Lynne Watson explains the importance of managing constipation in children and how following NICE guidance could help to reduce admissions
  • All healthcare professionals should be aware of:
    • the symptoms, assessment, and treatment of constipation and the impact and consequences of ineffective or inadequate treatment, both in the short and long term
    • current evidence-based prescribing, along with how to provide advice to best support the child or young person and their family
  • Healthcare professionals need to be competent in carrying out an assessment in order to:
    • recognise red-flag signs and diagnostic clues that require urgent onward referral
    • diagnose idiopathic constipation with or without faecal impaction
  • Children and young people undergoing:
    • disimpaction therapy should be reviewed within 1 week
    • maintenance therapy should be reviewed within 6 weeks
    after the start of treatment, preferably by the same healthcare professional who carried out the initial assessment
  • The practitioner may need to ask a colleague competent in non-medical prescribing to prescribe laxatives, or arrange for a prescription through the child’s GP
  • Children who do not respond to initial treatment within 3 months should be referred to a practitioner with expertise in the problem.

Read this article to learn more about:
  • the short- and long-term impacts of constipation
  • how Quality Standard 62 should improve management and treatment of constipation in children and young people
  • the importance of a thorough assessment and the key components of effective history-taking.

It would be easy to introduce this article by saying, ‘Constipation is common in childhood’, because it is a condition which, depending on the criteria for diagnosis, affects around 5%–30% of the child population in the UK.1 However, this would seem to almost deny the significance and the impact that constipation can have on both the child and their family. It would be more appropriate to say, ‘Constipation causes significant misery in children and young people and is often poorly recognised and treated.

Background

As the prevalence of constipation appears to be highest in toddlers (again, depending on the criteria used for diagnosis), it could be assumed that the process of potty training, as well as the many common childhood minor illnesses, with their associated fever and reduced fluid intake, are contributing factors. In accepting this, and considering the UK population,2 this would suggest that 30% of children aged 0–4 years, or around 585,000 individuals, experience constipation at some point. A significant number of these children may present to general practice, in pharmacies, or at baby clinics, with the potential for early identification, positive diagnosis, and effective management.

Unfortunately, it is also estimated that 1 in 100 children and young people aged between 11 and 18 years have idiopathic constipation and that symptoms become chronic in more than one-third of these individuals.3 This would suggest that constipation is much more than just a condition of infancy and early childhood development. It also suggests that the condition is complex, requiring a greater understanding of its cause and impact, so that it can be effectively treated and prevented and the long-term consequences of chronicity avoided. Furthermore, as only approximately 5% of cases of constipation in children and young people are due to anatomical or physiological causes, in the overwhelming majority of cases there will be no underlying medical disease.4 For the 95% of children experiencing idiopathic (functional) constipation, treatment could and should be carried out in the community by healthcare professionals who are competent and experienced in the diagnosis, treatment, and support of children with constipation, and who have an awareness of both the short- and long-term impacts of the condition. The consequences of chronic constipation (i.e. constipation lasting longer than 8 weeks) can have a devastating impact on a child/young person’s self-esteem and emotional wellbeing, making effective treatment deserving of any professional’s full attention. Time spent pondering whether constipation is encopresis, functional, chronic, or otherwise4 gets in the way of speedy assessment and diagnosis.

The need for a quality standard

In 2010, NICE produced Clinical Guideline (CG) 99 on Constipation in children and young people (see www.nice.org.uk/CG99)1 to provide strategies based on best evidence in order to improve outcomes. A 2012 NICE Evidence Update5 had no impact on the 2010 guideline. In May 2014, NICE published Quality Standard 62 on Constipation in children and young people (see www.nice.org.uk/guidance/QS62 and Table 1, below).3 The six statements of this quality standard build on the previous guidance and will ensure that people have a positive experience of care.6 They will also help to reduce the levels of school absence and improve health as determined by the child development review at 2–2.5 years.7

Table 1: Quality standard for constipation in children and young people3
No. Quality statement
1 Children and young people with constipation receive a full assessment before a diagnosis of idiopathic constipation is made.
2 Children and young people with idiopathic constipation receive oral macrogols as first-line treatment.
3 Children and young people with idiopathic constipation starting disimpaction therapy have their treatment reviewed by a healthcare professional within 1 week.
4 Children and young people with idiopathic constipation starting maintenance therapy have their first treatment review by a healthcare professional within 6 weeks.
5 Children and young people with idiopathic constipation starting laxative treatment, or their parents or carers, receive written information about laxatives.
6 Children and young people with idiopathic constipation that does not respond to initial treatment within 3 months are referred to a healthcare professional with expertise in the problem.
NICE (2014) QS62. Quality standard for constipation in children and young people. Available at: www.nice.org.uk/guidance/QS62. Reproduced with permission

Diagnosing idiopathic constipation

The term ‘constipation’ refers to the inability to pass stools regularly or to empty the bowels completely and can arise as a symptom of another condition. A short-term illness may provide one cause for constipation but the term ‘idiopathic’ is used when constipation is not the result of an anatomical, physiological, radiological, or histological abnormality and when the exact cause of the constipation cannot (currently) be explained.1 The diagnosis of idiopathic constipation, therefore, requires careful and thorough assessment to exclude any red or amber flags suggesting an underlying cause that would require urgent referral to a specialist, and to ascertain whether impaction of faeces is present in addition to constipation.

Used in conjunction with Table 2 (see below),1, the Bristol Stool Chart8 can help practitioners diagnose idiopathic constipation. Such tools are, however, only one element of a full and careful assessment, which must consider not only stool consistency and frequency but also other symptoms such as behaviours associated with bowel movements, appetite, pain, and the presence of soiling.9 Looking at stool consistency alone fails to take into account the child’s behaviour in passing it: for example, a child passing a hard, lumpy stool every 2–3 days with no pain or distress may not have a problem whereas a child with a poor appetite and who is passing frequent, loose stools into their underwear may have faecal impaction. The difficulty in recognising the symptoms of constipation, alongside fear or embarrassment, may explain why advice is not sought earlier and why, in 2012/13, there were 13,135 finished consultant episodes for constipation in children and young people aged under 18 years, 79% of which were emergency admissions.3

Two or more of the key components from Table 2 indicate constipation. Symptoms may include:1

  • irregular bowel habit/frequent loose stools passed without sensation/large stools
  • loss of appetite that improves with passage of a large stool
  • a lack of energy
  • being irritable, angry, or unhappy
  • foul-smelling wind and stools
  • stomach pain and discomfort
  • soiling
  • generally feeling unwell.

If constipation is under-reported due to embarrassment, fear, or shame and portrayed as a trivial and minor condition, effective early diagnosis and treatment may be prevented. Conflicting and inconsistent advice from both healthcare professionals and the lay public can further exacerbate the problem, increasing the risk of chronicity. If prevalence is indeed at its peak in toddlerhood, effective management during this period, for example by including a relevant question in the 2–2.5 year review, might reduce the number of children aged 11–18 years experiencing chronic constipation and thereby improve school attendance.

The key to treating childhood constipation therefore lies with both understanding the significance and long-term consequences of this condition, and the importance of early and effective treatment. A thorough and comprehensive assessment:1

  • enables a tailored approach
  • differentiates between faecal impaction and constipation
  • includes treatment, advice, and support and (importantly) empowers parents and the child/young person.
Table 2: Key components of history-taking to diagnose constipation1
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
NICE (2010) CG 99. Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. Reproduced with permission. Available at www.nice.org.uk/guidance/cg99

NICE Quality Standard 62 on constipation in children and young people

NICE Quality Standard (QS) 623 consists of six concise quality statements that build on the evidence-based recommendations given in NICE CG991 (see Table 1). The quality standard should improve effective treatment for idiopathic constipation and help to:3

  • reduce rates of attendance at accident and emergency departments and subsequent hospitalisation
  • prevent recurrence of constipation and/or impaction in children and young people
  • enable children and young people, together with their parents, to receive information and advice so that they can manage their condition with confidence and satisfaction.

It should also improve treatment in younger children, reduce the number of 11–18-year-olds who experience constipation, and improve school attendance.10

Assessment—statement 1

The healthcare professional whom the parent or child/young person presents to should carry out a full assessment to:1

  • identify any red-flag symptoms that require urgent referral to an appropriate specialist
  • determine whether the idiopathic constipation is presenting with symptoms of faecal impaction.


Red-flag findings

Table 3 1 shows red-flag (and one amber-flag) findings in the history that might indicate a possible underlying anatomical or physiological problem requiring urgent referral to a practitioner with expertise in the area of concern. In summary, the indicators for red and amber flags relate to:1

  • timing of onset of constipation: reported from birth or first few weeks
  • passage of meconium: failure or delay of more than 48 hours (in term baby)
  • stool patterns: ‘ribbon stools’ (more likely in a child younger than 1 year)
  • symptoms/weakness in legs/locomotor delay
  • abdominal distension with vomiting.

Where there is an ‘amber flag’ (see Table 3), treat for possible idiopathic constipation and seek further advice from the relevant guidance or healthcare professional with expertise in the area of concern.1

The assessment should include a detailed history, together with a physical examination (see Table 4).
NB: NICE CG99 states: ‘Do not perform a digital rectal examination in children or young people older than 1 year with a ‘red flag’ in the history-taking and/or physical examination that might indicate an underlying disorder. Instead, refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung’s disease.1 Table 4 illustrates the key components to a physical examination.

As constipation describes a collection of symptoms, it is also important that the assessment covers the reported behaviours as well as an accurate description of bowel habits. Although the Paris Consensus on Childhood Constipation Terminology (PACCT) group criteria cited by Auth et al13 is useful as a framework for history-taking, concentrating on stool consistency and frequency alone, as previously mentioned, overlooks the behaviours associated with stooling and may miss the signs of faecal impaction. In order to instigate treatment in accordance with quality statement 2, it is important to recognise the presence or absence of faecal impaction because without this additional diagnosis, treatment may only be partially effective.

A combination of history-taking and physical examination, in particular asking about overflow soiling and/or a faecal mass which is palpable abdominally, can help to diagnose faecal impaction. Overflow soiling, the ‘involuntary passage of stool’,14 may have gone unnoticed by parents for a number of weeks and may prove to be a potential barrier in explaining to parents/carers the diagnosis of idiopathic constipation.


Table 3: Key components of history-taking to diagnose idiopathic constipation1
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 [NICE Clinical Guideline 8611]
Personal/familial/social factors: disclosure or evidence that raises concerns over possibility of child maltreatment12
Adapted from: NICE (2010) CG 99. Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. Reproduced with permission. Available at www.nice.org.uk/guidance/cg99
Table 4: Key components of physical examination to diagnose idiopathic constipation1
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
NICE (2010) CG 99. Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. Reproduced with permission. Available at www.nice.org.uk/guidance/cg99

First-line treatment with laxatives—statement 2

Following the assessment outlined above and in Tables 2 and 3, treatment should be started using oral macrogols unless otherwise indicated. The assessing healthcare professional either requires the skills, competency, and authority to prescribe appropriate laxatives or needs to ensure that the child is referred to another practitioner able to prescribe laxative therapy as indicated. Start either a disimpaction regimen or maintenance therapy, according to findings from assessment. 1

  • faecal disimpaction should be achieved using an escalating dose of macrogols
  • maintenance therapy at an appropriate dose should be started immediately if faecal impaction is not present, using macrogols as the first-line treatment unless otherwise indicated
  • advice should be provided about the:
    • medication
      (e.g palatability and how it is administered)
    • laxative regimen, together with fluid and dietary information.

Macrogols

Macrogols are a powder that is reconstituted in water and drunk. They are available either as unflavoured (plain), allowing the addition of a favoured squash, juice, or milk, or as paediatric chocolate-flavoured. Palatability is an important consideration; some children dislike the flavour if the medicine is administered in water only. For children who drink only water, a few crisps given with the medicine can help to disguise the taste. The provision of squash, cordial, juice, or crisps needs to be balanced with the evidence that macrogols are the first-line treatment for idiopathic constipation but that treatments other than macrogols may be presented in a syrup solution (this may be sugar-free depending on the medication).

Oral macrogols are easily administered at home; advice and information should be provided to empower children, young people, and their families to adjust the dose according to response. Written information (see text under heading about statement 5, below) will help them to understand that the treatment may initially make the symptoms worse (e.g. with soiling), therefore they need to understand how the medication works and what to expect.3 This support should be provided alongside an explanation of what idiopathic constipation is and possible reasons for why the condition is presenting as it is (e.g. with soiling, changes in behaviour, retentive posturing). Included in the written advice should be details of how to titrate the medication, the next review, and how to seek advice and support. Information should be provided about fluid and dietary measures but it should be emphasised that dietary measures alone are not sufficient as first-line treatment.

Reviewing disimpaction therapy—statement 3

Children who have been prescribed an escalating dose of macrogols should have their treatment reviewed after 1 week to monitor whether the treatment has worked and to discuss how to proceed onto a maintenance dose to prevent relapse.3 The timing and type of review, such as in clinic or by phone, will depend on the individual need of the child/young person and their family. The need for ongoing maintenance therapy can be explained at this review and arrangements made for ongoing monitoring to prevent recurrence of the faecal impaction.

Reviewing maintenance therapy—statement 4

Children who have either started a maintenance dose of macrogols straightaway or who have undergone a disimpaction regimen should be reviewed within 6 weeks,3 preferably by the same healthcare professional who carried out the initial assessment. Issues to consider at this review may include:1

  • toileting regimens
  • toilet training
  • maintaining laxative treatment
  • encouragement/reward systems.

Negotiated and non-punitive interventions should be tailored to the individual child’s needs and stage of development.1 Involving the child and their family in finding the most suitable incentives in order to encourage and motivate them should be a priority at this treatment review. Frequent reassessment and laxative therapy may continue for some time after either the initial review (following disimpaction) or the 6-week review, even after a regular bowel habit has been established.15 The provision of written guidance (see text under heading for statement 5, below) can help empower children/young people and their parents and carers in self-management and in understanding the benefits of laxative therapy.


Written information—statement 5

Written information about laxatives should be provided to children and young people and their parents/carers at the start of treatment, whether for disimpaction or maintenance.3 A version of the Bristol Stool Form Chart8 is available that has been adapted for use with children and young people 16 and uses terminology appropriate to the child/young person and their family/carer. To maintain adherence to treatment, it is important to explain that appropriate laxative treatment is not addictive and will not create a lazy bowel or dependency. Empowering children/young people and their families to adjust the dose of laxatives according to response reassures them and helps them to prevent recurrence. In addition, advice on how to recognise relapse allows for quicker treatment, and explaining symptoms that may indicate an underlying problem further supports effective self-management.

A number of organisations provide resources that give advice appropriate to meet individual needs, from toilet training to a balanced diet and sufficient fluid intake (see Box 1). In addition, there are campaigns to ensure that children have access to good quality toilet facilities during the school day;17 this can be a contributory factor to constipation that arises when the child starts school.

Providing evidence-based information to both the child/young person and their parent/carer engages both parties with the treatment plan, helping to reduce embarrassment. Providing information about prevalence rates of constipation, as well as how a healthy bowel functions, can also help to reduce the shame felt by children and young people about soiling and normal bowel function. Regular reviews or telephone support can help as a reminder of advice previously given. In addition, access to self-help groups can provide a safe and anonymous haven for either the child/young person or the parent/carer to share experiences.

Box 1: Sources of information for children, young people, parents, and carers

Referral if no response to treatment—statement 6

Unfortunately, there will be some children who do not respond to treatment for a number of reasons. There may be problems with adherence of medication or parents/carers may feel that there is a serious underlying medical problem. Therefore, the healthcare professional needs to review progress and assess for any improvement in symptoms when treatment has been adhered to. If there is no response to initial treatment within 3 months, the child/young person should be referred to a practitioner with expertise in the problem.3

Conclusion

The importance of a comprehensive assessment cannot be over-emphasised as, along with the recognition of red or amber flags, this will help to identify the presence of faecal impaction as a co-factor alongside idiopathic constipation. Successful disimpaction is vital in order to achieve successful maintenance therapy from the start. In addition, regular reviews form a vital component of successful ongoing treatment and the prevention of relapse or recurrence. Reviews need to be tailored to the individual child’s and family’s needs but should take place initially 1 week after initial disimpaction (or after 6 weeks for maintenance therapy). Barriers to successful treatment include inconsistent and contradictory advice from professionals and the lay public as well as a fear of treatment. Poor knowledge and understanding of how the bowel works is also a contributory factor and confusion around what faecal soiling is, together with difficulty in accepting this as a consequence of faecal impaction, adds to the overall reluctance of people in accepting laxative therapy.

  • Proportion of children and young people:
    • with constipation who receive a full assessment
    • diagnosed with idiopathic constipation who receive oral macrogols as first-line treatment
    • who receive a review within 1 week following a disimpaction regimen
    • who receive a review within 6 weeks following commencement on a maintenance regimen
  • Evidence of local arrangements to provide written information to children, young people, and their parents and carers about laxative treatment
  • Evidence of local clinical protocols and arrangements to refer children who do not respond to initial treatment to a healthcare professional with expertise in the problem.

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • Constipation in children is a common problem that can present to many healthcare professionals, e.g. health visitors, school nurses, GPs, accident and emergency, pharmacies, GP out-of-hours services, and specialist paediatric services
  • To ensure a consistent approach and compliance with the NICE quality standard, a local care pathway based on the relevant NICE guidance should be agreed between all these health agencies:
    • this pathway can act as a stimulus for education about this common condition to healthcare professionals and others, e.g education services
  • Local CCG drug formularies should list macrogols and give guidance for their use and supervision in children (including written guidance for children and young people, or their parents and carers, on their use)
  • GP practices could run audits of prescriptions for senna products, lactulose, and suppositories in children to ensure that prescribing practice is to use macrogols as the first-line treatment for this group.

CCG=clinical commissioning group

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  2. Office for National Statistics. Population Estimates for UK, England and Wales, Scotland and Northern Ireland, Mid-2011 and Mid-2012. London: ONS, 2013. Available at www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-319259
  3. NICE website. Constipation in children and young people. Quality Standard 62. www.nice.org.uk/guidance/QS62 (accessed 25 June 2014).
  4. Von Gontard A, Néveus T. The management of disorders of bladder and bowel control in childhood. London: Cambridge University Press, 2006.
  5. NHS Evidence website. Constipation in children and young people. Evidence Update 20. www.evidence.nhs.uk/evidence-update-20 (accessed 25 June 2014).
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  7. Department of Health. The NHS Outcomes Framework 2014/15. London: Department of Health, 2014. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/256456/NHS_outcomes.pdf
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  10. Department of Health. The public health outcomes framework for England, 2013–2016. London: DH, 2012. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/216159/dh_132362.pdf
  11. NICE. Coeliac disease. Clinical Guideline 86. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG86
  12. NICE. When to suspect child maltreatment. Clinical Guideline 89. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG89
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  16. Candy D and Davey E. The Bristol stool form scale (for children). Commercially sponsored resource. Available at: www.nursingtimes.net/Journals/1/Files/2011/3/25/Children's%20version%20of%20the%20Bristol%20Stool%20Chart.pdf
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