1. Constipation in children
GP REFRESHER NOVEMBER 2015
Phil Wylie

2. WHY??!!
Common 5-30% (depending on definition) – 1/3 become chronic (ie last > 8 weeks)
Causes lot of suffering
Prognosis altered by speed at which access effective advice/treatment

3. Based on Academy Paediatric Gastroenterology study day 30/9/14
ESPGHAN/NASPGHAN evidence based recommendations 2014
NICE guideline 99 – Constipation in children and young people

4. What is constipation?
Rome III criteria > 2 features 1/12 (2/12 > 4 yrs)
< 2 per week
Painful/hard
Faecal mass rectum
Large diameter stools
Stool retention
Soiling (>1 episodes per week)
Bristol stool chart

5. Infant dyschezia <6 months
Crying, straining/anal sphincter (? Related allergy)
Soft stool
Failure to coordinate intra-abdominal pressure with relaxation pelvic floor
Incidence 1 month 21%, 3 months 7%
Self resolving
Not related to future constipation

6. Functional (95%) or organic (5%)?
Constipation is a symptom not a diagnosis
RED FLAGS
Onset < 1/12 (at least daily)
NB Breastfed babies > 6 weeks can have infrequent bowel actions
Delay passing meconium > 48 hours
Ribbon stools
Abdominal distension with vomiting
Neurological problems with lower limbs/urinary problems

7. Other features in history
AMBER FLAGS
Psychosocial concerns - ? Safeguarding
Faltering growth
OTHERS
Allergy (CMPA allergic first year more likely to have constipation)
FH – assoc conditions – coeliac, constipation (functional – 30% vs 7% in control), HD – 7% FH

8. Examination Growth Dysmorphism
Abdo examination – distension (vomit), mass
Dysmorphism/hypermobility
Anus – position, tags, ?stenosis (ribbon stools), perianal redness (?strep)
PR? (? Impaction, red flags, ? Stenosis)
NICE suggests rectal if not responding optimal treatment within 4 weeks in < 1 year old
Lumbosacral
Gait and lower limb neurology (reflexes lower limb)
Cremasteric reflex/anal reflex?

9. What is usual position of anus?
Anal position index
Ratio anus-fourschette (girls) or anus-scrotum boys to the distance between coccyx and fourscette/scrotum
API girls 0.45 (95%CI: )
API boys 0.54 (95%CI: )

10. Investigations AXR – not to diagnose constipation
Transit time – not routine
Coeliac – 0.2% coeliac – constipation as only presenting feature – not recommended
Hypothyroid – 0.08% - not recommended (still in NICE)
Calcium/Pb no different to general population – not recommended (still in NICE)
Rectal biopsy gold standard for HD (suction usually sufficient)

11. Treatment Fibre – “normal” – may make worse in short term
NICE – don’t use first line without other treatment and don’t recommend unprocessed bran
Chocolate/banana no association stool frequency/consistency
Fluid – “normal” (NICE gives recommended volumes)
Physical activity – “normal”
Behavioural advice important (schedule, diary, reward system etc)
Written information (

12. Disimpaction
Oral vs enema – equally effective but NICE recommends oral route first Use PEG usual recommended regime Warn soiling will get worse before it gets better

13. Maintenance PEG first line (Movicol Paed Plain)
Maintenance – PEG superior to lactulose
Stimulants 2nd line
Can chronic use stimulants cause any long term issues?? No evidence. Can see melanosis coli
At least 2 months in maintenance phase with at least 1 month of normal bowel habit before gradual reduction of treatment

14. Prognosis Duration symptoms key
< 3/12 duration at presentation – 80% not using laxatives at 6 months compared to 32% if symptoms >3/12 at presentation
Overall 50% off laxatives by 12 months (relapse common and parents need to be aware of this)
Intractable 80% off laxatives 10 years (need to be confident and “aggressive”

15. Summary Diagnose accurately and know “red flags”
Start treatment early and be bold
Don’t just advise increased fibre
Use PEG first line (lactulose by itself often ineffective)
Don’t be put off by licensing restrictions – refer to NICE guideline (informed consent)
Patient information key
Follow up/availability to support

16. Licensing in the UK Lactulose – licensed 1 month onwards
PEG – not licensed faecal impaction < 5 years or maintenance treatment < 2 years but NICE quotes recommended dosages down to < 1 year
Senokot – syrup not licensed < 2 years but NICE quotes recommended doses > 1/12 age
Picosulphate – age range not specified by manufacturer but NICE quotes recommended dosages from >1/12 age
Dosages in NICE often not BNFC recommended
Use but informed consent documented