Trip Answers

Question answered:21/08/07 Warning! this question is over two years old.

The information we have found discusses young children as well as infants so the recommendations should be viewed with reference to the very young age of your patient.

 

Patient Plus (aimed at clinicians) states in its article on constipation:

 

“Constipation in children Breast fed babies have on average 3 stools per day (bottle fed have 2). Provided there is no pain, bowel movements less frequently than this (eg every other day) should be considered normal.
History: Always take a full and careful dietary history. Social/family history is also important. Delay in passing meconium (>48 hrs) or constipation at a very early age suggests Hirschsprung's Disease (associated with failure to thrive, abdominal distension and vomiting)…

 
Examination: Palpate abdomen (to demonstrate distention or faecal loading). PR is usually unnecessary; as are plain abdominal X-rays (except to confirm faecal impaction and overflow where the presentation is diarrhoea). Solid marker transit studies are occasionally necessary where rectal retention or colonic inertia is suspected (child swallows radio-opaque markers over 3 days and X-ray taken on day 5).” [1]

 

The CKS guideline on constipation discusses the causes and management of this condition across all age groups, and provides a list of conditions predisposing children to constipation:

 

• Underlying conditions in children that predispose to constipation include:
o Attention deficit hyperactivity disorder
o Autism
o Coeliac disease
o Cystic fibrosis
o Dehydration
o Depression
o Hirschsprung’s disease
o Metabolic conditions (e.g. diabetes insipidus, hypothyroidism)
o Spinal cord abnormalities
o Painful anal conditions (e.g. anal fissure)
o Cerebral palsy [Rasquin-Weber et al, 1999].”

 

Concerning investigations, CKS states:

 

“Investigations to look for conditions that predispose to constipation should be guided by symptoms and examination findings.”

 

It also notes:

 

“What else might it be?
• Infant dyschezia occurs during the first few months of life. It describes a functional problem caused by discoordainated muscles involved in defecation.
o It is characterized by straining and screaming during prolonged attempts to defecate.
o This behaviour persists for up to 20 minutes, until soft or liquid stools pass.
o This may be repeated several times a day.
o Infant dyschezia resolves spontaneously in a few weeks.”

 

In the clinical scenario on constipation in children, CKS differentiates between short-lived and mild constipation and long-standing and severe constipation. Concerning, short-term constipation, the guideline recommends:

 

“How do I manage short-lived or mild constipation in children?
• Dietary advice to increase fluid intake and dietary fibre is recommended.
• Oral laxatives are recommended if dietary treatment fails or if treatment is necessary while dietary measures take effect.”
• Osmotic laxatives (e.g. lactulose, macrogols) are recommended in infants and young children, because bulk-forming laxatives may be difficult to give to this age group.
o Lactulose is the only osmotic laxative specifically licensed in children of all age groups.
o Macrogols are available in a different Movicol® preparation for children: Movicol® is licensed for children over the age of 12 years, and Movicol® Paediatric Plain is licensed for children of 2 years of age and older.

 

In addition, CKS provides recommendations on referral to a paediatrician:

 

• "Treatment in primary care is not effective.
• Constipation is prolonged (present for more than 6 months).
• There is frequent soiling.
• The condition is causing distress, interfering with the child’s schooling and social relationships.
• Restriction of dietary intake (e.g. of formula milk in young children) is being considered.
• Major feeding problems are present.” [2]

 

The North American Society for Gastroenterology, Hepatology and Nutrition recommends:

 

“A thorough history and physical examination are an important part of the complete evaluation of the infant or child with constipation [III].”

 

 

And:

 

“In infants, rectal disimpaction can be carried out with glycerin suppositories. Enemas are to be avoided [II-3].
In infants, juices that contain sorbitol, such as prune, pear, and apple juice, can decrease constipation [II-3].
Barley malt extract, corn syrup, lactulose, or sorbitol (osmotic laxatives) can be used as stool softeners [III].
Mineral oil and stimulant laxatives are not recommended for infants [III].” [3]

 

References
1. PatientPlus. Constipation. May 2006. (http://www.patient.co.uk/showdoc/40000841/)
2. CKS. Constipation. Last revised November 2005. (http://cks.library.nhs.uk/constipation/).
3. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. 2006.
http://www.guideline.gov/summary/summary.aspx?doc_id=9792&nbr=5245&ss=6&xl=999

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