NICE guidelines - Constipation in children

Recent NICE guidance will assist in assessing and managing constipation, explains Dr Zoe Rawlinson.

Physical examination will help to ascertain whether faecal impaction is present (Photograph:SPL)
Physical examination will help to ascertain whether faecal impaction is present (Photograph:SPL)

In May 2010, NICE published guidelines on managing idiopathic childhood constipation in primary and secondary care.

Constipation is defined as the subjective complaint of passing abnormally delayed or infrequent dry, hardened faeces. It is often accompanied by pain and straining.

Epidemiology
Constipation affects up to 30 per cent of children in the UK.1 However, it is under-reported because of the family's embarrassment and fear of seeking help. Symptoms become chronic in more than a third of patients.

Constipation is a common reason for secondary care referral - it is the second most referred condition in paediatric gastroenterology, accounting for at least 25 per cent of visits.1 However, until now there has been no clear guidance on how to manage this condition.

Most cases are idiopathic. However, this is by no means a reason to underestimate the impact of the condition on the child, their family and school life. Risk factors and precipitants include low birth weight, low fibre intake, obesity, toilet training, dehydration, illness and fever. Boys and girls suffer equally, as do both breastand bottle-fed infants.

Diagnosis
The first priority is to confirm the diagnosis during history taking. Note that symptoms differ in children under and over 12 months old. A positive diagnosis of idiopathic constipation is confirmed by excluding underlying causes.

Helpfully the Bristol stool form scale, which is a measure of stool consistency, is featured in the guideline.

The guideline states that two or more factors from the following list confirm a diagnosis of constipation:

  • Fewer than three complete stools per week of type 3 or 4 (excluding fully breast-fed babies from six weeks)
  • Hard large stools
  • Type 1 stools (rabbit droppings)
  • Overflow soiling (continuous small amounts of loose stool with strong odour passed into underwear without sensation.
  • Large infrequent stools that can block the toilet
  • Pain/distress on stooling
  • Bleeding with hard stool
  • Straining
  • Poor appetite improving with passing of a large stool
  • Waxing and waning abdominal pain with passage of stool
  • Retentive posturing: straight legged, tiptoed, back arching posture
  • Anal pain
  • Previous episode(s) of constipation
  • Previous or current anal fissure.

It is important to undertake a physical examination to ascertain whether the child has faecal impaction.

This must be cleared before maintenance therapy is prescribed.

Management
The guideline recommends the following in relation to management, maintenance therapy and investigation.

  • The correct dosage of laxatives is crucial for disimpaction.
  • The child must be followed up within one week to ensure the laxatives are working. It may be necessary to increase the dosage or change the laxative if the first medication has not been successful.
  • Laxatives should be prescribed as maintenance therapy, to help the child establish a regular bowel habit. This may take some months, during which time the child needs to be seen frequently, to ensure that faecal impaction does not reoccur.
  • If this treatment does not work, the situation should be re-assessed and the child referred to a specialist if appropriate.
  • Dietary intervention alone is not recommended as a first-line treatment, but advice should be given on eating the right food and drinking enough fluids.
  • Children should be encouraged to take time when going to the toilet and to keep a bowel diary.

Investigation
If red flag symptoms (such as gross abdominal distension, abnormal reflexes or deformity in lower limbs, eg talipes) are found, the child should be referred urgently to the relevant area of secondary care.

In primary care, investigation is only indicated if there are amber flags suggesting the possibility of underlying disorder, although idiopathic constipation could also be present.

Faltering growth or evidence of child maltreatment are both amber flags.

In both cases the constipation should be treated but, for the former, consider testing for coeliac disease2 and hypothyroidism.

If there is concern about child maltreatment, refer to NICE guideline 89.3

  • Dr Rawlinson is a GP in London and a member of the NICE guideline development group
CPD IMPACT: earn more credits

These further action points allow you to earn more credits by increasing the time spent and the impact achieved.

  • Spend some time familiarising yourself with the Bristol stool form scale and print off copies for use in your consultations.
  • Develop a protocol for managing constipation in children, based on the guidelines. Audit in six months to identify whether improvements have been made since introducing the protocol.
  • Perform a search for all patients who currently have chronic constipation, and ensure they are being managed according to the guidelines.

Record all your learning with your free online CPD Organiser

 

References

1. NICE. Constipation in children and young people. CG99. NICE, London, 2010. Available from http://guidance.nice.org.uk/CG99

2. NICE. Recognition and assessment of coeliac disease. CG86. NICE, London, 2010. Available from http://guidance.nice.org.uk/CG86

3.NICE. When to suspect child maltreatment. CG89. NICE, London, 2009. http://guidance.nice.org.uk/CG89

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