Ep 66 – Childhood constipation

In this podcast, Dr Kate Chesterman discusses constipation in children. She takes us through the clinical features associated with idiopathic constipation and red flags that would cause concern. She discusses disimpaction regimes and when these should be used, as well as talking about the importance of ongoing maintenance regimes. She provides some tips on encouraging children to take laxatives and also highlights some useful patient and professional resources.

Key references and resources

1. The Children’s Bowel and Bladder Charity. Constipation in children: symptoms, causes and relief.
2. ERIC Poo Diary.
3. NICE. Constipation in children and young people: diagnosis and management [CG99]. Last updated July 2017.
4. Bradshaw O et al. BMJ 2021 Dec 2;375:e065046. doi: 10.1136/bmj-2021-065046.
5. GP Infant Feeding Network. Constipation.
6. Bladder & Bowel UK. Bowel problems in children.

Key take-home points

• Constipation is really very common, affecting 1 in 10 children worldwide. Younger children are more frequently affected, and it is particularly common around times of weaning, toilet training and starting school
• Idiopathic constipation presents with infrequent and hard stools, and may be accompanied by straining, anal pain, and a reduced appetite and abdominal distension that improve with defecation. It can also be associated with urinary symptoms, and constipation can exert pressure on the bladder, resulting in increasing urinary tract infections and nocturnal enuresis.
• Concerning signs and symptoms include faltering growth, issues from birth, a delay of more than 48 hours in passing meconium, ribbon stools, persistent blood in the stools, abdominal distension with vomiting, abnormal appearance of the anus, any neurodevelopmental delay or abnormalities of the spine or lower limbs.
• Investigation is not required for idiopathic constipation.
• Dietary interventions alone are unlikely to be effective.
• Macrogols are the first line treatment. Alternative osmotic laxatives, such as lactulose, can be considered if the macrogols are not tolerated.
• If treatment is not effective with osmotic laxatives, then a stimulant laxative such as senna can be used either as an alternative, or in addition to, osmotic laxatives.
• Disimpaction treatment should be considered for children who have not effectively opened their bowels for 7 days.
• As soon as the child is disimpacted, maintenance treatment should start.
• Maintenance treatment should not be stopped too soon. The bowel needs time to recover and regain its tone, and so maintenance treatment needs to be continued for at least as long as the child was constipated for.
• Consider a referral if there are red flags or concerning features, for children less than 1 year who are unresponsive to treatment after 4 weeks, for those over a year who have not responded to appropriate treatment within 3 months and for any child who is unable to wean off laxatives after 12 months.