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Constipation in Children: Advice for Referrers

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Constipation in childhood can manifest with a variety of symptoms, most commonly:

  • Infrequent passage of stool (fewer than 3 complete stools weekly)
  • Difficulty/pain when passing stool
  • Passage of hard, large stools or hard pellets (rabbit droppings)
  • Stool with-holding behaviours including passage of numerous small stools during day
  • Abdominal discomfort
  • Faecal incontinence
  • Watery stool (as a feature of overflow/faecal impaction)

Idiopathic constipation is described as constipation that cannot be explained by any anatomical or physiological abnormalities.

Red Flags

Red Flag symptoms and signs include:

• Constipation from birth or first weeks of life (possible Hirschsprung’s disease)
• Delay in passage of meconium for more than 48 hours after birth (possible Hirschsprung’s disease)
• Abdominal distension and vomiting (possible surgical cause e.g. intestinal obstruction)
• Family history of Hirschsprung’s or coeliac disease
• Unexplained gross motor delay, leg weakness, abnormal gait (possible problem with spinal cord or neurological abnormality)
• Growth faltering (weight or height)
• Safeguarding issues

Who to Refer

Referrals to the Nurse-led Continence Service will be accepted directly via SCI gateway for children:

  • Aged 18 months – 16 years with functional constipation (without the need to be vetted first by a paediatrician), with parent, carer, child, young person consent
  • Who reside within the boundary area of NHS Greater Glasgow and Clyde
  • Who have no other concerning features or red flags (see below)

Children younger than 18 months, and those with red flag features, should be referred to Medical Paediatrics via SCI Gateway in the first instance for appointment at a medical paediatric clinic.

Information to Include - History

Please include the following points from history in the referral letter:

  • Stool frequency per week (including whether stools are passed overnight)
  • Using Bristol Stool Chart types of stool most commonly passed
  • Length of history of constipation
  • If pain present, description of pain frequency (including whether nocturnal pain is present)
  • Description of growth of child, including recent measurements – is the child thriving, weight faltering, or overweight?
  • Is there blood present on stooling/wiping?
  • Are there any Child Protection concerns?
  • Fluid intake and basic information about diet
  • What medication or other strategies have been tried already

Please include any Red Flag symptoms and signs (see above)

Please include the following points from the clinical examination in the referral letter:

  • Details of general examination of child
  • Abdominal examination – is there distension, are masses palpable, is there pain on palpation?
  • If anal inspection undertaken are fissures or haemorrhoids present?
  • Any abnormalities of the spine – including scoliosis, skin changes/hairy patches, sacral dimple (see pre-referral guidance on Sacral Dimples)
  • Any abnormalities of the gluteal region including asymmetry of the gluteal muscles
Information to Include - Examination

Please include the following points from the clinical examination in the referral letter:

  • Details of general examination of child
  • Abdominal examination – is there distension, are masses palpable, is there pain on palpation?
  • If anal inspection undertaken are fissures or haemorrhoids present?
  • Any abnormalities of the spine – including scoliosis, skin changes/hairy patches, sacral dimple (see pre-referral guidance on Sacral Dimples)
  • Any abnormalities of the gluteal region including asymmetry of the gluteal muscles
Suggestions for Management whilst waiting for an Outpatient Appointment
  • Ensure adequate fluid intake. Approximate volumes per 24 hours by age and sex are:
    • Age 1-2 years: 900mls
    • Age 2-3 years: 1 litre
    • Age 4-8 years: 1.2 litres per day
    • Age 9-13 years:
      • Boys: 1.6 litres
      • Girls 1.5 litres
    • Age over 13 years:
      • Boys: 2 litres
      • Girls: 1.6 litres
  • Encourage healthy diet with 5 portions of fruit/vegetables a day
  • If idiopathic constipation start on a macrogol – paediatric Laxido or paediatric Movicol
  • If child is impacted, with no red flag signs or symptoms, start a disimpaction regimen of macrogol (see parental advice leaflet)
  • Encourage regular toileting, for example after meals
Useful resources for Parents
  • Signpost parents to the ERIC website, and encourage them to read the information and watch the videos
  • Encourage parents to watch the video produced by NHS ‘The Poo Nurses’: thepoonurses.uk
  • Sign post parents to the Bowel and Bladder UK website: https://www.bbuk.org.uk/
  • Ask parents to look at the ‘Bristol Stool Chart’ images available on the internet, and to assess and record the types of stool their child is passing each day
Useful resources for Health Professionals
Editorial Information

Last reviewed: 02 May 2022

Next review: 08 August 2024

Author(s): Sister Ingrid Eckelkamp, Lead of Nurse-led Continence Service Dr Ruth Bland, Medical Paediatric Consultant