How to Treat
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Background
Normal bowel
function and stool
patterns
Diagnosis and
epidemiology
Aetiology
and clinical
presentation
Investigations
Management
Case study
the authors
Dr Kathleen H McGrath
fellow, department of
gastroenterology and clinical
nutrition,The Royal Children’s
Hospital, Parkville, Victoria.
Constipation
in children
Professor Anthony
Catto-Smith
director, department of
gastroenterology and clinical
nutrition, The Royal Children’s
Hospital, Parkville, Victoria;
department of paediatrics, The
University of Melbourne, Parkville,
Victoria; Murdoch Childrens
Research Institute, Parkville,
Victoria.
Background
CONSTIPATION is a common childhood problem from infancy to adolescence. Prevalence rates reported
by studies performed overseas range
from 0.7% to 29.6%.2 This broad
range may reflect genuine ethnic and
socioeconomic differences but is also
influenced by study size, methodology and, particularly, differing criteria
used to define constipation. Despite
its relative prevalence, a key challenge
lies in the lack of a consensus on the
definition for paediatric constipation
among medical professionals. In addition, there is often significant disparity between parental and physician
assessment of the problem. This may
result in misdiagnosis, underdiagnosis
or inadequate treatment.
Constipation has a significant
impact not only on the child but also
their family. This includes physical
discomfort, psychological and emotional stress, behavioural problems
and school absenteeism, which can
in turn affect learning and peer group
socialisation. It can also place considerable economic and resource burden
on the primary and tertiary healthcare
systems as a result of repeated presentations to outpatient clinics, ED and,
at times, avoidable admissions to hospital.
Despite being a common problem,
recognition and successful management of constipation in children can be
challenging. Recognition of constipation in children relies on an awareness
of the problem, thorough historywww.australiandoctor.com.au
taking from both child (if possible)
and parent or guardian, and a focused
physical examination. Careful consideration of the age and developmental
stage of the child is crucial in framing
questions appropriately and engaging
in a successful physical examination.
This How to Treat article reviews
the pathophysiology of constipation
in children, and presents a practical
approach to its assessment, investigation and management.
cont’d next page
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23 January 2015 | Australian Doctor |
17
How To Treat – Constipation in children
Normal bowel function and stool patterns
Physiology of defecation
DEFECATION is a complex process involving interactions between
abdominal and pelvic musculature,
internal and external anal sphincters, and the autonomic and somatic
nervous systems. Faecal matter is
propelled by peristalsis from the
colon into the rectum. Distension of
the rectal wall reaches a threshold
response, which triggers relaxation
of the internal anal sphincter and
contraction of the rectal wall via a
parasympathetic response. Movement of faecal matter into the anal
canal activates anal receptors and a
somatic nervous system response.
Given an appropriate environment
and posture, voluntary relaxation
of the external anal sphincter and
puborectalis muscle takes place synchronously with contraction of the
abdominal muscles, the diaphragm
and the levator ani muscles —
thereby expelling the faecal matter
from the body.
Normal paediatric stool patterns
Meconium, the first stool to be
formed in the human gut, is passed
by most infants in the first 24 (87%)
to 48 hours (99%).3 Following this,
stool patterns are closely related
to the chosen method of feeding.
Infants who are breastfed have
much more variability in the frequency of their bowel actions and
may defecate anywhere between five
times a day to once every five days
or less. Their stools tend to be softer
and uniformly yellow or ‘mustard’
coloured, and they rarely get constipated. In contrast, babies who are
formula fed have more consistent
Figure 1: Modified paediatric Bristol stool chart, using a visual aid to classify
stool consistency in children, based on concept by Professor DCA Candy and
Emma Davey. Adapted with permission from Norgine, ‘Choose Your Poo’,
Norgine Limited, 2005.
Most children
achieve full bowel
and bladder control
between the ages of
24 and 48 months.
passage of stool — usually once to
twice daily — but more variability in
colour and consistency (tending to
be firmer and more green-brown). It
can be normal for healthy infants to
have apparent straining (signalled by
crying and a red face) before passing
a soft stool. This is known as ‘infant
dyschezia’, where the infant’s difficulty in defecation is associated with
incoordination of the defecating process rather than stool impaction.
Frequency of bowel movements
decreases with age; by the time they
start solids at 4-6 months of age,
most babies pass an average of two
stools daily.4 At this time, stools
become firmer, darker and more
offensive.
Toilet-training patterns differ
between ethnic groups and individual families, but most children
achieve full bowel and bladder control between the ages of 24 and 48
months. Children become much
more aware of their bodily functions
at this time, and development of withholding behaviours may complicate
this period. In later childhood, stool
patterns vary between individuals,
ranging from one bowel action every
second day to three times daily.5,6
Visual assessment tools, such as a
paediatric version of the Bristol stool
chart, can be a useful aid for gaining
additional information from the parent or child. Normal consistency is
generally defined as type 4-5 on the
Bristol stool chart (see figure 1).
stipation found constipation was
significantly more prevalent in children aged two and 4-5, with the highest prevalence at preschool age (3-4
years old).2 Awareness of the higher
risk associated with these developmental periods is important and
there should be a lower threshold to
engage in detailed specific questioning about bowel function in children
of these age groups.
Data about gender ratio for constipation are conflicting, with some
studies showing a male preponderance. Some subgroups of the paediatric population are more likely to
be affected by functional constipation, including overweight or obese
children and children with behavioural problems (eg, autism spectrum disorder).12
cont’d page 20
Diagnosis and epidemiology
CONSTIPATION is associated with
a constellation of symptoms related
to the difficult passage of stool. This
may include infrequent movements,
hard consistency, associated straining or pain (including from related
anal fissures), retentive posturing
and faecal incontinence.
Several different classification
tools have been designed to aid clinicians in the diagnosis of functional
constipation, separating it from
constipation caused by underlying
organic disorders or medications.
A key challenge lies in the lack of
a universally accepted definition of
constipation. Despite the published
classification tools, there is still a
degree of variability in the diagnosis
of constipation between clinicians.
The most recently published classification tool is the Rome III criteria
(see box, ‘Rome III criteria for functional constipation’).
Note that faecal incontinence
replaces the terms ‘soiling’ and
‘encopresis’, as recommended by an
expert group of clinicians in the Paris
Consensus on Childhood Constipation Terminology (PACCT) group
in 2005. The reasoning behind this
nomenclature change was that the
terms ‘soiling’ and ‘encopresis’ were
felt to be too broad, with potentially
negative connotations of dirtiness
and blame in some cultures. Faecal incontinence was defined more
simply as the passage of stools in
an inappropriate place.10 Stool con-
18
| Australian Doctor | 23 January 2015
Rome III criteria for functional constipation.8,9
In infants up to four years of age
Functional constipation may be diagnosed if the infant has one month of at
least TWO of the following:
• Two or fewer defecations a week
• At least one episode a week of incontinence after the acquisition of toileting
skills
• History of excessive stool retention
• History of painful or hard bowel movements
• Presence of a large faecal mass in the rectum
• History of large-diameter stools that may obstruct the toilet
In a child with developmental age of at least four years
Functional constipation may be diagnosed if the infant has TWO or more of the
following at least once a week for at least two months, prior to diagnosis (with
insufficient features to fulfil the diagnostic criteria for irritable bowel syndrome):
• Two or fewer defecations in the toilet a week
• At least one episode of faecal incontinence a week
• History of retentive posturing or excessive volitional stool retention
• History of painful or hard bowel movements
• Presence of a large faecal mass in the rectum
• History of large-diameter stools that may obstruct the toilet
sistency is best defined by using the
modified paediatric Bristol stool
chart.11
Epidemiology
Allowing for the varying definitions
of constipation, clinicians identify
three key stages of childhood where
children are more prone to the onset
of functional constipation (constipation without underlying medical dis-
ease or condition). These include the
following:
• Time of weaning from breast
or bottle feeds onto solids (4-6
months old).
• Commencement of toilet training
(2-4 years old).
• School commencement (5-6 years
old).
A 2006 systematic review assessing epidemiology of childhood conwww.australiandoctor.com.au
How To Treat – Constipation in children
Aetiology and clinical presentation
Underlying causes
CONSTIPATION can be broadly
classified into two categories in
terms of aetiology: functional (or
idiopathic) constipation, and constipation as a result of an underlying
disease or condition. The majority
of constipation in children is classified as functional with no associated
underlying medical condition or
medication-related cause. While not
causative, various other factors may
precipitate or worsen functional
constipation — including diet, fluid
intake, behavioural and emotional
problems and urinary dysfunction.
It is critical for all clinicians to be
aware of the ‘red flags’ on history
and/or examination that may indicate the presence of serious underlying organic causes of constipation
because their management may
differ quite significantly from those
of functional constipation. Table 1
outlines secondary causes of constipation in infants and children.
Pathophysiology of functional
constipation
Normally, faecal matter accumulates in the rectum, and in an
appropriate environment (in toilettrained children), voluntary, coordinated pelvic and abdominal
muscular activity expels faecal matter from the body.
In functional constipation, stool
accumulates in the rectum as a result
of withholding behaviours originating from a painful defecation experience (eg, anal fissures or passage of
hard stools) or changes to toileting
environment or routine (eg, with
school commencement). Withholding behaviours can be hard for parents and carers to identify, and signs
may include grunting, back arching, buttock clenching, repetitive
rocking or fidgeting. When stool is
withheld, the rectal wall adapts and
gradually distends, allowing more
stool to accumulate. Water is reabsorbed, and the stool may become
quite hard, large and eventually
impacted, leading to further pain
on attempted defecation, reinforcing further avoidance and withholding behaviour. With time, this cycle
leads to increasing rectal distension,
impaired rectal sensitivity and parasympathetic responses, resulting in
an inability to appropriately sense
rectal ‘fullness’. When a stool is
eventually passed, the rectal wall
remains distended and weakened
and will easily refill quickly with
hard stool again unless this vicious
cycle is broken through effective
constipation management.
Clinical presentation
A thorough medical history taken
from the parent and the child (if
possible) is crucial to ascertain the
presence of constipation, the extent
of the problem, any ‘red flags’
for organic constipation and the
impact on the child and family (see
box, ‘Important history in a child
with constipation’). In all paediatric encounters, questions must
be framed in a developmentally
appropriate manner using nonmedicalised terminology.
Different parents and children
have very individual views of what
constitutes ‘constipation’ — clinicians should not simply ask a child
20
| Australian Doctor | 23 January 2015
Table 1: Secondary causes of constipation
Important history components in a child with constipation
Classification
Infants and toddlers
Adolescents
Past medical history
Structural
Anal fissures
Anorectal malformations
Anal fissures
Timing of passage of meconium
Metabolic,
systemic
Coeliac disease
Cystic fibrosis
Cystic fibrosis
Diabetes mellitus
Hypothyroidism
Hypercalcaemia
Toilet training
Diet history
Developmental history
Dietary,
behavioural and
psychological
Breastfeeding to bottle feeding
Stool-withholding behaviour
Cows milk protein allergy
Anorexia nervosa
Depression
Other
Hirschsprung’s disease
Spina bifida
Non-accidental injury
Toxicity (opiates,
antidepressants, iron
supplements)
Slow-transit constipation
Table 2: Suggested terminology and questions for use when
taking a history about constipation in children
Symptom or
component of history
Child-friendly questions or terminology
Stool frequency
“Do you do a poo every day?”
“How many poos do you do each day?”
“Do you sometimes have a day (or more) where you
don’t do a poo?
Presence of straining
“When you do a poo is it hard or soft or runny?”
Refer directly to the modified visual Bristol stool
chart for children (Figure 1) or a similar stool chart by
showing the child pictures and asking them to point
to what their poo looks like (may be more than one
type).
“Do you sometimes have to push really hard to get
your poo out?”
“Does it ever hurt around your bottom when you are
trying to get your poo out?”
“Does this happen all the time or just sometimes?”
Presence of faecal
incontinence
“Do you ever get some poo leaking out when you
didn’t mean it to?”
“Do you ever get poo stains on your undies?”
Presence of rectal
bleeding or anal
fissures
“Has there ever been blood on the toilet paper when
you wiped your bottom after a poo?”
“Has there ever been blood in the toilet bowl after
you did a poo?”
If so; “Was it bright red like this [point to a bright red
object in room] or darker brown-red like this [point to
another appropriate object in room].”
Presence of mucus in
stools
“Is there ever any clear jelly or slimy stuff when you
wipe your bottom?”
Abdominal pain
“Is it ever sore in your tummy?”
“Does the tummy pain get better after you do a
poo?”
Presence of urinary
symptoms
“Do you ever get some wee leaking into your undies
in the daytime?”
“Do you ever need to rush to the toilet really quickly
because you think the wee is going to come out?”
Presence of systemic
symptoms
“Do you have the same amount of energy as your
friends?”
or their parent whether the child is
constipated. Parents tend to underreport constipation in their children
but are good at recognising when
their child is not constipated. When
specifically asked questions about
individual symptoms (eg, stool
frequency, consistency, straining,
presence of faecal incontinence),
parents are able to identify these
factors but do not always recognise
that these symptoms signify constipation.14 Thus, clinicians should
specifically ask in detail about each
of these components and use this
information to formulate their diagnosis. Table 2 contains suggested
child-friendly ways in which to ask
children directly about gastrointestinal symptoms.
Discussing bowel habits and
toileting can be confronting or
embarrassing for some children (particularly adolescents) or
humorous and hard to take seri-
Social circumstances and any recent changes
Feeding method(s) in infancy
Current diet and fluid intake
Activity levels
Presenting problem
Timing of onset of problem
Any associated changes (eg, diet, lifestyle) at time
Adapted from McGrath KH, Caldwell PH, 2012.
7
Stool consistency and
size
Relevant family history
ously for other children. It is
important to preface your historytaking appropriately to normalise
the encounter and its purpose, for
example: “Now, I need to find out
a bit more about why your tummy
is sore, so I need to ask some questions about your poos. Some children find talking about this a bit
embarrassing/funny/strange, but as
a doctor, I talk to lots of different
children about these things, and
then I can help make your tummy
feel better.”
It is important to note that soft
or watery stool may leak around
the edge of a hard, impacted faecal
mass in constipated children, leading to faecal incontinence.
Children have little or no awareness of this happening and no control over this behaviour. Parents or
the child may often mistake it for
diarrhoea when in fact it reflects
quite the opposite.
www.australiandoctor.com.au
Pattern of problem (eg, intermittent, ongoing)
Presence of withholding behaviours
Current pattern of bowel actions:
• Stool frequency
• Stool consistency and size
• Presence of straining
• Presence of faecal incontinence
• Presence of any rectal bleeding or anal fissures
• Presence of mucus in stools
Abdominal pain
Symptoms of urinary dysfunction
Presence of systemic symptoms (eg, fever, weight loss, appetite, nausea,
vomiting)
Previous investigations
Previous treatment strategies and response
Toileting routine
Examination
A complete physical examination is
important at the initial consultation.
This involves assessing the child’s
general appearance and growth,
which includes the weight and height
in all children and the head circumference if the infant is younger than
two. Growth parameters should be
plotted on appropriate centile charts
for age and sex and the trajectory
over time assessed, using previous
parameters if available.
A lower-limb neurological examination — including close inspection
of the spine and sacral area for any
skin changes, sinuses, hairy patch or
central pit — should be done. The
presence of these findings may indicate possible underlying spinal malformations (which can be associated
with constipation) and the need for
further imaging or assessment by a
paediatrician. Thyroid size and nodularity should be assessed. Abdomi-
nal examination should include
inspection of the perianal area for
rare congenital malformations (perineal fistula, anal stenosis) or more
common findings (anal fissures, skin
tags) that may suggest an underlying
cause of pain or inflammatory process. Digital rectal examination is
not routinely performed in paediatrics, and the indication for the procedure needs to be weighed against
the physical and psychological discomfort for the child.
Prognosis
Constipation is often a relapsing
and remitting problem in paediatric
patients, and one-third of them will
have persisting symptoms of constipation into young adulthood. Half
will have at least one relapse within
five years of initial success from
treatment — more commonly boys
than girls.13
cont’d page 22
How To Treat – Constipation in children
Investigations
A THOROUGH clinical history
and focused examination is often
enough to confirm a diagnosis of
constipation, particularly functional
constipation. Further investigations
may be indicated in certain situations to confirm the diagnosis, ascertain an underlying organic cause or
assist in the optimal management of
the child.
The most commonly performed
investigations in this context are
blood tests and abdominal radiography. Blood tests should be done
in any child with chronic functional
or intractable constipation or in
those whose history or examination suggests an underlying organic
cause. These should include a FBC,
electrolytes including calcium (for
hypercalcaemia), glucose (for diabetes mellitus), thyroid function tests
(for hypothyroidism) and coeliac
serology (suggestive of coeliac disease). Other tests may be ordered
as indicated by clinical findings (eg,
inflammatory markers when suspecting inflammatory bowel disease
in an adolescent.
Abdominal radiography may be
requested by some clinicians as part
of diagnostic assessment or to moni-
tor treatment response; however,
it is not routinely needed because
most cases of constipation can be
diagnosed on history and examination alone. The North American
Society for Paediatric Gastroenterology, Hepatology and Nutrition
(NASPGHAN) clinical practice
guideline does not recommend routine use of a plain abdominal radiograph for diagnosing functional
constipation. It recommends a
potential role when assessing a child
in whom faecal impaction is suspected but where physical examination is unreliable or not possible.15
Examples of such situations include
an overweight or obese child, a child
who is not co-operating with examination because of anxiety or behav-
ioural and developmental problems
or a child in whom rectal examination as a means of confirming faecal impaction is contraindicated (eg,
past sexual abuse).
Less common specialised diagnostic modalities used in childhood
constipation include ultrasound,
gastrointestinal transit studies,
manometry, rectal biopsy (for
Hirschsprung’s disease), sweat test
(for cystic fibrosis) and MRI spine
(for spinal malformations). These
tests, alongside other gastrointestinal related investigations such as
colonoscopy and faecal calprotectin
should generally be considered only
following consultation with a paediatric gastroenterologist or general
paediatrician.
Management
THE goal of constipation therapy
is to empty the bowel, avoid reaccumulation of excessive amounts
of faecal matter and achieve longterm painless passage of soft, regular bowel motions. Management
of constipation is a multifaceted
approach involving the use of laxatives, dietary and toileting education, and psychological tools, such
as reward charts, to guide motivation. Follow-up and assessment of
treatment response are critical to the
short- and longer-term successful
management of constipation.
Laxative therapy
There are two key roles for the use
of laxative in constipation: first, to
dislodge faecal impaction if it is present; and second, as maintenance
agents used to achieve ongoing soft,
regular, painless stools.
The choice and dose of laxatives
are initially guided by the age of the
child. In general, the aim is to use
exclusive oral therapy and avoid the
use of suppository agents if possible.
Rectal administration of medications is invasive and can be associated with physical discomfort and
longer-term anxiety, exacerbating
the problem. In rare instances, such
as acute severe rectal pain or distress
from impaction, suppositories may
be indicated, and the agent of choice
is sodium citrate 5mL enemas.
Sodium phosphate enemas should
not be used in children without
close monitoring and only with caution under specialist care because
of the serious risk of electrolyte
and water disturbances due to their
larger volumes not being appropriate for small children.
Disimpaction
Before starting disimpacting treatment, its purpose, how it is performed and the expected response
should be explained in detail. There
is often confusion when seemingly
‘runny’ stools are passed, and laxatives may be prematurely ceased,
leading to treatment failure. Symptoms of abdominal pain and faecal
incontinence may initially worsen.
Therapy should continue until the
child is passing clear faecal effluent,
which generally takes two to five
days, but may take up to two weeks.
Table 3 outlines the different agents
commonly used for faecal disimpac-
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| Australian Doctor | 23 January 2015
Table 3: Oral laxative agents used for faecal disimpaction16-18
Agent*#
Age (years)
Dose
Side effects
Additional notes
Macrogol 3350
(‘Movicol-half’ or
in older children
‘Movicol’)
With electrolytes
Younger
than 1
Half-to-one sachet Movicol-half daily.
1-5
One sachet Movicol-half bd on Day 1, two sachets bd on Day
2-3, increasing by two sachets every 1-2 days to maximum four
sachets bd.
Nausea and
vomiting, diarrhoea,
abdominal cramping
and distension
Comes in pre-measured sachets
to mix with cold drink of choice.
Different flavours available
6-12
Two sachets Movicol-half bd on Day 1, three sachets bd on Day 2,
increasing by two sachets daily to maximum six sachets bd.
13-18
Two sachets Movicol bd on Day 1, four sachets bd on Day 2,
increasing by two sachets daily to maximum four sachets bd.
1-5
One small scoop daily on Day 1, two small scoops daily on Day 2,
three small scoops daily on Day 3 and continue.
6-12
Two small scoops daily on Day 1, three small scoops daily on Day
2, increasing by one small scoop daily to maximum four small
scoops daily.
Older than
12
One large scoop daily on Day 1, two large scoops daily on Day 2,
increasing by one large scoop daily to maximum four large scoops
daily.
Macrogol 3350
(Osmolax) without
electrolytes
Macrogol 3350
(ColonLYTELY,
Glycoprep)
with electrolytes
1-3L/day at rate of 25mL/kg/h (maximum 1L/h via NGT until faecal
disimpaction achieved.
Comes in tub with two scoop sizes
(8.5g and 17g).
Flavourless and can be mixed with
any drink (hot or cold).
Given via NGT in hospital for
children who cannot tolerate
oral disimpaction agents. Risk
of dehydration so should be
given with maintenance fluids or
gastrolyte.
*Macrogol = polyethylene glycol
#Examples of commonly used brands in paediatrics have been included in brackets along with dosing recommendations from paediatric-based guidelines/medicines
information sources. Other similar products may be available but there is limited information on paediatric dosing and use.
Figure 2: Proper toileting position for children.
tion in children. A stimulant laxative may be added if disimpaction is
not achieved with an osmotic agent
or macrogol alone for two weeks.
In infants younger than six
months of age, faecal impaction
is rare and usually related to an
underlying organic cause (eg,
Hirschsprung’s disease). When it
does occur, limited data about the
use and safety of polyethylene glycol osmotic agents in infants mean
that glycerol suppositories are the
mainstay of treatment.
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Maintenance therapy
Once faecal disimpaction is
achieved, the child should continue on a daily maintenance dose
of a laxative. Various medication
options are outlined with a stepwise approach in table 4. The parents and child should be advised
to titrate therapy, aiming for a soft
bowel movement (Bristol stool
chart type 4-5) once to twice daily.
Therapy should continue for at least
four weeks, and in many children,
ongoing laxatives may be required
for months. When the decision is
made to wean therapy, this should
take place gradually without abrupt
cessation.
For infants younger than six
months, options for maintenance
therapy include coloxyl drops and
lactulose. Dietary modifications
such as prune juice, apple and pear
may be used if the infant is over four
months old and has commenced
solids.
Behavioural modification
Education of the child and carers is an essential part of constipation management. The underlying
physiology of chronic constipation
and faecal impaction should be
explained in simple terms and the
roles of laxatives in combination
with behavioural modifications as
outlined below.
Timed toilet sits
In children who are toilet trained,
management of constipation should
include twice-daily timed toilet sits.
This involves the child sitting on the
toilet, undisturbed twice a day, preferably 20-30 minutes after a main
meal.
They should sit for three to five
minutes and focus on trying to ‘push
a poo’ out — free from distractions,
such as books, electronic games or
iPads. The focus should be on the
child actually spending the time
sitting and effectively ‘trying to do
a poo’ rather than whether a stool
successfully comes out or not.
Correct toilet positioning
When children are sitting on the
toilet, it is essential that they have
correct posture and positioning to
optimise their ability to effectively
engage the necessary muscles. Fig-
ure 2 illustrates correct toilet positioning. Clinicians should explain
this stepwise to both child and parents with demonstration using their
chair if possible.
Diet and fluid intake
Dietary interventions and fluid management should never be used alone
as first-line management; however,
optimisation of these lifestyle factors can complement a successful
management approach.
Clinicians should ask a thorough dietary and fluid history and
educate about the importance of
adequate fluid intake for age; a balanced diet, including fibre (eg, fruit,
vegetables, wholegrain cereals); regular activity; and limited screen or
sedentary time.
Reward charts and motivational tools
An important part of successful
management of constipation is
ensuring ongoing involvement and
motivation by the child. It is very
important to involve children from
initial consultation and provide
explanations in a developmentally
appropriate way.
Positive reinforcement is essential
as a form of encouragement when
things go well (eg, a poo is passed
on the toilet, or they sit and try to
push without getting distracted for
timed toilet sits).
There should be no punitive
behaviours or negative commentary
from household members, especially
if the child has episodes of faecal
incontinence.
Depending on the age, developmental stage and interests of the
child, reward and motivational systems can be tailored. It is important
that the child sees instantaneous
reward for their efforts — that is, no
delayed gratification.
A commonly used tool is a sticker
chart to be placed in a prominent
place, such as the kitchen fridge
door, where a star or sticker is
placed every time a successful toilet sit occurs or a day of successful
toileting. There may be an agreement with the child that a ‘prize’
(eg, a small toy, extra screen or
play time) is given as a reward after
a certain time frame or number of
Table 4: Oral laxative agents used for maintenance therapy16-18
Agent*
Age (years)
Dose
Side effects
Other
First-line therapy: osmotic stool softener
Macrogol 3350
(Movicol-half or
Movicol)
Macrogol 3350
(Osmolax)
Younger than 1
Half-to-one sachet Movicol-half daily.
1-6
Start one sachet Movicol-half daily and titrate.
7-12
Start two sachets Movicol-half daily and titrate.
Older than 12
One to three sachets Movicol daily and titrate.
1-6
Start one small scoop daily and titrate.
7-12
Start two small scoops daily and titrate.
Older than 12
Start one big scoop daily and titrate.
Lactulose
Younger than 1
(Actilax, Duphalac)
Abdominal discomfort
and flatulence common.
Less common
hyperglycaemia and
electrolyte disturbances.
5mL daily.
1-5
5-20mL daily and titrate.
6-12
10-40mL daily and titrate.
Nausea and vomiting,
diarrhoea, abdominal
cramping and distension.
Mix with water, milk or
fruit juice to improve
palatablility.
Second-line therapy: simulant (added if inadequate effect from osmotic agent alone despite titrating dose)
Younger than 4
Use with specialist consultation
4-10
2.5-5mg (5-10 drops) daily
11-18
5-10mg (10-20 drops) daily
Bisacodyl
(Dulcolax)
3-12
5-10mg nocte
13-18
5-15mg nocte
Sennosides
(Senokot)
2-6
3.75-7.5mg nocte
7-12
7.5-15mg nocte
13-18
7.5-30mg nocte
3-6
50mg daily
7-12
50-150mg daily in divided doses
13-18
50-150mg daily in divided doses (maximum
480mg daily)
Sodium
picosulfate
(Dulcolax SP)
Docusate sodium
(Co-senna,
Coloxyl)
Abdominal cramping
or pain, diarrhoea,
dizziness.
Drip onto spoon or put in
glass of water.
Granules can be eaten or
mixed with milk, water or
food.
Fast onset of action (within
6-12 hours).
Coloxyl drops used in
children younger than
three.
Other: lubricant or stool softener
Liquid paraffin
(Parachoc, Agarol)
1-6
10-15mL daily
7-12y
20mL daily
13-18y
20-40mL daily
Do not use in children
younger than six months
or with swallowing
difficulties or gastrooesophageal reflux
because of aspiration risk.
Chronic use rarely leads
to malabsorption of fat
soluble vitamins.
Can be mixed into foods
(will emulsify in liquids).
Onset of action within two
to three days.
*Macrogol = polyethylene glycol
#Examples of commonly used brands in paediatrics have been included in brackets along with dosing recommendations from paediatric-based guidelines/medicines
information sources. Oher similar products may be available but there is limited information on paediatric dosing and use.
stickers is reached. It does not need
to be expensive and parents can
be inventive — the most import-
ant thing is making the incentives
something that is motivational for
that individual child; for example,
Case study
a 10-year-old boy may not be interested in a sticker chart but may be
motivated by a star chart that entails
him working towards a collectable
sporting card or time for computer
games.
Online resources
The Royal Children’s Hospital
clinical practice guideline on
constipation
BEN, a three-year-old boy, has been
seeing a paediatric gastroenterologist for chronic constipation since
the age of one. The problem started
at about 12-18 months of age with
no identifiable trigger. He has
enough symptoms to fulfil Rome III
criteria for constipation, including
history of withholding behaviours
(rocking), reduced stool frequency
(usually three bowel actions weekly
but up to 12 days without passing
stool), hard stools (rated Bristol
stool type 1 by his mother), significant straining and passage of large
stools. There has been one episode
of passing bright red blood around
his stool.
He has previously had trials of
a polyethylene glycol agent (Movicol-half), lactulose, liquid paraffin
(Parachoc), as well as enema and
suppositories. Since starting childcare recently, his diet and fluid
intake have been optimised.
cont’d next page
www.rch.org.au/clinicalguide/
guideline_index/Constipation_
Guideline/
References
Available on request from
[email protected]
www.australiandoctor.com.au
23 January 2015 | Australian Doctor |
23
How To Treat – Constipation in children
from previous page
Ben is a normally growing boy
with recently diagnosed autism
spectrum disorder and is still being
toilet trained. He has no known
allergies and no significant family
history. He was born vaginally, at
term, with meconium liquor. He is
an only child with separated parents.
Examination places his growth
between 50th and 75th centiles
for weight and 25th and 50th centiles for height. He has a palpable abdominal faecal mass in the
suprapubic region, with normal
perianal inspection, normal spinal,
lower-limb neurological and thyroid
examination.
Blood tests previously performed
showed normal FBC, electrolytes
including calcium, thyroid function
and coeliac screen.
He is diagnosed with likely
functional constipation and faecal
impaction. He is commenced on an
escalating dose of a polyethylene
glycol agent (Osmolax) over a week
to be reduced to a maintenance dose
of two scoops daily and titrated for
Bristol type 4-5 stool by his mother.
Education is given on behavioural
modifications and timed toileting,
and the importance of consistent
management across different home
Conclusion
CONSTIPATION in childhood is a commonly encountered problem for
clinicians. The presentation is not always straightforward or obvious.
Most constipation in children is functional with no underlying medical
condition or cause. The diagnosis of constipation and its aetiology relies
on strong clinical acumen — including careful history-taking with developmentally appropriate use of language, a thorough physical examination
and an appropriate use of investigations (which are often not needed).
Effective management involves the synchronous use of laxative agents
and behavioural modifications. The parents and child should be educated
and involved in management from the outset, with close follow-up and
review to assess for treatment response.
Summary
environments is emphasised.
He is reviewed a few months later
in clinic. His mother reports initial
good response to disimpaction and
maintenance management, but an
episode of hard stool with significant associated painful defecation
has set things back. He is taking
Osmolax disguised in drinks but is
uncooperative and refusing most
toilet sits. His bowel actions remain
soft (type 4-5 Bristol stool chart)
and not too large, with no apparent straining or pain; however, he is
passing stool only two to three times
weekly. His mother has tried sticker
charts and other reward systems
with minimal success. In summary,
effective management of Ben’s con-
stipation is limited by fear from a
previously painful experience, compounded by communication and
behavioural challenges related to his
autism.
After further review, sodium picosulfate (Dulcolax SP) four to five
drops daily is added to the regime
of one to two scoops daily of polyethylene glycol (Osmolax). Various
alternative methods of motivation
and reward systems are discussed.
This case illustrates the stepwise
approach to the use of laxatives and
the challenges that can be associated
when children have setbacks, such
as a painful experience or underlying comorbidities affecting development or behaviour.
Certain key developmental stages are a risk factor for the development of
constipation. Constipation is most common in preschool age children
Clinical tools such as classification systems (Rome III) and visual aids (Bristol
stool chart) can be useful in assessment
The diagnosis of constipation in children relies on specific questioning about
individual symptoms
Appropriate choice of language for the developmental stage of the child is key
to paediatric practice
Effective management of constipation relies on synchronous use of laxative
agents and education about behavioural modifications
Instructions
How to Treat Quiz
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Constipation in children —
23 January 2015
GO ONLINE TO COMPLETE THE QUIZ
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1. W
hich TWO statements are correct
regarding stool patterns and toileting
characteristics in children?
a) Infants who are breastfed may defecate
anywhere between five times a day to once
every five days or less
b) After starting solids at four to six months of
age, babies should only pass stools once daily
c) Even for healthy infants, straining despite
passing a soft stool is always abnormal
d) Most children achieve full bowel and bladder
control between the ages of 24 and 48 months
a) The criteria differ depending on whether the
child is older than the age of one
b) For older children, features of constipation
should not fulfil the Rome III criteria for irritable
bowel syndrome
c) For both younger and older children, the
diagnosis may not be made until the criteria
have been fulfilled for at least four months
d) The six criteria are similar for all children,
taking into consideration cognitive ability
except, in older children, a history of retentive
posturing may also be accepted
2. W
hich THREE statements are correct
regarding the general diagnostic
considerations in children with
constipation?
a) Faecal impaction may present as incontinence
or diarrhoea
b) The modified paediatric Bristol stool chart
is recommended when describing stool
consistency for diagnosis
c) Withholding behaviour leading to constipation
may include grunting, back arching, buttock
clenching, repetitive rocking or fidgeting
d) Data suggest that constipation is most
common in girls, peaking at the age of 10
4. Which THREE diagnoses should be
considered when assessing for underlying
causes of constipation in children?
a) Cows milk protein allergy
b) Anal fissures
c) Hip dysplasia
d) Non-accidental injury
3. W
hich TWO statements are correct
about the Rome III criteria for diagnosing
functional constipation in children?
Normal stool patterns vary during infancy and early childhood
5. Which THREE diagnoses or diagnostic
groups should be considered when
assessing for underlying causes of
constipation in adolescents?
a) Indirect inguinal hernias
b) Psychiatric conditions, such as anorexia
nervosa and depression
c) Diabetes mellitus
d) Medications, such as antidepressants and iron
supplements
6. Which THREE components should be
explored when taking a history about a
child presenting with constipation?
a) Toilet training and routine
b) Presence of withholding behaviours
c) Exposure to passive smoking
d) Social circumstances and any recent changes
7. Which THREE physical examinations
should be performed when assessing a
child with constipation?
a) Growth parameters
b) Thyroid size and nodularity
c) A lower-limb neurological examination
d) Digital rectal examination
8. Which TWO statements are correct
regarding investigations in a child with
constipation?
a) Investigations are often not needed if a
thorough clinical history and focussed
examination point to a diagnosis of functional
constipation
b) Abdominal radiography should be routinely
requested if a child presents with constipation
c) Calcium, thyroid function tests and coeliac
serology may all help identify the underlying
organic cause for constipation in a child
d) Inflammatory markers may be ordered if
Hirschsprung’s disease or cystic fibrosis are
suspected
9. Which TWO statements are correct
regarding the pharmacological
management of a child with constipation?
a) Generally, pharmacological management for a
child with constipation should avoid the use of
suppository agents
b) Once the child passes runny stool, laxatives
should be ceased immediately
c) A stimulant laxative may be added if
disimpaction is not achieved with an osmotic
agent or macrogol alone for two weeks
d) Once faecal disimpaction is achieved, all
laxatives should be ceased
10. W
hich TWO statements are correct
regarding the non-pharmacological
management of a child with constipation?
a) Dietary interventions and fluid management
should always be trialled as first-line
management before considering other
treatments
b) Correcting posture and positioning on the
toilet can engage muscles necessary for
effective defecation
c) Management of constipation in children who
are toilet trained should include 20-30 minutes
of sitting on the toilet after each meal
d) Motivational strategies should aim to provide
instantaneous reward for successful toileting
CPD QUIZ UPDATE
The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2014-16 triennium.
You can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept
the quiz by post or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
Next
week
24
how to treat Editor: Dr Steve Liang
Email: [email protected]
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determining prognosis and management. This How to Treat reviews the clinical features of Parkinson’s disease as well as the parkinsonian mimics that may be encountered
in practice. The authors are Dr Omar Ahmad, neurologist, Macquarie Neurology, Macquarie Univeristy, Macquarie Park, NSW; and Dr Daniel Schweitzer, neurology advanced
trainee, Macquarie Neurology, Macquarie University, Macquarie Park, NSW.
| Australian Doctor | 23 January 2015
www.australiandoctor.com.au