Management of constipation in children

For the management of constipation in adults refer to the guidance here.

This guidance has been developed from NICE CG99: Constipation in children and young adults (July 2017) and in collaboration with local specialists.

Treat a child for constipation in primary care only if a working diagnosis of idiopathic constipation has been made and red flags have been excluded.

  • Give information and advice to the child and/or their parents/carers:
    • Reassure that underlying causes of constipation have been excluded by the history and physical examination.
    • Advise that idiopathic constipation is treatable with laxatives, although they may need to be taken for several months.
    • Offer sources of information and support: ERIC – The Children's Bowel and Bladder Charity has a range of resources for patients and/or their parents/carers.
  • Check for faecal impaction and if present, treat using a recommended disimpaction regimen (see below for guidance)
  • Start maintenance laxative drug treatment if impaction is not present or has been successfully treated (see below for guidance)
  • Offer advice on behavioural interventions for children started on maintenance laxative drug treatment. The intervention should be consistent with the child's age and stage of development and may include:
    • Scheduled toileting — encourage the child to try and open their bowels at pre-planned intervals or activities, such as after each meal for five minutes, or before bedtime.
    • Use of a bowel habit diary to track the frequency and consistency of stool. The ERIC Poo Diary and Toileting Reward Chart may be helpful, available here
    • Use of encouragement and rewards systems — such as star charts incorporated into toileting routines, to help praise good behaviour
  • Give diet and lifestyle advice and information on recommended fluid intake, in combination with advice on the early use of laxatives and behavioural interventions.
  • Provide tailored follow-up according to response to treatment, measured by frequency, amount and consistency of stools (use the Bristol Stool Form Scale).
  • When considering specialist referral see: North Devon Referral Guideline: Constipation and faecal incontinence and East Devon Referral Guideline: Constipation and faecal incontinence.

Diet and Lifestyle Advice

Dietary interventions alone should not be used as first-line treatment for idiopathic constipation.

  • Recommend a balanced diet with sufficient fibre (in all children that have been weaned):
    • Foods with a high fibre content include fruit, vegetables, high-fibre bread, baked beans, and wholegrain breakfast cereals.
    • Do not recommend unprocessed bran (which may cause bloating and flatulence and reduces the absorption of micronutrients) or fibre supplements.
  • Do not switch formula feed or start a cows' milk exclusion diet unless advised by specialist services.
  • Advise normal daily physical activity that is tailored to the child or young person's stage of development and ability.
    • Physical activity guidelines are available from the Chief Medical Officer for different age groups which can be found here
  • Encourage children with a poor fluid intake to increase fluids to a recommended level. Approximately three-quarters of the daily fluid requirement in children is obtained from water in drinks. Higher intakes of total water will be required for children who are physically active, exposed to hot environments, or obese. The following is a guide to adequate total water intake per day, including water contained in food. It should not be interpreted as a specific requirement:
    • Infants 0–6 months of age: 700 ml, assumed to be from milk.
    • Babies 7–12 months of age: 800 ml from milk and complementary foods and beverages, of which 600 ml is assumed to be water from drinks.
    • Children 1–3 years of age: 1300 ml (900 ml from drinks).
    • Children 4–8 years of age: 1700 ml (1200 ml from drinks).
    • Children 9–13 years of age:
      • Boys — 2400 ml (1800 ml from drinks).
      • Girls — 2100 ml (1600 ml from drinks).
    • Young people 14–18 years of age:
      • Boys — 3300 ml (2600 ml from drinks).
      • Girls — 2300 ml (1800 ml from drinks)

Faecal Impaction Treatment

See 1.6.2 Stimulant laxatives and 1.6.4 Osmotic laxatives

Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain.

Review children and young people undergoing disimpaction within 1 week.

NICE recommends the use of unflavoured macrogol preparations.

Consider seeking specialist advice or arranging urgent referral if all oral laxative regimens below fail, or the child is very distressed.

NICE recommends that suppositories or enemas should not be used routinely in primary care. However, it should be noted that the specialist paediatric bladder and bowel care team may recommend the use of bisacodyl and lecicarbon C suppositories for use in individual patients.

NICE states that sodium citrate enemas should only be administered if all oral medications for disimpaction have failed.

If faecal impaction has been diagnosed offer:

Cosmocol® Paediatric sachets or Laxido® Paediatric Plain sachets

(Macrogol Compound oral powder)

  • Child 1 – 11 months: ½ -1 sachet daily. (Unlicensed dose)
  • Child 1 – 4 years: 2 sachets on first day, then 4 sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily, total daily dose to be taken over a 12-hour period (Unlicensed dose)
  • Child 5 – 11 years: 4 sachets on the first day, then increased in steps of 2 sachets daily to a maximum of 12 sachets daily.

Notes

  1. Total daily dose to be taken over a 12 hour period
  2. Choose a product appropriate for the age of patient.
  3. Start with the number of sachets appropriate to the age of the child and increase the dose every few days until one or two soft, formed stools are produced each day.
  4. Give adequate fluids to reduce the risk of dehydration.
  5. The use of paediatric macrogol formulations to treat faecal impaction in children younger than 5 years of age is unlicensed.
  6. Doses higher than the maximum licensed dose may often be needed to adequately treat constipation.
  7. Informed consent should be verbally obtained and documented if unlicensed treatments are used.

If this fails to lead to disimpaction after 2 weeks, add a stimulant laxative. If a macrogol is not tolerated, substitute with a stimulant laxative either on its own or, if stools are hard, in combination with lactulose or another stool softener such as docusate:

Senna
  • Child 1 month to 2 years: 3.75mg -15mg syrup once daily
  • Child 2–18 years: 3.75mg–30mg syrup or tablets once daily

Notes

  1. Do not prescribe the 15mg OTC tablets (Senokot Max®) due to higher acquisition cost.
  2. The use of senna syrup to treat faecal impaction in children younger than 2 years of age is unlicensed.
  3. The use of senna tablets to treat faecal impaction in children younger than 6 years of age is unlicensed.

Or

Bisacodyl Tablets
  • Child 4 – 18 years: 5–20mg once daily, adjusted according to response

If stools are hard consider adding:

Lactulose
  • 1 – 11 months: 2.5 mL twice daily, adjusted according to response.
  • 1 – 4 years: 2.5–10 mL twice daily, adjusted according to response
  • 5 – 17 years: 5–20 mL twice daily, adjusted according to response

Or

Docusate sodium
  • Child 6 months – 1 year: 12.5mg 3 times daily (use paediatric oral solution).
  • Child 2 – 11 years: 12.5–25mg 3 times daily (use paediatric oral solution)
  • Child 12 – 17 years: Up to 500mg daily in divided doses

Start maintenance laxative treatment as soon as the bowel is disimpacted.

Maintenance Constipation Treatment

See 1.6.2 Stimulant laxatives and 1.6.4 Osmotic laxatives

Maintenance treatment should be used alongside diet and lifestyle advice (see above).

If impaction is not present or has been treated, start maintenance laxative treatment promptly (even if constipation is reported for only a few days), aiming for regular soft formed stools. Ensure the child has easy access to a toilet.

Cosmocol® Paediatric sachets or Laxido® Paediatric Plain sachets

(Macrogol Compound oral powder)

  • 1 – 11 months: ½ -1 sachet daily. (Unlicensed dose).
  • 2 – 5 years: 1 sachet daily, adjust dose to produce regular soft stool (maximum 4 sachets daily).
  • 6 – 12 years: 2 sachets daily, adjust dose to produce regular soft stool (maximum 4 sachets daily).

Notes

  1. Choose a product appropriate for the age of patient
  2. If the child required disimpaction, the usual maintenance dose is half the disimpaction dose.
  3. Adjust dose according to symptoms and response
  4. If diarrhoea occurs, reduce the dose of laxative(s) as prolonged diarrhoea can cause electrolyte disturbances, including hypokalaemia.
  5. The use of paediatric macrogol preparations to treat chronic constipation in children younger than 2 years of age is unlicensed.
  6. Doses higher than the maximum licensed dose may often be needed to adequately treat constipation.
  7. Informed consent should be verbally obtained and documented if unlicensed treatments are used.

If constipation persists despite optimal doses of the macrogol, add a stimulant laxative. If the macrogol is not tolerated, substitute with a stimulant laxative and, if stools are hard, consider combining with lactulose or another stool softener laxative such as docusate:

Senna
  • Child 1 month to 2 years: 3.75mg -15mg syrup once daily
  • Child 2–18 years: 3.75mg–30mg syrup or tablets once daily

Notes

  1. Do not prescribe the 15mg OTC tablets due to higher acquisition cost

Or

Bisacodyl Tablets
  • Child 4 – 18 years: 5–20mg once daily, adjusted according to response

If stools are hard consider adding:

Lactulose
  • 1 – 11 months: 2.5 mL twice daily, adjusted according to response.
  • 1 - 4 years: 2.5–10 mL twice daily, adjusted according to response
  • 5 - 17 years: 5–20 mL twice daily, adjusted according to response

Or

Docusate sodium
  • Child 6 months–1 year: 12.5mg 3 times daily (use paediatric oral solution).
  • Child 2–11 years: 12.5–25mg 3 times daily (use paediatric oral solution)
  • Child 12-17 years: Up to 500mg daily in divided doses

Continue medication at maintenance dose for several weeks after regular bowel habit is established – this may take several months.

Children who are toilet training should remain on laxatives until toilet training is well established.

Do not stop medication abruptly: gradually reduce the dose over a period of months in response to stool consistency and frequency. Some children may require laxative therapy for several years. A minority may require ongoing laxative therapy.

 

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