Dr Jenny Gordon explains how the NICE guideline on constipation in children will help to improve recognition and management of this distressing and disruptive condition
  • The NICE guideline gives constipation its due credence
  • Establish if the child or young person has constipation through history-taking
  • Perform a physical examination and take a history using the key components table to establish a positive diagnosis of idiopathic constipation by excluding underlying causes
  • Do not perform a digital rectal examination in children or young people aged >1 year with a ‘red flag’ symptom that might indicate an underlying disorder. Instead, they should be referred urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung’s disease
  • Assess all children and young people with idiopathic constipation for faecal impaction and offer oral medication if indicated. Review children and young people undergoing disimpaction within 1 week
  • Start maintenance therapy as soon as the child or young person’s bowel is disimpacted
  • Reassess children frequently during maintenance treatment to ensure that they do not become re-impacted and assess issues in maintaining treatment such as taking medicine and toileting
  • Adjust dose of medication to patient response; dose should be reduced gradually over a period of months in response to stool consistency and frequency
  • Do not use dietary interventions alone as first-line treatment for idiopathic constipation

Constipation is a common problem and can be a source of considerable distress to children and their families. In the United Kingdom, 5% of children between the ages of 4 and 11 years experience constipation that lasts longer than 6 months.1 Mild constipation has a short duration and usually clears up easily with drug therapy and dietary modifications. However, constipation is not always easily recognised or treated appropriately and this may lead to the development of the chronic (long-standing) form of the condition.

Parents of children with constipation are frequently worried because of the possibility of serious underlying disease and they may delay seeking help because they feel that the condition will not be taken seriously. The impact of constipation on the patient and family:

  • can be considerable, causing distress, disruption, and frustration
  • is often underestimated and as a result, they may be given conflicting advice, experience inconsistent practice, and receive treatment that is potentially less effective and frustrating for all concerned.

A health visitor may be the first point of contact for families of newborns and pre-school children. For other children, the emergency department may serve as the first port of call for concerned parents. Many children, however, are seen by their own doctors in primary care.

Consequently, there is a need to increase the credence given to the effect of constipation, both to raise awareness of the importance of timely recognition and to address wide variation in the treatment and support offered to affected children and families. A recently published NICE guideline has addressed the common problem of childhood constipation.2 Clinical Guideline 99 on Diagnosis and management of idiopathic childhood constipation in primary and secondary care provides strategies based on the best available evidence to support early identification, positive diagnosis, and timely, effective management.2 Where minimal evidence was available, recommendations were based on the Guideline Development Group’s experience and opinion of what constitutes good practice.

Pathology

Constipation is a condition characterised by the infrequent and/or painful passage of hard stools. Long-standing constipation can cause chronic abdominal pain; faecal retention with overflow soiling; and faecal incontinence, with associated social and behavioural consequences. Most children with constipation have no underlying pathological condition and are described as having idiopathic or functional constipation. This most commonly stems from a combination of painful defecation associated with voluntary withholding of stools.

Anal fissures
The most common cause of pain on defecation is an anal fissure—a tear of the squamous epithelial mucosa of the anal canal—most commonly occurring during passage of a firm stool.3,4 Anal fissures are common in infancy; most seem to affect children aged 6–24 months,4 although the overall incidence of the problem is not well described. The severe pain on defaecation may result in the child withholding the stool in an effort to avoid further pain.5–7 If fissures are not diagnosed and treated quickly, they set in motion a cycle of negativity towards stooling, constipation caused by withholding, and increasing pain with subsequent defaecation.4

Infection
Pyrexia, dehydration, and immobility as a result of infection may cause stools to become dry and hard because water is reabsorbed from the gut back into the tissues. Weaning issues, inadequate dietary intake, excessive milk intake (current thinking is that this contributes to constipation because it makes the child feel full and therefore limits their intake of other dietary sources), and ‘faddy’ eating patterns, which are common in toddlers, can also precipitate constipation.

Toilet training and weaning
Toilet training can be a cause of behavioural conflict and can therefore lead to constipation; the combination of the physiology of defecation and the learned behavioural responses necessary for appropriate and socially acceptable defecation can be disturbed or compromised if pain and/or fear are experienced. Many studies report that children and parents admit that fear of pain is a major factor in childhood constipation.8 Toilet training was identified as a factor in children becoming constipated and who were aged over 2 years. The transition from breast to bottle and or weaning was seen as a precipitant in children who had symptoms before the age of 2 years.9–12

Hirschsprung’s disease
Of the serious underlying disorders associated with constipation, Hirschsprung’s disease is a condition that requires surgical treatment and is characterised by neurological abnormalities in the wall of the gut. It is important to differentiate between children with idiopathic constipation (the vast majority) and those with organic disease so that they all receive appropriate diagnosis and management. Unfortunately, many children with constipation have repeated (and unnecessary) biopsies to exclude Hirschsprung’s. A child that had a ‘normal’ bowel habit prior to the onset of their constipation makes a diagnosis of Hirschprung’s disease highly unlikely.2

Diagnosis

The NICE guideline covers history-taking and physical examination and includes tables that illustrate the key components required to make a positive diagnosis of idiopathic constipation; these include a list of ‘red flag’ symptoms that are suggestive of other conditions and require further investigation and/or referral to other services (see Tables 1–3).2

A digital rectal examination should not be performed in children or young people aged >1 year with a ‘red flag’ symptom that might indicate an underlying disorder. These patients should be referred urgently to a healthcare professional who is competent in performing digital rectal examinations and in interpreting features of anatomical abnormalities and Hirschsprung’s disease.2

Table 1: Key components of history-taking to diagnose constipation2
Key components Potential findings in a child
younger than 1 year
Potential findings in a child/young person older than 1 year

Stool patterns

Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale) (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)

Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale)

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)

Large, infrequent stools that can block the toilet

Symptoms associated with defecation

Distress on stooling

Bleeding associated with hard stool

Straining

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

History

Previous episode(s) of constipation

Previous or current anal fissure

Previous episode(s) of constipation

Previous or current anal fissure

Painful bowel movements and bleeding associated with hard stools

National Institute for Health and Care Excellence (NICE) (2010) CG 99 Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: NICE. Reproduced with permission. Available from www.nice.org.uk.

Table 2: Key components of history-taking to diagnose idiopathic constipation2
Key components Findings and diagnostic clues that indicate idiopathic constipation ‘Red flag’ findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation

Timing of onset of constipation and potential precipitating factors

In a child younger than 1 year:

  • Starts after a few weeks of life
  • Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, infections

In a child/young person older than 1 year:

  • 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

Reported from birth or first few weeks of life

Passage of meconium

Normal (within 48 hours after birth, in term baby)

Failure to pass meconium/delay (more than 48 hours after birth, in term baby)

Stool patterns

'Ribbon stools' (more likely in a child younger than 1 year)

Growth and general wellbeing

In a child younger than 1 year:

  • Generally well, weight, and height within normal limits

In a child/young person older than 1 year:

  • Generally well, weight and height within normal limits, fit and active

No 'red flag', but see 'amber flag' below

Symptoms in legs/locomotor development

No neurological problems in legs (such as falling over in a child/young person older than 1 year), normal locomotor development

Previously unknown or undiagnosed weakness in legs, locomotor delay

Abdomen

Abdominal distension with vomiting

Diet and fluid intake

In a child younger than 1 year:

  • Changes in infant formula, weaning, insufficient fluid intake

In a child/young person older than 1 year:

  • History of poor diet and/or insufficient fluid intake

'Amber flag': possible idiopathic constipation

Growth and general wellbeing: faltering growth

Personal/familial/social factors: disclosure or evidence that raises concerns over possibility of child maltreatment

National Institute for Health and Care Excellence (NICE) (2010) CG 99 Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: NICE. Reproduced with permission. Available from www.nice.org.uk.

Table 3: Key components of physical examination to diagnose idiopathic constipation2
Key components Findings and diagnostic clues that indicate idiopathic constipation 'Red flag' findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation

Inspection of perianal area: appearance, position, patency, etc

Normal appearance of anus and surrounding area

Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal wink

Abdominal examination

Soft abdomen. Flat or distension that can be explained because of age or excess weight

Gross abdominal distension

Spine/lumbosacral region/gluteal examination

Normal appearance of the skin and anatomical structures of lumbosacral/gluteal regions

Abnormal: 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

Lower limb neuromuscular examination including tone and strength

Normal gait. Normal tone and strength in lower limbs

Deformity in lower limbs such as talipes

Abnormal neuromuscular signs unexplained by any existing condition, such as cerebral palsy

Lower limb neuromuscular examination: reflexes (perform only if 'red flags' in history or physical examination suggest new onset neurological impairment)

Reflexes present and of normal amplitude

Abnormal reflexes

National Institute for Health and Care Excellence (NICE) (2010) CG 99 Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: NICE. Reproduced with permission. Available from www.nice.org.uk.

Clinical management

The recommendations under clinical management clearly set out medication options and doses for disimpaction, maintenance, and reducing treatment. The NICE guideline states explicitly that the doses required to elicit an adequate response may be higher than those recommended in the British national formulary for children (BNFC)13 and that regular reassessment and follow up are essential for effective treatment.

Disimpaction
Healthcare professionals should inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain. Patients undergoing disimpaction should be reviewed within 1 week. The following oral medication regimen should be used for disimpaction:2

  • An escalating dose regimen of polyethylene glycol 3350 + electrolytes as the first-line treatment (informed consent should obtained and documented if there is no marketing authorisation). Polyethylene glycol 3350 + electrolytes may be mixed with a cold drink
  • Add a stimulant laxative if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks
  • Substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if polyethylene glycol 3350 + electrolytes is not tolerated.

Rectal medications for disimpaction should not be used unless all oral medications have failed and only if the child or young person and their family consent.2

Maintenance therapy
Maintenance therapy should be initiated if the child or young person is not faecally impacted/as soon as their bowel is dismpacted. The regimen below should be offered for ongoing treatment or maintenance therapy:2

  • Polyethylene glycol 3350 + electrolytes is the first-line treatment. Dosage should be adjusted according to symptoms and response. As a guide for patients who have had treatment for disimpaction, the starting maintenance dose might be half the disimpaction dose.
  • Add a stimulant laxative if polyethylene glycol 3350 + electrolytes is not effective
  • Substitute a stimulant laxative if polyethylene glycol 3350 + electrolytes is not tolerated. Add another laxative such as lactulose or docusate if stools are hard.

Medication at a maintenance dose should be continued for several weeks after a regular bowel habit is established—this may take several months. Children who are toilet training should remain on laxatives until toilet training is well established. Medication should not be stopped abruptly but reduced gradually over a period of months in response to stool consistency and frequency. Some patients may require laxative treatment for several years and a minority may need ongoing laxative therapy.2

Lifestyle interventions

While diet is recognised as important, it should not be the first and only intervention. Together with other lifestyle choices that may require changes in behaviour over time, dietary interventions are recommended as supplementary to drug therapy.2

Behavioural interventions may be used in combination with medical management. These interventions use psychological approaches to encourage positive changes in behaviour that should be child friendly and age appropriate. These include the use of toilet training programmes to encourage regular bowel habit; diet and fluid colouring and sticker charts are used to encourage healthy eating and an adequate fluid intake with rewards for positive behaviour. Interventions are more likely to succeed if the child is engaged and involved with the programme. Rewards can be appropriate although this must be discussed with individual children, as some do not like rewards. It is important to negotiate the right reward and the reward/effort ratio. Children will not work towards a reward if they feel that the effort involved is not worth the reward they achieve.

Emphasis should always be placed on positive results rather than negative. Parents, other family members, friends, and school or nursery teachers can contribute by providing ongoing support and motivation. This may be challenging to achieve given the sensitivity of the topic; some children do not wish anyone to know about the problem and it is vital to recognise their need for privacy and work with them to build their trust in other professionals who may be able to support them.

Information and support

The guideline section on information and support gives practical suggestions for the type and format of information and the ways in which support can be provided and tailored to individual patient needs. Children and young people with idiopathic constipation and their families should be offered a point of contact with specialist healthcare professionals (including school nurses) who can give ongoing support.2 Healthcare professionals should work with school nurses to provide information and support and to help raise awareness of childhood constipation.2

Patients who do not respond to initial treatment should be referred to a practitioner with expertise in this clinical area.2

Implementation

The lack of understanding given to constipation is the biggest impediment to implementation of the NICE guideline. Currently there is wide variation in practice. The worst-case scenario is of inconsistent diagnosis, multiple investigations that are unnecessary, insufficient doses of medication, and inadequate follow up and support for children and their families; this can result in poor outcomes, and frustration and despair all round. The challenge is to implement this guideline in a way that clearly raises the awareness of the condition and its associated issues, and stimulates the interest of healthcare professionals to ensure that children and families receive optimal treatment and support.

The NICE guideline provides an opportunity for multidisciplinary teams working within primary care to reflect on their current practice in the management of constipation in children and to use the recommendations to make innovative changes that will improve patient care. It offers a framework for practice in the form of key component tables (see Tables 1–3, above) while giving plenty of scope for local adaptation, allowing healthcare professionals and families to make the best use of services and expertise available.

The key priorities in the guideline may require a change in the way the diagnosis is made, relying less on investigations and more on history taking. Support tools for diagnosis may be an appropriate way forward and are currently used in some primary care settings. The drugs that are used in the management of this condition have been used for many years; however, as discussed earlier, the doses that may be required for an effective response often need to be higher than those recommended in the BNFC. Some practitioners may not have the confidence to prescribe in this way. This barrier could be overcome by accessing the experienced support of paediatric gastroenterology networks and online collaborative workspaces to facilitate discussion, information exchange, and support.

Treatment and care should take into account patients’ needs and preferences. Children and young people with idiopathic constipation, together with their parents and carers should have the opportunity to make informed decisions about their care and treatment in partnership with their healthcare professionals. They often do not have access to adequate follow up and support. There may be a need to re-commission services to ensure that they are accessible to a higher proportion of patients. This may also mean looking at different ways to deliver support using e-health technologies such as telemedicine. This guideline may offer the opportunity for patient-led initiatives that would benefit the community and foster a real culture of involvement.

The guideline includes recommendations that, if implemented, could result in financial savings, reducing repeated clinic appointments, investigations, and additional referrals to acute services. The financial saving of more effective treatment may be relatively minor, but the social and emotional impact for families could be huge and should not be underestimated. Primary care is best placed to bring about the fundamental changes that will improve outcomes for children and young people with constipation and their families.

Conclusion

Following the launch of the NICE guideline for constipation in children, there was an immediate response from parents who are members of the ERIC charity (Education and Resources for Improving Childhood Continence: www.eric.org.uk) in the form of overwhelming relief that this condition was being taken seriously.

Constipation can be a complex condition to manage and may require prolonged interventions including high-dose laxatives. Children who do not respond to initial treatment or where there are concerns regarding underlying disorders may need referral to specialist services, but the majority of children can be managed in primary care with appropriate support.

NICE implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 99 on Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. The tools are now available to download from the NICE website: www.nice.org.uk

Audit support

Audit support has been developed to support the implementation of this guideline. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

Baseline assessment tool

The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

Frequently asked questions

This document has been produced to help staff in Children’s Centres implement and further develop their understanding of the guidance.

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself.

Questionnaire

These questionnaire checklists have been produced for those taking histories of children under the age of 1 year with constipation and children or young people aged 1 year or older with constipation.

Template letter

A discharge advice template has been developed for use by clinical services for the parents/carers of a child or young person with constipation. The sheet contains useful information on the range of factors that influence the management of this condition at home.


References

  1. Yong D, Beattie R. Normal bowel habit and prevalence of constipation in primary-school children. Ambul Child Health 1998; 4: 277–282.
  2. National Institute for Health and Care Excellence. Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG99
  3. Kenny S, Irvine T, Driver C et al. Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure. Arch Dis Child 2001; 85 (5): 404–407.
  4. Gillet B, Paidas C. Anal fissure. 2005. Available at: emedicine.medscape.com/article/934952-overview
  5. Clayden G, Agnarrson U. Constipation in childhood. Oxford: Oxford University Press, 1991.
  6. Sutcliffe J, King S, Southwell B. Pediatric constipation for adult surgeons part 1: targeting the cause. Australia & New Zealand J Surgery 2004; 74: 777–780.
  7. Rogers J. Paediatric bowel problems. Gastrointestinal Nurs 2004; 2 (4): 31–39.
  8. Borowitz S, Cox D, Tam A et al. Precipitants of constipation during early childhood. J Am Board Fam Pract 2003; 16: 213–218.
  9. Bernard-Bonnin A, Haley N, Belanger S, Nadeau D. Parental and patient perceptions about encopresis and its treatment. Dev Behaviour Pediatrics 1993; 14: 397–400.
  10. Partin J, Hamill S, Fischel J, Partin S. Painful defecation and fecal soiling in children. Pediatrics 1992; 89 (6 pt1): 1007–1009.
  11. McGrath M, Clawson E. The defecation anxiety scale for parents and children. 1994. Unpublished assessment instrument. Cited by McGrath M, Mellon M, Murphy L (2000). Empirically supported treatments in pediatric psychology: constipation and encopresis. J Pediatric Psychology 2000; 25: 225–254.
  12. Loening-Baucke V. Assessment, diagnosis and treatment of constipation in childhood. J Wound, Ostomy Continence Nurs 1994; 21: 49–58.
  13. British Medical Association, the Royal Pharmaceutical Society of Great Britain, the Royal College of Paediatrics and Child Health, and the Neonatal and Paediatric Pharmacists Group. British national formulary for children. London: BMJ Publishing Group, RPS Publishing, and RCPCH Publications Ltd: 2010. G
  • Childhood constipation is common and often simple to treat but some cases require specialist involvement and ongoing support
  • Commissioners should ensure that a specialist service is available
  • Although this will need specialist medical leadership, much of the work can be performed by specialist nurses and primary care clinicians who use locally adapted guidelines
  • Commissioners should look to avoid paying expensive tariff charges for nurse workload—a community provided service can bypass this for now
  • This guideline could be adapted locally and made available to primary care clincians on a local PBC internet site or local Map of Medicine
  • Tariff costs: paediatric outpatient £236 (new), £120 follow upa

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