![]() Specifying chronicity and previous treatment measures in the referral letter can assist with prioritising referrals. If there are ongoing symptoms of constipation after six months of appropriate treatment, a referral for specialist care and a second opinion is warranted. 17 It is uncommon for specific foods (eg dairy, wheat) to be contributing, but reassessment during treatment failure should be an opportunity to consider coeliac disease, 18 cow’s milk protein allergy 19 or food intolerance. While an increase in dietary fibre and adequate water intake may assist in improving stool consistency, this alone will be insufficient to resolve the condition. NA, not applicable PBS, Pharmaceutical Benefits Scheme PEG, polyethylene glycolįamilies often ask whether increased fibre or a change in diet will improve their child’s constipation. ![]() Sodium citrate/sodium lauryl sulfoacetate/ Drops are helpful if unable to swallow large volumes.Can cause bloating/abdominal discomfort.Can stain underpants orange colour from oil.Contraindicated in those with aspiration risk.Aged 2–5 years – 1 half strength sachet daily.Childhood constipation key history and red flags The presence of red flag symptoms (Table 1), such as urinary incontinence in a previously continent child, should prompt specialist referral. Organic disorders are uncommon, but consider the possibility of coeliac disease or cow’s milk protein allergy if the history is suggestive. Ask about other medications (eg anticholinergics), previous laxative use, and their duration and effect. When constipated, there may be hard stools (types 1–2) if there is retained impacted stool, there may be watery overflow diarrhoea (types 6–7).ĭietary factors, including inadequate fibre and water intake, are rarely the primary cause of constipation but may contribute. 10 A Bristol type 3 or 4 stool every day or every second day is the goal. The Bristol stool form scale (Figure 1) allows a reproducible, subjective assessment of stool consistency, 6 and the chart is freely available online from the Royal Children’s Hospital’s Constipation clinical practice guideline. Other precipitants to investigate include painful bowel actions leading to withholding behaviour (eg perianal skin conditions, anal fissures), toileting refusal, change of diet and psychosocial stressors. While the median age for onset of functional constipation is 2.3 years, 5 common times for constipation to arise include transition to solids, toilet training and school entry. >1 episode per week of faecal incontinence after toilet training completed.presence of large faecal mass in rectum.Childhood functional constipation is best described using the Rome IV criteria and is defined by the presence of two or more of the following features for at least one month: 5,7–9 Key features to ask about are the stool frequency and consistency using the Bristol stool form scale (Figure 1), 6 precipitating factors (eg painful stool events, behavioural toileting refusal), faecal soiling, and the presence of any red flags that suggest serious organic pathology (Table 1). Successful management of childhood functional constipation in primary care will have a significant positive impact for children and families, and be very rewarding for clinicians. A supportive and long-term outlook to treatment over months is required. Treatment needs to first disimpact hard stool from the bowel, then maintain ongoing soft stools. Soiling can be embarrassing and distressing. This rectal hyposensitivity can lead to involuntary soiling and will persist until chronic stretching is alleviated and prevented from recurring. Over time, the sensation of ‘needing to go’ when the rectum is full diminishes with persistent rectal stretching from chronic stool loading. 5 This faecal retention stretches the lower bowel and rectum. ![]() Stool builds up within the colon and rectum, leading to the absorption of water and, therefore, accumulation of hard faecal matter. 4Ĭonstipation in children is usually functional or idiopathic, and related to behavioural withholding after a painful or unpleasant stool event. ![]() ![]() ‘Functional constipation’ describes constipation that does not have an organic aetiology. Constipation is defined as the infrequent passage of stools (≤2 per week) with associated stool retention, and possible painful bowel actions or overflow faecal incontinence and soiling (encopresis). 1–3 There is a degree of variability in the expected frequency of stools in healthy children however, most children pass stools every two to three days, whereas breastfed babies may only pass stool once a week. Constipation is a common problem in childhood, affecting an estimated 3% of children worldwide and up to 30% in some settings. ![]()
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