Download Paediatric Constipation Guidelines SDCCGv2

Guideline:
Management of idiopathic constipation in children
and young people
Introduction
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Childhood constipation is common, affecting 5-30% children.
More than one third become chronic.
90% of causes are functional and multifactorial - contributing factors including
pain, fever, dehydration, dietary, fluid intake, psychological, toilet training,
medicines.
‘Idiopathic’ if cannot be explained by anatomical, physiological, radiological or
histological abnormalities
‘Chronic’ if lasting longer than 8 weeks
‘Intractable’ if not responding to sustained optimal medical management
Assessment – see appendix 1&2
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Exclude red flags.
Failure to thrive - consider systemic condition.
Examination - abdo, spine/lumbosacral/gluteal region/lower limb neurology
Inspect perianal area - refer if feel needs PR (only to be done if suspicion of
hirschsprungs/anatomical abnormality)
Assess for faecal impaction (overflow soiling, palpable faeces on exam)
Investigations
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Idiopathic constipation is a clinical diagnosis
Consider coeliac screen/TFT if history or exam suggestive
Swab perianal area if suspect infection
USS/AXR not indicated
Date Written: February 2015
Review Date: February 2017
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
Version: 2.0
Page 1 of 9
Management (see appendix 3 for doses)
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Do not use dietary interventions alone as first line treatment for idiopathic
constipation – diet should be used in conjunction with drug treatment
Treat impaction if indicated - inform families that this may initially increase
soiling symptoms, arrange review within 1 week
Maintenance drug treatment
1. ‘Movicol Paediatric Plain’ (Polyethylene glycol 3350+electrolyes) first line. This
promotes disimpaction, improves stool frequency and consistency, reduces pain
at defaecation and straining, and has fewer side effects than lactulose. Adjust
dose according to symptoms and response
2. Add a stimulant laxative if this is ineffective
3. Add lactulose or docusate if stools are hard
4. Continue medication for several weeks after regular bowel habit is established
5. Children toilet training should remain on laxatives until this is well established
Reduce gradually over months
Diet and lifestyle
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Behavioral interventions - evidence shows that education about constipation and
toilet training, the use of a bowel habit diary (with a reward system for younger
children), review for assessment of adherence of drugs, and clear information on
expected treatment duration are important for success
Adequate fluid and fibre intake (appendix 5)- foods with high fibre content, not
unprocessed bran, which can cause bloating/flatulence and reduce absorption of
micronutrients
Follow up
Use Bristol stool chart (appendix 6) to assess response. Consider health visitor and
school nurse support
Referral
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Red flags
After 6 months of appropriate medical management in primary care, if
symptoms are ongoing
Date Written: February 2015
Review Date: February 2017
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
Version: 2.0
Page 2 of 9
References
1. NICE CG 99 – 2010
2. Derby Hospitals Guideline for clinical management of Idiopathic constipation in
children and young people ,2011, Dr R Morton, Dr J Smith. (appendices from this
guideline)
3. BMJ clinical review Childhood constipation BMJ 2012;345:e7309
Details of consultation
Dr O O’Connell, SDCCG Paeds CIG,
Contacts
Email Dr O O’Connell – olivia.o'[email protected]
Paediatric CIG via [email protected]
Keywords
Constipation; paediatric; idiopathic; children; childhood;
Date Written: February 2015
Review Date: February 2017
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
Version: 2.0
Page 3 of 9
Appendix 1
Algorithm for Diagnosis of Idiopathic Constipation in children younger than one year
Does the child have constipation?
2 or more of the following symptoms indicate constipation
 < 3 complete stools per week (type 3 or 4, see appendix 6) (this does not apply to exclusively breastfed babies after
6 weeks of age)
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Hard large stool
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‘Rabbit droppings’ (type 1, see Bristol Stool Form Scale – appendix 6)
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Distress on stooling
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Bleeding associated with hard stool
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Straining
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Previous episode(s) of constipation
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Previous or current anal fissure
Yes
YES
Are there any ‘Red Flags’ to indicate an underlying diagnosis?
History
 Constipation from birth or first few weeks of life
 Failure to pass meconium/delay (more than 48 hours after birth, in term baby)
 ‘Ribbon stools’
 Previously unknown or undiagnosed weakness in legs, locomotor delay
 Abdominal distension with vomiting
Examination
 Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly
placed anus, absent anal wink
 Gross abdominal distension
 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
 Deformity in lower limbs such as talipes
 Abnormal lower limb neuromuscular signs unexplained by any existing condition, such as cerebral palsy
No
Are the findings consistent with Idiopathic Constipation?
History
 Starts after a few weeks of life
 Obvious precipitating factors: fissure, change of diet, infections
 Passage of meconium within 48 hours in term babies
 Generally well, weight and height within normal limits (if faltering growth can treat as constipation but test for coeliac
disease & hypothroidism)
 No neurological problems in legs, normal locomotor development
 Changes in infant formula, weaning, insufficient fluid intake
Examination
 Normal appearance of anus and surrounding area
 Soft abdomen. Flat or distension that can be explained because of age or excess weight
Date Written:
February
 Normal
appearance
of the2015
skin and anatomical structures of lumbosacral/gluteal regions
Review
Date:
February
2017
 Normal gait, tone, strength
and reflexes in lower limbs
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
Version: 2.0
Page 4 of 9
Appendix 2
Algorithm for Diagnosis of Idiopathic Constipation in children older than one year
Does the child have constipation?
2 or more of the following symptoms indicate constipation
 < 3 complete stools per week (type 3 or 4, see Bristol Stool Form Scale – appendix 6)
 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 6)
 Large, infrequent stools that can block the toilet
 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
 Previous episode(s) of constipation
 Previous or current anal fissure
 Painful bowel movements and bleeding associated with hard stools
YES
Yes
Are there any ‘Red Flags’?
History
 Constipation from birth or first few weeks of life
 Failure to pass meconium/delay (more than 48 hours after birth, in term baby)
 ‘Ribbon stools’
 Previously unknown or undiagnosed weakness in legs, locomotor delay
 Abdominal distension with vomiting
Examination
 Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly
placed anus, absent anal wink
 Gross abdominal distension
 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
 Deformity in lower limbs such as talipes
 Abnormal lower limb neuromuscular signs unexplained by any existing condition, such as cerebral palsy
No
Are the findings consistent with Idiopathic Constipation?
History
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Starts after a few weeks of life
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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
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Passage of meconium within 48 hrs in term babies
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Generally well, weight and height within normal limits, active
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No neurological problems in legs, normal locomotor development
Date Written:
February
 History
of poor diet
and/or2015
insufficient fluid intake
Review Date: February 2017
Examination
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
 Normal
of anus and surrounding area
Version:appearance
2.0
Page
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 Soft abdomen. Flat or distension that can be explained because of age or excess weight
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Normal appearance of the skin and anatomical structures of lumbosacral/gluteal regions
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Normal gait, tone, strength and reflexes in lower limbs
Appendix 3: drug treatment
Osmotic laxatives
Recommended Doses
Macrogols
Polyethylene
glycol 3350 +
electrolytes
Paediatric formula e.g. ‘Movicol paediatric plain’:
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
Child 1–5 years(treat until impaction resolves): 2 sachets on 1st day, then 4
sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily
Child 5–12 years: 4 sachets on 1st day, then increased in steps of 2 sachets
daily to maximum of 12 sachets daily
Ongoing maintenance (chronic constipation, prevention of faecal
impaction)
Child under 1 year: ½–1 sachet daily
Child 1–6 years: 1 sachet daily; adjust dose to produce regular soft stools
(maximum 4 sachets daily)
Child 6–12 years: 2 sachets daily; adjust dose to produce regular soft stools
(maximum 4 sachets daily)
Adult formula e.g. ‘movicol’: 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.
Lactulose
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
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
Child/young person 5–18 years: 5–20 ml twice daily, adjusted according to
response
Date Written: February 2015
Review Date: February 2017
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
Version: 2.0
Page 6 of 9
Appendix 4
Stimulant laxatives
Sodium
picosulfate
Bisacodyl
Senna
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
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
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
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 m
medications/doses are prescribed that are different from those recommended by the BNFC.
a 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.
Docusate sodium
Date Written: February 2015
Review Date: February 2017
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
Version: 2.0
Page 7 of 9
Appendix 5- Fluid intake
Age
Total water intake per day,
including water contained in
food
700 ml assumed to be from
breast milk
Water obtained from drinks per day
600 ml
1–3 years
800 ml from milk and
complementary foods and
beverages
1300 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
Infants 0–6 months
7–12 months
900 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.
Date Written: February 2015
Review Date: February 2017
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
Version: 2.0
Page 8 of 9
Bristol Stool Form Scale
Date Written: February 2015
Review Date: February 2017
Author and Lead Clinician: Dr Olivia O’Connell with Paediatric CIG, SDCCG
Version: 2.0
Page 9 of 9
Appendix 6