary foods and beverages

600 ml

1–3 years

1300 ml

900 ml

4–8 years

1700 ml

1200 ml

Boys 9–13 years

2400 ml

1800 ml

Girls 9–13 years

2100 ml

1600 ml

Boys 14–18 years

3300 ml

2600 ml

Girls 14–18 years

2300 ml

1800 ml

The above recommendations are for adequate intakes and should not be interpreted as a specific requirement. Higher intakes of total water will be required for those who are physically active or who are exposed to hot environments. It should be noted that obese children may also require higher total intakes of water.

1.5.4 Provide children and young people with idiopathic constipation and their families with written information about diet and fluid intake.

1.5.5 In children with idiopathic constipation, start a cows' milk exclusion diet only on the advice of the relevant specialist services.

1.5.6 Advise daily physical activity that is tailored to the child or young person's stage of development and individual ability as part of ongoing maintenance in children and young people with idiopathic constipation.

1.6 Psychological interventions

1.6.1 Do not use biofeedback for ongoing treatment in children and young people with idiopathic constipation.

1.6.2 Do not routinely refer children and young people with idiopathic constipation to a psychologist or child and adolescent mental health services unless the child or young person has been identified as likely to benefit from receiving a psychological intervention.

1.7 Antegrade colonic enema procedure

1.7.1 Refer children and young people with idiopathic constipation who still have unresolved symptoms on optimum management to a paediatric surgical centre to assess their suitability for an antegrade colonic enema (ACE) procedure.

1.7.2 Ensure that all children and young people who are referred for an ACE procedure have access to support, information and follow-up from paediatric healthcare professionals with experience in managing children and young people who have had an ACE procedure.

1.8 Information and support

1.8.1 Provide tailored follow-up to children and young people and their parents or carers according to the child or young person's response to treatment, measured by frequency, amount and consistency of stools. Use the Bristol Stool Form Scale to assess this (see appendix D). This could include:

  • telephoning or face-to-face talks

  • giving detailed evidence-based information about their condition and its management, using, for example, NICE's Information for the public for this guideline

  • giving verbal information supported by (but not replaced by) written or website information in several formats about how the bowels work, symptoms that might indicate a serious underlying problem, how to take their medication, what to expect when taking laxatives, how to poo, origins of constipation, criteria to recognise risk situations for relapse (such as worsening of any symptoms, soiling etc.) and the importance of continuing treatment until advised otherwise by the healthcare professional.

1.8.2 Offer children and young people with idiopathic constipation and their families a point of contact with specialist healthcare professionals, including school nurses, who can give ongoing support.

1.8.3 Healthcare professionals should liaise with school nurses to provide information and support, and to help school nurses raise awareness of the issues surrounding constipation with children and young people and school staff.

1.8.4 Refer children and young people with idiopathic constipation who do not respond to initial treatment within 3 months to a practitioner with expertise in the problem.



[2] See also Coeliac disease: recognition and assessment of coeliac disease. NICE clinical guideline 86 (2009).

[3] See When to suspect child maltreatment. NICE clinical guideline 89 (2009).

[4] At the time of publication (May 2010), Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that includes electrolytes. It does not have UK marketing authorisation for use in faecal impaction in children under 5 years, or for chronic constipation in children under 2 years. Informed consent should be obtained and documented. Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that is also unflavoured.