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Constipation and Soiling

Constipation and Soiling

  • Common, affecting up to 30% of the child population
  • Majority is idiopathic
  • The exact cause of constipation is not fully understood but factors that may contribute include pain, fever, dehydration, dietary and fluid intake, psychological issues, toilet training, medicines and familial history of constipation
  • It is rarely Hirschsprung’s, Neurological lumbosacral abnormalities, Anorectal malformations, Hypothyroid, Coeliac, Cystic fibrosis, Cow’s milk protein intolerance
  • Bloods tests and imaging are usually not required
  • Soiling/faecal incontinence is commonly due to constipation with impaction
  • It often takes months-years for the condition to be resolved

Who to refer:

  • Any child with red flags -> refer to General Paeds
  • Children < 1 years of age with idiopathic constipation that does not respond to optimum treatment within 4 weeks  -> refer to General Paeds
  • Children and young people with idiopathic constipation that does not respond to initial treatment within 3 months –> refer to health visitor if pre-school child or school nurse
  • Children whose constipation doesn’t improve despite input from health visitor or school

 

Red flags

  • Onset before 4 weeks of life
  • History of failure/delay to pass meconium within 48hrs of birth
  • ‘Ribbon like’ stools
  • Abdominal distension with vomiting
  • Abnormal physical exam – including anal, spinal and lower limb neuromuscular abnormalities
  • Difficulties passing urine
  • Faltering growth
  • Suspicion of abuse

 Key components of the physical examination:

  1. Inspection of the perianal area
  2. Abdominal examination
  3. Spine/Lumbosacral region/gluteal examination
  4. Lower limb neuromuscular examination including tone and strength (reflexes if red flags in hx)

Do not do a PR exam in General Practice.

If the history taking and /or physical examination shows evidence of faltering growth treat for constipation and test for coeliac disease and hypothyroidism.

The Bristol Stool Chart is a good reference source.

 

 

Management:

 

 

 

NB –Please see the NICE Constipation in children and young people: diagnosis and management guideline if needing further information about management using lactulose.

https://www.nice.org.uk/guidance/CG99

 

References:

NICE Constipation in children and young people: diagnosis and management.

Clinical guideline [CG99] Published date: May 2010 Last updated: July 2017

https://www.nice.org.uk/guidance/CG99

 

Review Date                            21/08/20149

Next Review Date                    21/08/2020

Author                                      Dr Rebecca Harling, RMS GP Paediatrics Lead

Contributors                             Dr Matt Thorpe, Consultant Paediatrician, Royal Cornwall Hospital, October 2018

 

 

Version No.  2.1