Key priorities for implementation

Key priorities for implementation

History-taking and physical examination

  • Establish during history-taking whether the child or young person has constipation. Two or more findings from table 1 indicate constipation.

  • If the child or young person has constipation, take a history using table 2 to establish a positive diagnosis of idiopathic constipation by excluding underlying causes. If a child or young person has any 'red flag' symptoms, do not treat them for constipation. Instead, refer them urgently to a healthcare professional with experience in the specific aspect of child health that is causing concern.

  • Do a physical examination. Use table 3 to establish a positive diagnosis of idiopathic constipation by excluding underlying causes. If a child or young person has any 'red flag' symptoms do not treat them for constipation. Instead, refer them urgently to a healthcare professional with experience in the specific aspect of child health that is causing concern.

  • Inform the child or young person and his or her parents or carers of a positive diagnosis of idiopathic constipation and also that underlying causes have been excluded by the history and/or physical examination. Reassure them that there is a suitable treatment for idiopathic constipation but that it may take several months for the condition to be resolved.

Digital rectal examination

  • Do not perform a digital rectal examination in children or young people older than 1 year with a 'red flag' (see tables 2 and 3) in the history-taking and/or physical examination that might indicate an underlying disorder. Instead, refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung's disease.

Disimpaction

  • Assess all children and young people with idiopathic constipation for faecal impaction, including children and young people who were originally referred to the relevant services because of 'red flags' but in whom there were no significant findings following further investigations (see tables 2 and 3). Use a combination of history-taking and physical examination to diagnose faecal impaction – look for overflow soiling and/or faecal mass palpable abdominally and/or rectally if indicated.

  • Offer the following oral medication regimen for disimpaction if indicated:

    • Polyethylene glycol 3350 + electrolytes, using an escalating dose regimen (see table 4), as the first-line treatment[1].

    • Adjust the dose of polyethylene glycol 3350 + electrolytes according to symptoms and response. As a guide for children and young people who have had disimpaction, the starting maintenance dose might be half the disimpaction dose (see table 4).

    • Add a stimulant laxative (see table 4) if polyethylene glycol 3350 + electrolytes does not work.

    • Substitute a stimulant laxative if polyethylene glycol 3350 + electrolytes is not tolerated by the child or young person. Add another laxative such as lactulose or docusate (see table 4) if stools are hard.

    • 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 and young people may require laxative therapy for several years. A minority may require ongoing laxative therapy.

Diet and lifestyle

  • Do not use dietary interventions alone as first-line treatment for idiopathic constipation.

  • Treat constipation with laxatives and a combination of:

    • Negotiated and non-punitive behavioural interventions suited to the child or young person's stage of development. These could include scheduled toileting and support to establish a regular bowel habit, maintenance and discussion of a bowel diary, information on constipation, and use of encouragement and rewards systems.

    • Dietary modifications to ensure a balanced diet and sufficient fluids are consumed.

Information and support

  • Offer children and young people with idiopathic constipation and their families a point of contact with specialist healthcare professionals, including school nurses, who can give ongoing support.



[1] At the time of publication (May 2010), Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that includes electrolytes. It does not have UK marketing authorisation for use in faecal impaction in children under 5 years, or for chronic constipation in children under 2 years. Informed consent should be obtained and documented. Movicol Paediatric Plain is the only macrogol licensed for children under 12 years that is also unflavoured.

  • National Institute for Health and Care Excellence (NICE)