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Guideline: Management of idiopathic constipation in children and young people Introduction 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 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 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) 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 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 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) Hard large stool ‘Rabbit droppings’ (type 1, see Bristol Stool Form Scale – appendix 6) Distress on stooling Bleeding associated with hard stool Straining Previous episode(s) of constipation 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 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 Passage of meconium within 48 hrs in term babies Generally well, weight and height within normal limits, active 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 5 of 9 Soft abdomen. Flat or distension that can be explained because of age or excess weight Normal appearance of the skin and anatomical structures of lumbosacral/gluteal regions 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