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Primary care management and referral guideline Primary care management and referral guideline

Constipation in Children – Management and referral guideline

Red flags

  • Intestinal obstruction
  • Delayed passage of meconium, or constipation in the first weeks of life
  • Neurological deficit
  • Anal malformation
  • Inflammatory bowel disease (IBD)

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

Constipation is the difficult passage of infrequent, hard stools. It is a common problem, occurring in up to 30% of children.

The normal frequency of bowel movements varies between children and with age.

  • Breastfed babies may pass stool after every feed or as little as every 7 to 10 days.
  • Bottle‑fed babies and children aged > 1 year will usually defecate at least every 2 days.

Mild constipation may follow weaning from breast milk to formula, or introduction of solids. Straining or crying before passing soft stool can be normal in infants and is not constipation.

Constipation in children is usually functional i.e., there is no underlying organic cause. It is a risk factor for UTIs, enuresis, faecal incontinence and recurrent abdominal pain. Successful treatment requires education, a good bowel regime, and adequate dose and duration of laxatives.

Organic causes of constipation are uncommon.

  • Constipation has been proposed as a symptom of cow’s milk protein intolerance, but this is controversial.
  • Rare causes include Hirschsprung’s disease, slow colonic transit, coeliac disease, hypothyroidism, hypercalcemia, and spinal cord problems.

Assessment

Take an age appropriate history and check:

  • timeline.

    Timeline

    • Duration of problem
    • Onset:
      • Neonatal constipation – suspicious for Hirschprung’s disease (HD)
      • Onset after illness (e.g., gastroenteritis) or period of dehydration (e.g., hot weather) leading to hard stool, pain, then voluntary withholding
      • History of fearful event e.g., scared by toilet flushing
  • stool patterns and stooling behaviour.

    Stool patterns and stooling behaviour

    • Stool pattern – frequency, consistency, size of stools (see Bristol Stool Chart), any pain or bleeding, soiling underwear
    • ‘Ribbon’ stools – suggest anal stenosis
    • Stooling behaviour – awareness of need to go, straining, withholding behaviours (e.g., unusual body positioning like squatting and straining), toilet refusal, soiling
  • associated symptoms.

    Associated symptoms

    • Rectal bleeding – investigate further if no fissures
    • Enuresis or urinary incontinence
    • UTIs
  • personal and family history.

    Personal and family history

    • Treatments already tried
    • Medical history, including neonatal – confirm newborn screen negative, passage of meconium (within 48 hours of birth)
    • Medications, especially iron supplements, antihistamines, ADHD drugs, proton pump inhibitors
    • Family history of coeliac disease
  • other factors.

    Other factors

    • Lifestyle factors – range of foods eaten, dairy and fluid intake, physical activity
    • Social factors – toilet training, change in family dynamics or routine, especially starting school

Examine the patient and check:

  • height, weight, and head circumference. Plot in the appropriate growth chart – consider poor growth if drops across percentile lines or below third percentile.
  • for mouth ulcers.
  • abdomen for distension, tenderness, palpable faeces or masses, or organomegaly – distention and palpable stool in the distal colon may suggest faecal impaction.

    Faecal impaction

    • Occurs when there has been no adequate bowel movement for several days or weeks, and a large, compacted mass of faeces builds up in the rectum and/or colon which cannot be easily passed by the child.
    • Symptoms include failing to pass a stool for several days, followed by a large often painful or distressing bowel motion. Between bowel movements children with faecal impaction often soil their underclothes.
  • spine and lower limb – perform neurological examination.

    Spine and lower limb examination

    • Midline skin defects in the lumbosacral area e.g., dimples, hair tufts, haemangiomas, lipomas or abnormal gluteal clefts suggest underlying spinal abnormality, especially if located proximal to the sacrococcygeal area – request imaging with ultrasound or MRI.
    • Look for evidence suggesting a primary neurological problem – muscle wasting, hypotonia, weakness, abnormal reflexes (including absent anal or cremasteric reflexes), bladder distension.
  • perianal area for anal malposition, fissures, skin tags, signs of perianal infection (streptococcal), or patulous anus – follow recommended protocol and consider a chaperone.

    Recommended protocol

    • Only perform a genital examination if there is a specific and clear clinical indication.
    • Always seek voluntary consent from the parent or guardian, and the child or young person.
      • Explain the purpose of the examination and only proceed if the child or young person consents. Do not proceed if the child refuses to cooperate.
      • Consider capacity to consent of patients who are physically, mentally, or intellectually impaired, and those of culturally or linguistically diverse background (amongst others).
    • Always consider:
      • the presence of a chaperone in the room. Adolescents are entitled to decline this, and the doctor may decline conducting the examination if a chaperone is declined by the patient.
      • needs of infants and younger children – allow the parent or guardian to remain close to the child or hold the child on their lap during the examination.
      • needs of older children and adolescents – allow them to undress or dress in private and wear a gown for the examination.
      • the patient’s specific needs, e.g. if disabled or of culturally or linguistically diverse background.
    • If relevant, discuss and explain limits of confidentiality with adolescents.

Rectal examination usually not necessary in general practice.

Consider differential diagnosis:

  • Functional gastrointestinal disorders:
    • Functional constipation (most common – 95% of cases)
      Functional constipation

      • Functional constipation is defined by the Rome IV criteria as the occurrence of ≥ 2 of the following for at least 1 month, where criteria not met for irritable bowel syndrome (IBS) and the symptoms cannot be explained by another medical condition:
        • ≤ 2 bowel motions per week in a child aged ≥ 4 years
        • Retentive posturing and withholding behaviour
        • Painful or hard defecation
        • Large diameter stools
        • Large faecal mass in the rectum
        • ≥ 1 episode per week of soiling or incontinence
      • Children with functional constipation are generally well, thriving, fit and active, and with a normal physical examination.
    • Irritable bowel syndrome (IBS)
      Irritable bowel syndrome (IBS)

      • Suspect if associated abdominal pain or discomfort relieved with passage of stool or gas and normal physical examination and investigations – see Rome IV criteria.
      • Children with IBS are generally well, thriving, fit and active, and with a normal physical examination.
      • IBS tends to involve older children and adolescents, whereas constipation is more common in the preschool age group.

      See Irritable Bowel Syndrome (IBS) in Children and Adolescents

  • Organic causes (uncommon):
    • Medical causes
      Medical causes

      • Cow’s milk protein intolerance
      • Coeliac disease
      • Hypothyroidism
      • Hypercalcaemia
      • Inflammatory bowel disease (IBD) (constipation is a rare presentation) – suspect if associated extraintestinal features (i.e., recurrent mouth ulcers, joint symptoms, recurrent fevers, rashes), weight loss, short stature, delayed puberty, perianal disease
    • Surgical causes
      Surgical causes

      • Hirschsprung’s disease – usually causes failure to pass meconium in first 24 hours of life, but can present in the first 2 years
      • Anatomical abnormalities of anus
      • Abdominal mass – tumour
      • Meconium ileus – consider cystic fibrosis
      • Spinal dysraphism

Arrange investigations:

  • Consider targeted investigations if an organic cause is suspected.
    Targeted investigations
    These should be guided by clinical findings and may include serum calcium (hypercalcaemia), coeliac serology, TSH (hypothyroidism), FBC, and ferritin (excessive cow’s milk consumption often results in iron deficiency).
  • Consider abdominal X-ray to differentiate encopresis (e.g., overflow) from diarrhoea, or if unable to adequately examine the patient.

Management

Discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate if:

  • neonate not passing stools.
  • intestinal obstruction suspected e.g., abdominal distension and vomiting, especially if bilious.
  • faecal impaction and patient not well for outpatient management e.g., reduced oral intake due to abdominal distension and therefore inability to drink movicol or osmolax.

Urgently discuss with your local paediatric team if:

  • constipation in the first weeks of life e.g., delayed meconium.
  • motor delay or neurological deficit (e.g., lower limbs, patulous anus, primary enuresis), or suspected spinal cord problem.
  • suspected or confirmed anal malformation e.g., ribbon‑like stools.

Consider referring to your local General Paediatrics service if constipation secondary to a medical cause, or manage appropriately:

If patient with severe constipation or suspected faecal impaction (abdominal distension, faecal mass on palpation, decreased appetite with constipation), organic causes excluded, and patient stable, consider outpatient disimpaction therapy. If disimpaction fails, discuss immediately with your local paediatric team on call and consider transfer to your nearest ED as appropriate for inpatient management.

Disimpaction therapy

  • Start clean out using doses indicated below, and review in 2 to 4 days.
    • The number of sachets or scoops to be taken daily for disimpaction are listed below. They can be mixed in liquid and kept in the fridge to be taken across the day.
    • Use the table as a guide only. Some children may not require such large amounts for disimpaction. Titrate up until watery stools, then continue at the effective amount for another 5 to 7 days for effective disimpaction.
  • Advise parents to seek immediate medical advice if child worsens.
  • Consider clean out successful when reasonable volume of faeces or faecaloma and palpable faecal mass eliminated.
  • Move to maintenance phase as soon as clean out is successful.
Number of Movicol (full strength) sachets per day*
Age Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 to 6 years 1 2 2 3 3 4 4
6 to 12 years 2 3 4 5 6 6 6
12+ years 8 8 8

*Double the dose if using Movicol Junior or Half sachets

Number of OsmoLax small scoops (8.5 g) per day
Age Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 to 6 years 2 3 3 4 5 6 6
6 to 12 years 3 4 6 8 9 9 9

Adapted from: Royal Children’s Hospital Melbourne – Clinical Practice Guidelines: Constipation

If functional constipation:

  • educate parent and child – explain constipation.
    Explain constipation

    • Reassure that there is no organic problem, and that treatment is available.
    • Explain that developing a normal bowel habit may take many months.
      • May take 6 to 12 months in some children with severe functional constipation.
      • May get better and then worse throughout course of treatment
      • Most common cause of recurrence or treatment failure is stopping laxative treatment prematurely.
    • Provide written information.
  • recommend healthy eating. Ensure adequate intake of fluid and fibre, as well as regular exercise.
    Intake of fluid

    • Recommend that children should drink at each mealtime, with extra drinks during play and in hot weather.
    • Review Australian (NHMRC) recommendations.
      Australian (NHMRC) recommendations

      Age Recommended water intake in litres/day

      (fluid sources only, does not include water from foods)

      0 to 6 months 0.7 (breast milk or formula)
      7 to 12 months 0.6
      1 to 3 years 1
      4 to 8 years 1.2
      9 to 13 years 1.4 (girls) to 1.6 (boys)
      14 to 18 years 1.6 (girls) to 1.9 (boys)
    • There is no evidence to support the use of extra fibre supplements, extra fluid intake, or pre- or probiotics in functional constipation.
  • encourage establishing regular toileting.
    Regular toileting

    • Encourage sitting on the toilet for 5 to 10 minutes after meals to take advantage of the gastrocolic reflex.
    • Make the toilet a safe and interesting place to be e.g., posters, smartphone games.
    • Make sure the child is comfortable on the toilet e.g., inner seat, stool to rest feet on to ensure knees are higher than hips.
    • Encourage the child to lean forward and rest their elbows on their knees.
    • Keep a toileting diary to monitor progress.
    • Use a star chart to reward sitting on the toilet, even if the child doesn’t pass a stool. Do not punish child for soiling.
    • Provide printable patient information.
  • initiate and maintain laxatives or stool softeners.
    Laxatives or stool softeners

    • Ensure regular dosing until stools have the consistency of wet cement.
    • Aim for a daily soft stool (or minimum 3 per week) without abdominal pain, straining, or soiling.
    • Adequate doses achieve quicker results and improve adherence to the regime.
    • Reassure parents that dependence does not develop.
    • Start Movicol, OsmoLax, or ClearLax according to the table below.
      • Titrate up or down to ensure 1 to 2 soft bowel actions per day (don’t change doses more frequently than every 3 to 4 days).
      • If aged < 12 months, give Actilax (lactulose) 5 mL per day.
      • If unsuccessful, consider outpatient disimpaction therapy.
        Disimpaction therapy

        • Start clean out using doses indicated below, and review in 2 to 4 days.
          • The number of sachets or scoops to be taken daily for disimpaction are listed below. They can be mixed in liquid and kept in the fridge to be taken across the day.
          • Use the table as a guide only. Some children may not require such large amounts for disimpaction. Titrate up until watery stools, then continue at the effective amount for another 5 to 7 days for effective disimpaction.
        • Advise parents to seek immediate medical advice if child worsens.
        • Consider clean out successful when reasonable volume of faeces or faecaloma and palpable faecal mass eliminated.
        • Move to maintenance phase as soon as clean out is successful.
        Number of Movicol (full strength) sachets per day*
        Age Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
        1 to 6 years 1 2 2 3 3 4 4
        6 to 12 years 2 3 4 5 6 6 6
        12+ years 8 8 8

        *Double the dose if using Movicol Junior or Half sachets

        Number of OsmoLax small scoops (8.5 g) per day
        Age Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
        1 to 6 years 2 3 3 4 5 6 6
        6 to 12 years 3 4 6 8 9 9 9

        Adapted from: Royal Children’s Hospital Melbourne – Clinical Practice Guidelines: Constipation

    Medication Dosage Practical advice
    Movicil
    (macrogol 3350 + electrolytes)
    Movicol-Half or Movicol Junior:

    • Aged 1 to 6 years – 1 sachet (up to 4 per day)
    • Aged 6 to 12 years – 2 sachets (up to 4 per day)

    Movicol (full strength):

    • Aged > 12 years – 1 to 4 sachets per day
    • Movicol (full strength) 13 g available in lemon-lime, chocolate, or flavour‑free.
    • Movicol-Half 6.9 g (lemon‑lime).
    • Movicol Junior 6.9 g (flavour‑free).
    • Dissolve full strength sachet in half cup liquid (quarter cup for half‑strength or Junior sachet), more palatable if cold.
    • May cause cramps or diarrhoea.
    • PBS listed, authority not required.
    OsmoLax ClearLax
    (macrogol 3350)
    Starting doses:

    • Aged 2 to 6 years – 1 small scoop per day
    • Aged 6 to 12 years – 1 large scoop per day
    • Aged > 12 years – 1 to 2 large scoops per day
    • Tin with double ended scoop – large (17 g) and small (8.5 g).
    • Mix 17 g scoop with 1 cup of hot or cold liquid (half cup for 8.5 g scoop).
    • Same active ingredient as Movicol without electrolytes (no salty taste).
    • May cause cramps or diarrhoea.
    • PBS listed, authority not required.
    Actilax
    • Aged 1 to 12 months – 3 to 5 mL per day
    • Aged 1 to 5 years – 5 to 10 mL per day
    • Aged 5 to 14 years – 10 to 40 mL per day
    • Split larger doses twice daily.
    • Can mix with water, milk or juice. Can cause bloating or abdominal discomfort.

    Adapted from: Royal Children’s Hospital Melbourne – Clinical Practice Guidelines: Constipation

    • Maintenance is usually required – continue for at least 6 months. Some children need a small dose of laxative for prolonged periods e.g., > 12 months.
    • Reduce maintenance therapy gradually to avoid rebound constipation.
    • Avoid rectal therapy (e.g., suppositories, enemas) as it may increase anxiety around toileting.

Treat anal fissures if present.

Anal fissures

  • The main treatment is to soften the stools consistently for at least 6 weeks to allow the fissure to heal.
  • Barrier creams (e.g., Vaseline) can be used for comfort.

Arrange regular follow up.

Follow up

  • Ask parents to keep a toileting diary and review every 1 to 2 weeks for the first month to monitor progress and adjust medication as needed.
  • Aim for soft‑cement‑consistency stools – if watery, consider too much laxative (unless disimpacting) and titrate down.
  • If stooling not regular after 2 months, discuss with your local paediatric team.
  • If improving:
    • Review monthly, aiming to wean medication when the child has been regularly and effortlessly passing soft‑formed stools for several months.
    • Gradually wean laxatives rather than stopping suddenly, and promptly restart on signs of relapse.

If any other concerns, discuss with your local paediatric team.

When to refer

  • Discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate if:
    • neonate not passing stools.
    • intestinal obstruction suspected (e.g., abdominal distension and vomiting).
    • faecal impaction and patient not well for outpatient management.
  • Discuss immediately with your local paediatric team if:
    • constipation in the first weeks of life e.g., delayed meconium.
    • motor delay or neurological deficit in lower limbs.
    • suspected or confirmed anal malformation e.g., ribbon‑like stools.
  • If constipation secondary to a medical cause, consider referring to your local General Paediatrics service
  • Discuss with your local paediatric team and consider transfer to your nearest ED if outpatient disimpaction therapy fails.
  • Discuss with your local paediatric team if:
    • patient not improving after 2 months of adequate laxative therapy and lifestyle interventions.
    • any other concerns.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging
    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

Check the minimum referral criteria and insert the required information into referral.

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 30/06/2018 Review date 1/07/2021

Disclaimer

Referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.
Our referral guidelines aim to help GPs decide which tests and treatments are appropriate for their patients based on their presenting symptoms and previous medical history. Consulting the relevant referral guideline before a patient is referred on to a specialist service may mean that an appointment can be booked sooner and the outcome of their consultation is more conclusive. It can also eliminate the need to refer a patient where preliminary tests rule out the need for specialist intervention.
The information contained within our referral guidelines has been developed in collaboration with specialist medical professionals. They are intended to support referring GPs and are in no way intended to replace their professional medical judgement.

Resources

For health professionals
Further information

For families

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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