Constipation – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with constipation in Queensland.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Gastroenterology, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Constipation is a common problem in children with an estimated 1 in 10 children seeking medical attention.  Constipation accounts for approximately 3-5% of all General Paediatric and 25% of all Paediatric Gastroenterology visits.²

A diagnosis of constipation requires a decrease in stool frequency for more than two weeks (i.e. less than three per week in a child over three years of age) AND hard stools which can be painful to pass.¹

The normal frequency of stooling decreases with age from infancy until around three years when the average is one stool per day. A child with infrequent stools that remain soft (as can occur in older breast-fed children) does not have constipation.

Chronic retention of stools in the rectum may result in faecal incontinence due to passive overflow or stool loss during withholding attempts.² The term encopresis is no longer used as it is considered pejorative and implies deliberate faecal soiling.

The majority of children with constipation have no underlying anatomical or physiological abnormality. Functional faecal retention is the diagnosis given to children with constipation and no underlying abnormality.

Assessment

The aim of the assessment (history and clinical examination) is to identify children who have red flags to suggest underlying pathology (to enable appropriate referral). Once organic causes have been excluded, questioning may identify withholding behaviours and possible triggers for withholding.

History

History taking should include specific information on:

• the passage of meconium
• the frequency and consistency of stools and presence of blood (and whether blood is mixed into stools or found on wiping)
• other symptoms including abdominal pain, vomiting, urinary, systemic or extra-intestinal symptoms

In the absence of red flags, questioning should attempt to elicit potential withholding behaviours and possible triggering event for withholding. Abdominal pain as a cause of constipation is a diagnosis of exclusion.

Straining behaviour in the absence of hard and infrequent stools does not represent constipation. ‘Infant dyschezia’ refers to infants crying and straining for several minutes during the passage of soft stools. Infant dyschezia typically resolves as the baby matures.

Functional faecal retention

Functional faecal retention is a likely diagnosis for children who have ALL of the following:

• a history of stools that are less frequent and hard for more than a two-week period
• no red flags to suggest underlying pathology
• a soft non-tender abdomen with or without palpable masses particularly in lower left quadrant

Children with functional faecal retention have normal stooling prior to developing constipation. Onset may be acute (following a trigger event) or gradual. Attempts at withholding are often mistaken by the family for efforts to defecate due to the associated smells, cramping discomfort and “straining”.

Identifying withholding

In some children a “call to stool” can be associated with fear, anxiety, attempted denial and disruptive behaviour. It is important to ask specifically what the child does when the family perceive the child needs to pass a stool.

Possible trigger events for withholding

• toilet training
• disrupted routine e.g. intercurrent illness, travel, arrival of new sibling
• starting day care/kindergarten/school – especially if toilets lack privacy
• acute constipation – a single episode of painful/hard stools for any reason (viral illness) can be enough to begin withholding

Examination

A thorough examination is recommended to identify any red flags suggestive of underlying pathology. Anal fissures in the context of functional constipation are common. Digital rectal examination is not usually required however the anus should be visualised for signs of perianal disease. In the rare case that it is deemed necessary, it should be done on senior emergency/paediatric advice and only once as it can increase psychological distress in children.

Seek senior emergency/paediatric advice if red flag/s are identified on assessment.

Investigations

Management

Refer to flowchart [PDF 311KB] for a summary of the recommended emergency management and medications for a constipated child.

Seek senior emergency/paediatric advice if any red flags are identified on assessment.

Children with suspected underlying pathology will be managed by specialist services.

The management of functional constipation requires stool softeners and behaviour modification to tackle the fear of painful defecation. Treatment should be maintained until the child’s stretched bowel has recovered to a normal calibre (demonstrated by a return to regular bowel habits) and behaviour modification training is complete. Any attempts at toilet training should be ceased until stools are soft and regular. Diet based aperients, such as pears and prunes, can be encouraged but always in conjunction with laxative treatment.

Laxative treatment

Faecal impaction refers to a large faecal mass in either the rectum or abdomen that is unlikely to be passed on demand. If present, laxatives are required to empty the rectum of impacted stool. Once disimpacted, a maintenance dose of laxatives is required to prevent a stool mass forming and getting firmer until the fear of stooling has gone and a reliable bowel habit has been established. The duration of this should equal the time frame that the constipation occurred over,

Polyethylene glycol (PEG 3350) is the preferred laxative. It has been shown to be the safest, most effective and most palatable laxative when compared to traditional laxatives such as lactulose and milk of magnesia. Osmolax is the preferred product for children (age >2 years) as it is flavourless and readily available.^4,5 Movicol products contain electrolytes, potentially making their use safer in very young infants (age >1 month old) and those predisposed to electrolyte imbalance but it has a salty taste which is more difficult to conceal.

Laxatives should only be prescribed for neonates on paediatric advice. Lactulose can be effective in young infants at a dose of 2.5ml twice daily from 1month to 1 year.

Stools should be kept soft and unformed Bristol stool 5-6 on the maintenance dose until regular, painless stools have returned and any psychological impact has been reduced through behaviour modification. Treatment should then be gradually reduced, to ascertain if the bowel has sufficiently recovered. Stools will become firmer as the laxative is withdrawn. However, if the stools become difficult, painful or less frequent than every one to two days, medication should be reinstated at a therapeutic dose, to reduce the incidence of further large hard painful stools. The duration of laxative treatment is usually at least three months and often much longer. Reassure parents that their child will not become dependent on the medication.

The most common cause of treatment failure is stopping the medication too soon or using doses that are too small.⁶ Err on the side of prolonged treatment given the safety of the medication long-term and the emotional impact of relapse.

Rectal medications should not be used for disimpaction unless all oral medication (at adequate treatment dose) have failed and only if the child or young person and their family consent.¹

Behaviour modification and education of family

Education for the child and family is essential to reduce the vicious cycle of fear and frustration and enable a normal functioning bowel.² Many parents are stressed and frustrated, often blaming the child for laziness or carelessness. Successful treatment requires a culture change to one of positive reinforcement. The child should be encouraged to take advantage of the body’s natural gastro-colic reflex post meals by attempting to sit with their feet elevated on a stool for three minutes approximately 15 minutes after breakfast, lunch (or afternoon tea for school children) and dinner. This is referred to as sitting practice and the child should be rewarded in some way for undertaking this, EVEN if they are unable to pass a stool.

A balanced diet including whole grains, fruits and vegetables is recommended for children with constipation. Children are recommended to drink adequate amounts of fluid (1-2L per day as appropriate for age) – there is no evidence for increasing fluid intake further unless the child is dehydrated.

There is limited evidence for increase in fibre intake; whilst fibre adds bulk and water content to soften stool, it can also increase distension of the rectum in children with faecal retention and decrease the urge to defecate.

Sitting practice

• Correct sitting position is important and children may require a child sized seat insert and/or stool under their feet.
• Encourage the child to contract their abdominal muscles while sitting on the toilet e.g. by blowing up a balloon, or blowing a pinwheel.
• Sticker charts with the promise of some small reward if a certain goal is achieved can be useful (however, any reward should be realistic and achievable). Rewards should be for behaviours that are within the child’s control i.e. taking medication and doing sitting practice. Bowel motions and soiling events are not to be rewarded or punished.
• Stool diaries and resources such as the Bristol Stool Chart can help the child and family monitor progress. This can also be brought to any future reviews for the health professional to assess the success of treatment.

Escalation and advice outside of ED

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.

Inter-hospital transfers

Disposition

Most children with constipation will be safe to discharge home.

On discharge, parent/carers should be provided with the following:

• Treatment plan
• Constipation factsheet
• Conquering poo handout (PDF)

Follow-up

Children with no suspected underlying pathology should be reviewed by their GP in three to five days if given disimpaction dose, otherwise in seven to ten days.

Referral to local Paediatric service is recommended for children who appear to have treatment failure after six months of adequate treatment. Instruct the family to continue with laxatives during this time.

Persistent or medication-resistant constipation can occur as a result of cow’s milk protein intolerance. Consider a one-month trial of strict dairy free diet in children over 12 months of age while awaiting a specialist appointment. This diet requires calcium supplementation and two protein containing meals daily and should be supervised by a dietician or GP to ensure nutritional safety. A bowel diary of before, during and after the diet is recommended to objectively document the response. Exclusion should be trialled for 4 weeks and then reintroduced to show efficacy⁷.

Related documents

Guidelines

• NICE Guideline May 2010: Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care
• Guidelines for the Evaluation and Treatment of Constipation in Children. Children’s Health Services 2011 (PDF) (access via QH intranet)

Forms and factsheets

• Treatment plan
• Constipation factsheet
• Conquering poo handout (PDF)