Constipation

Disclaimer These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Introduction

Constipation is defined as an infrequency or difficulty in passing stools that has been present for >2 weeks ^1,2. It is a common paediatric problem affecting up to 30% of school-aged children ^{1, 2, 3}.

Symptoms are variable and can include:

• Infrequent bowel activity
• Hard, painful stools
• Foul smelling wind and stools
• Abdominal pain and distention

Treatment of constipation is outlined in Table 2: ‘Maintenance Treatment Regime’.

Prolonged painful defecation can lead to withholding behaviours which result in a cycle of constipation and faecal soiling ^{1, 2}. This can lead to faecal impaction which will require treatment with a disimpaction regime followed by maintenance treatment (See Table 1: ‘Disimpaction Treatment Regime’ and Table 2: ‘Maintenance Treatment Regime’).

The aim of treatment is to produce a daily soft, painless stool, but parents need to be reassured that this takes time and if treatment stops too soon, constipation can often recur ^{2, 4, 5}. Parents also need to be reassured that the treatment medication is not addictive.²

Pre-referral investigations

• History taking
  • stool frequency and consistency (see Bristol stool chart in the ‘useful resources’ section at the end of this document)
• Physical examination
• Exclude underlying causes. Concerning features include:
  • Failure to have passed meconium in the first 48 hours of life (Hirschsprung’s disease) ¹
  • Gross abdominal distention with abdominal tenderness
  • Skin changes over the lumbosacral region¹
  • Abnormal neurology in lower limbs¹
• Routine digital rectal examination is not advised.¹
• Abdominal x-rays are not indicated.

Pre-referral management

• Medication
  • Constipation only, see Table 2: ‘Maintenance Treatment Regime’
  • Faecal impaction, see Table 1: ‘Disimpaction Treatment Regime’ and Table 2: ‘Maintenance Treatment Regime’
• Education for patients and parents on adherence and expected duration of treatment and encouragement to foster a positive, supportive attitude with treatment
• Use of a bowel/stool diary for tracking
• A healthy diet with enough fibre (see useful resources section at the end of this document).
• Adequate fluid intake:
  • 4-6 cups fluid for younger children
  • Older children need 6-8 cups of fluid per day
  • Limit milk to 600mL/day.
• Regular toileting after meals:
  • Children should be encouraged to sit on the toilet for 3-5 minutes, 15 minutes after each main meal as this is when the bowel is most active
• Sitting position (see useful resources section at the end of this document):
  • Support feet on a footstool and ensure knees are higher than hips
  • Knees apart, back straight.
• Do not pressure the child to pass a stool, the child needs to feel relaxed
• Use of a sticker or reward chart can help some children ^{2, 4}
• Encourage regular physical activity.

Disimpaction

Parents need to be supported to understand that it may take 3-5 days before defaecation occurs and that the first bowel action the child passes may be a large hard mass, or a brown fluid that appears like diarrhoea. They also need to understand that this initial motion is just emptying of the rectum and it will take several days until all the faeces is passed and the child’s bowel can start to recover.

Enemas (e.g. Microlax®) or suppositories (e.g. glycerin) are rarely required and should only be considered in children with acute severe pain/distress related to faecal impaction.

Table 1: Disimpaction treatment regime ⁷

Medication: Movicol Junior® (macrogol 3350 6.563g per sachet) ⁷

Route: Oral

Stop once disimpaction occurs, then consider a maintenance treatment regime.

*Note that PCH use Movicol® and adjust dosages according to age, however for children <12 years this is considered off licence use, therefore for the purposes of this PRG, Movicol Junior® is recommended for children <12 years.

Age	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7	Days 8 to 14
1 - 12 months	1/2 - 1 sachet	1/2 - 1 sachet	1/2 - 1 sachet	1/2 - 1 sachet	1/2 - 1 sachet	1/2 - 1 sachet	1/2 - 1 sachet	Continue with day 7 dose until disimpaction occurs
1 - 6 years	2 sachets	4 sachets	4 sachets	6 sachets	6 sachets	8 sachets	8 sachets
6 - 12 years	4 sachets	6 sachets	8 sachets	10 sachets	12 sachets	12 sachets	12 sachets

Medication: Movicol® (macrogol 13.125g per sachet) ^7,8

Route: Oral

Stop once disimpaction occurs, then consider a maintenance treatment regime.

Age	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7	Days 8 to 14
12 - 18 years	8 sachets	8 sachets	8 sachets	Take 8 sachets within 6 hours for up to 3 days				Continue with day 7 dose until disimpaction occurs

*Cardiovascular disease: do not exceed >2 sachets an hour of Movicol®

• Add a stimulant laxative after 2 weeks if disimpaction has not been achieved.^1,2
• A child may require treatment to maintain soft stools for many weeks or months. This is not a quick fix. If treatment is stopped and constipation reoccurs, start the medication again and review in 3 months.

Constipation

Table 2: Maintenance treatment regime (all oral doses) ^{6, 7, 8}

First line treatment

Children < 2 years; stool softener and/or osmotic laxative

Children > 2 years; osmotic laxative. If treatment does not induce regular stooling after 2-3 months, consider adding a stimulant laxative⁸

Stool softeners

Poloxamer 10% oral liquid (Coloxyl® drops)

• < 6 months, oral 0.3mL three times a day
• 6-18 months, oral 0.5mL three times a day
• 18-36 months, oral, 0.8mL three times a day ⁷
  

Paraffin 50% emulsion (Parachoc®)

• 1-6 years, oral initially 10-15mL daily
• 6-12 years, oral initially 20mL daily
• >12 years, oral initially 40mL daily
• Adjust the dose by 5mL to produce 1 soft bowel motion every 1-2 days without paraffin leakage ⁷

Osmotic laxatives

Lactulose 0.67g/mL oral liquid (Dulose®)

The following are initial doses; adjust according to response.

• 1–12 months, oral 2.5 mL twice daily
• 1–5 years, oral 2.5–10 mL twice daily
• 5–18 years, oral 5–20 mL twice daily
• Up to 1.5 mL/kg twice daily may be needed. Daily maximum is 60mL⁷

Polyethylene glycol with electrolytes (Movicol® presentations)

Movicol -Half®, Movicol Junior® (macrogol 3350 6.563g per sachet)

• 1–12 months, oral, initially half to 1 sachet daily
• 1–6 years, oral, initially 1 sachet daily (maximum 4 sachets daily)
• 6–12 years, oral, initially 2 sachets daily (maximum 4 sachets daily)

Movicol® (macrogol 3350 13.125g per sachet)

• 12–18 years, oral, initially 1 sachet daily (maximum 3 sachets daily) ⁷

Polyethylene glycol (no electrolytes) (Osmolax®)

Measure powder using double-ended 8.5g and 17g scoop provided.

• Each level 8.5g scoop should be mixed with approximately 120mL liquid.
• Each level 17g scoop should be mixed with approximately 240mL of liquid ¹¹

2- 6 years, oral 8.5g once daily. Maximum 17g daily

6-12 years, oral 17g once daily; maximum 25.5g daily

12-18 years, oral 17g once daily; maximum 34g daily ⁷

Stimulant laxatives

Senna / Senokot® tablets

2 – 6 years, oral 3.75 – 7.5 mg at bedtime

6 –12 years, oral 7.5 – 15 mg at bedtime

12-18 years, oral 7.5-30mg at bedtime.⁷

Sodium picosulfate7.5mg/mL oral drops (Dulcolax®)

4 -10 years: 5 -10 drops once daily at night

>10 years: 10 - 20 drops once daily at night⁸

Enemas and suppositories

Enemas (e.g. Microlax®) or suppositories (e.g. glycerin) are rarely required and should only be considered in children with acute severe pain/distress related to faecal impaction. ⁷

When to refer

• Severe constipation resistant to above management approach or children requiring further investigation for concerning associated symptoms, such as failure to thrive.^1,2
• Children with soiling that is prolonged, resistant to treatment and impacting on day to day functioning will likely require multidisciplinary approach to management, with the support of psychological services.^1,2,4
• Severe constipation (>6 months) and not responding to treatment. ¹⁰
• Constipation with soiling/wetting
• If impacting on day-to-day functioning, patient will likely require a multidisciplinary approach with the support of psychological services. ^{1, 2, 4}
• Faltering growth
• Severe constipation resistant to above management approach or children requiring further investigation for concerning associated symptoms, such as failure to thrive. ^1,2

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service
• Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals go to the PCH Referral Office.

References

1. NICE Clinical guideline: Constipation in Children and Young People CG99 National Institute for Health and Clinical Excellence; 2010. Available from: Overview | Constipation in children and young people: diagnosis and management | Guidance | NICE
2. Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology HaN. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology and Nutrition 2006; 43 (3)e 1-13
3. Van Den Berg M, Benninga MA & Di Lorenzo C. Epidemiology of childhood constipation: A systematic review. American Journal of Gastroenterology 2006;101(10) 2401-9
4. van Dijk M, Bongers ME, de Vries GJ et al. Behavioural therapy for childhood constipation: a randomised controlled trial. Pediatrics 2008; 121: (5)e 1334-e1341.
5. Candy DC, Edwards D and Geraint M. Treatment of faecal impaction with polyethelene glycol plus electrolytes (PGE +E) followed by a double –blind comparison of PEG + E versus lactulose as maintenance therapy. Journal of Pediatric gastroenterology and Nutrition 2006; 43: (!) 65-70
6. Gordon M, Naidoo K, Akobeng AK, Thomas AG. Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD009118. DOI: 10.1002/14651858.CD009118.pub2.
7. AMH Children's Dosing Companion (CDC): Australian Medicines Handbook Pty Ltd 2013. Available from: https://childrens-amh-net-au.pklibresources.health.wa.gov.au/index.html
8. Gastrointestinal Expert Group. Therapeutic guidelines: Gastrointestinal. Version 5. Melbourne: Therapeutic Guidelines Limited; 2011.
9. Nurko S, Youssef NN Sabri M et al. PEG 3350 in the treatment of childhood constipation: a multicentre, double blinded, placebo-controlled trial. Journal of Pediatrics 2008; 153 (@) 254-61.
10. The Royal Children’s Hospital Melbourne. Constipation [Internet]. Parkville VIC: The Royal Children’s Hospital Melbourne; 2020 Mar [cited 2021 Dec 8]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Constipation_Guideline/
11. MIMS Online [Internet]. Sydney: MIMS Australia; c2022. Osmolax [cited 2022 Jan 12]; 2. Available from: https://www-mimsonline-com-au.pklibresources.health.wa.gov.au/Search/FullPI.aspx?ModuleName=Product%20Info&searchKeyword=osmolax&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=86760001_2#an-DosageAdministration8449

Reviewer/Team:	Dr Andrew Martin, Kerry Murphy, Continence CNC, Charlotte Allen DGP, CNS, Suret Nel, Suzanne Ford and Jessica Cole (Pharmacy Department)	Last reviewed:	Nov 2021
		Next review date:	Nov 2024
Endorsed by:	Department of General Paediatrics	Date:	Mar 2022

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