Constipation in children and young people: diagnosis and management

This guideline covers diagnosing and managing constipation in children and young people up to 18. It provides strategies to support the early identification and timely, effective treatment of constipation which will help improve outcomes for patients. It does not cover constipation caused by a specific condition.

# Introduction
Constipation is common in childhood. It is prevalent in around 5% to 30% of the child population, depending on the criteria used for diagnosis. Symptoms become chronic in more than one third of patients and constipation is a common reason for referral to secondary care. Morbidity may be under-reported because people may not seek advice because they are embarrassed.
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. Constipation is referred to as 'idiopathic' if it cannot be explained by anatomical or physiological abnormalities.
Many people don't recognise the signs and symptoms of constipation and few relate the presence of soiling to constipation. The signs and symptoms of childhood idiopathic constipation include: infrequent bowel activity, foul smelling wind and stools, excessive flatulence, irregular stool texture, passing occasional enormous stools or frequent small pellets, withholding or straining to stop passage of stools, soiling or overflow, abdominal pain, distension or discomfort, poor appetite, lack of energy, an unhappy, angry or irritable mood and general malaise.
Painful defecation is an important factor in constipation but it is not always recognised; withholding behaviours to prevent passage of painful stools are often confused with straining to pass stools. Families may delay seeking help for fear of a negative response from healthcare professionals. It has been suggested that some healthcare professionals underestimate the impact of constipation on the child or young person and their family. This may contribute to the poor clinical outcomes often seen in children and young people with constipation.
Soiling is debilitating but rarely life threatening so it might be expected to have little impact on healthcare provision. But many children and young people experience social, psychological and educational consequences that require prolonged support.
Some children and young people with physical disabilities, such as cerebral palsy, are more prone to idiopathic constipation as a result of impaired mobility. Children and young people with Down's syndrome or autism are also more prone to the condition. It is important that assessment and ongoing management for these children and young people happen in the same way as is recommended for all children and young people.
Without early diagnosis and treatment, an acute episode of constipation can lead to anal fissure and become chronic. By the time the child or young person is seen they may be in a vicious cycle. Children and young people and their families are often given conflicting advice and practice is inconsistent, making treatment potentially less effective and frustrating for all concerned. Early identification of constipation and effective treatment can improve outcomes for children and young people. This guideline provides strategies based on the best available evidence to support early identification, positive diagnosis and timely, effective management. Implementation of this guideline will provide a consistent, coordinated approach and will improve outcomes for children and young people.# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

# 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.
Key components
Potential findings in a child younger than 1 year
Potential findings in a child/young person older than 1 year
Stool patterns
Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale  appendix B) (this does not apply to exclusively breastfed babies after 6 weeks of age)
Hard large stool
'Rabbit droppings' (type 1, see Bristol Stool Form Scale  appendix B)
Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale  appendix B)
Overflow soiling (commonly very loose , very smelly , stool passed without sensation. Can also be thick and sticky or dry and flaky.)
'Rabbit droppings' (type 1, see Bristol Stool Form Scale  appendix B)
Large, infrequent stools that can block the toilet
Symptoms associated with defecation
Distress on stooling
Bleeding associated with hard stool
Straining
Poor appetite that improves with passage of large stool
Waxing and waning of abdominal pain with passage of stool
Evidence of retentive posturing: typical straight legged, tiptoed, back arching posture
Straining
Anal pain
History
Previous episode(s) of constipation
Previous or current anal fissure
Previous episode(s) of constipation
Previous or current anal fissure
Painful bowel movements and bleeding associated with hard stools
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.
Key components
Findings and diagnostic clues that indicate idiopathic constipation
'Red flag' findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation
Timing of onset of constipation and potential precipitating factors
In a child younger than 1 year:
Starts after a few weeks of life
Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, infections
In a child/young person older than 1 year:
Starts after a few weeks of life
Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking medicines
Reported from birth or first few weeks of life
Passage of meconium
Normal (within 48 hours after birth )
Failure to pass meconium/delay (more than 48 hours after birth )
Stool patterns
'Ribbon stools' (more likely in a child younger than 1 year)
Growth and general wellbeing (for faltering growth, see recommendation 1.1.4)
In a child younger than 1 year:
Generally well, weight and height within normal limits
In a child/young person older than 1 year:
Generally well, weight and height within normal limits, fit and active
No 'red flag', but 'amber flag' (possible idiopathic constipation)
Symptoms in legs/locomotor development
No neurological problems in legs (such as falling over in a child/young person older than 1 year), normal locomotor development
Previously unknown or undiagnosed weakness in legs, locomotor delay
Abdomen
Abdominal distension with vomiting
Diet and fluid intake
In a child younger than 1 year:
Changes in infant formula, weaning, insufficient fluid intake
In a child/young person older than 1 year:
History of poor diet and/or insufficient fluid intake
Note that for personal, familial or social factors, such as disclosure or evidence that raises concerns over possibility of child maltreatment, see recommendation 1.1.5.
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.
Key components
Findings and diagnostic clues that indicate idiopathic constipation
'Red flag' findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation
Inspection of perianal area: appearance, position, patency, etc
Normal appearance of anus and surrounding area
Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal wink
Abdominal examination
Soft abdomen. Flat or distension that can be explained because of age or excess weight
Gross abdominal distension
Spine/lumbosacral region/gluteal examination
Normal appearance of the skin and anatomical structures of lumbosacral/gluteal regions
Abnormal: asymmetry or flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi or sinus, hairy patch, lipoma, central pit (dimple that you can't see the bottom of), scoliosis
Lower limb neuromuscular examination including tone and strength
Normal gait. Normal tone and strength in lower limbs
Deformity in lower limbs such as talipes
Abnormal neuromuscular signs unexplained by any existing condition, such as cerebral palsy
Lower limb neuromuscular examination: reflexes (perform only if 'red flags' in history or physical examination suggest new onset neurological impairment)
Reflexes present and of normal amplitude
Abnormal reflexes
If the history-taking and/or physical examination show evidence of faltering growth treat for constipation and test for coeliac disease (see the NICE guideline on coeliac disease) and hypothyroidism.
If either the history-taking or the physical examination show evidence of possible maltreatment treat for constipation and refer to the NICE guideline on child maltreatment: when to suspect maltreatment in under 18s.
If the physical examination shows evidence of perianal streptococcal infection, treat for constipation and also treat the infection.
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
A digital rectal examination should be undertaken only by healthcare professionals competent to interpret features of anatomical abnormalities or Hirschsprung's disease.
If a child younger than 1 year has a diagnosis of idiopathic constipation that does not respond to optimum treatment within 4 weeks, refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung's disease.
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.
For a digital rectal examination ensure:
privacy
informed consent is given by the child or young person, or the parent or legal guardian if the child is not able to give it, and is documented
a chaperone is present
the child or young person's individual preferences about degree of body exposure and gender of the examiner are taken into account
all findings are documented.

# Clinical investigations

## Endoscopy
Do not use gastrointestinal endoscopy to investigate idiopathic constipation.

## Coeliac disease and hypothyroidism
Test for coeliac disease (see the NICE guideline on coeliac disease) and hypothyroidism in the ongoing management of intractable constipation in children and young people if requested by specialist services.

## Manometry
Do not use anorectal manometry to exclude Hirschsprung's disease in children and young people with chronic constipation.

## Radiography
Do not use a plain abdominal radiograph to make a diagnosis of idiopathic constipation.
Consider using a plain abdominal radiograph only if requested by specialist services in the ongoing management of intractable idiopathic constipation.

## Rectal biopsy
Do not perform rectal biopsy unless any of the following clinical features of Hirschsprung's disease are or have been present:
delayed passage of meconium (more than 48 hours after birth in term babies)
constipation since first few weeks of life
chronic abdominal distension plus vomiting
family history of Hirschsprung's disease
faltering growth in addition to any of the previous features.

## Transit studies
Do not use transit studies to make a diagnosis of idiopathic constipation.
Consider using transit studies in the ongoing management of intractable idiopathic constipation only if requested by specialist services.

## Ultrasound
Do not use abdominal ultrasound to make a diagnosis of idiopathic constipation.
Consider using abdominal ultrasound in the ongoing management of intractable idiopathic constipation only if requested by specialist services.

# Clinical management

## 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.
Start maintenance therapy if the child or young person is not faecally impacted.
Offer the following oral medication regimen for disimpaction if indicated:
Polyethylene glycol 3350 + electrolytes, using an escalating dose regimen, as the first-line treatment. (November 2021: Not all macrogol preparations are licensed for chronic constipation and faecal impaction. Of those that are licensed for these indications, not all of them are licensed for use in children under 12, and those that are may have different licence starting ages. See individual summaries of product characteristics for further detail. See NICE's information on prescribing medicines.)
Polyethylene glycol 3350 + electrolytes may be mixed with a cold drink.
Add a stimulant laxative if polyethylene glycol 3350 + electrolytes does not lead to disimpaction after 2 weeks.
Substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if polyethylene glycol 3350 + electrolytes is not tolerated.
Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain.
Do not use rectal medications for disimpaction unless all oral medications have failed and only if the child or young person and their family consent.
Administer sodium citrate enemas only if all oral medications for disimpaction have failed.
Do not administer phosphate enemas for disimpaction unless under specialist supervision in hospital/health centre/clinic, and only if all oral medications and sodium citrate enemas have failed.
Do not perform manual evacuation of the bowel under anaesthesia unless optimum treatment with oral and rectal medications has failed.
Review children and young people undergoing disimpaction within 1 week.

## Maintenance therapy
Start maintenance therapy as soon as the child or young person's bowel is disimpacted.
Reassess children frequently during maintenance treatment to ensure they do not become reimpacted and assess issues in maintaining treatment such as taking medicine and toileting. Tailor the frequency of assessment to the individual needs of the child and their families (this could range from daily contact to contact every few weeks). Where possible, reassessment should be provided by the same person/team.
Offer the following regimen for ongoing treatment or maintenance therapy:
Polyethylene glycol 3350 + electrolytes as the first-line treatment. (November 2021: Not all macrogol preparations are licensed for chronic constipation and faecal impaction. Of those that are licensed for these indications, not all of them are licensed for use in children under 12, and those that are may have different licence starting ages. See individual summaries of product characteristics for further detail. See NICE's information on prescribing medicines).
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.
Add a stimulant laxative 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 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 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.
Advise parents and children and young people (if appropriate) that a balanced diet should include:
Adequate fluid intake (see table 4).
Adequate fibre. Recommend including foods with a high fibre content (such as fruit, vegetables, high-fibre bread, baked beans and wholegrain breakfast cereals) (not applicable to exclusively breastfed infants). Do not recommend unprocessed bran, which can cause bloating and flatulence and reduce the absorption of micronutrients.
Total water intake per day, including water contained in food
Water obtained from drinks per day
Infants 0 to 6 months
ml assumed to be from breast milk
to 12 months
ml from milk and complementary foods and beverages
ml
to 3 years
,300 ml
ml
to 8 years
,700 ml
,200 ml
Boys 9 to 13 years
,400 ml
,800 ml
Girls 9 to 13 years
,100 ml
,600 ml
Boys 14 to 18 years
,300 ml
,600 ml
Girls 14 to 18 years
,300 ml
,800 ml
The above recommendations are for adequate intakes and should not be interpreted as a specific requirement. Higher intakes of total water will be required for those who are physically active or who are exposed to hot environments. It should be noted that obese children may also require higher total intakes of water. (Institute of Medicine, 2005). Dietary reference intakes for water, potassium, sodium chloride and sulfate. Washington DC: The National Academies Press.
Provide children and young people with idiopathic constipation and their families with written information about diet and fluid intake.
In children with idiopathic constipation, start a cows' milk exclusion diet only on the advice of the relevant specialist services.
Advise daily physical activity that is tailored to the child or young person's stage of development and individual ability as part of ongoing maintenance in children and young people with idiopathic constipation.

# Psychological interventions
Do not use biofeedback for ongoing treatment in children and young people with idiopathic constipation.
Do not routinely refer children and young people with idiopathic constipation to a psychologist or child and adolescent mental health services unless the child or young person has been identified as likely to benefit from receiving a psychological intervention.

# Antegrade colonic enema procedure
Refer children and young people with idiopathic constipation who still have unresolved symptoms on optimum management to a paediatric surgical centre to assess their suitability for an antegrade colonic enema (ACE) procedure.
Ensure that all children and young people who are referred for an ACE procedure have access to support, information and follow-up from paediatric healthcare professionals with experience in managing children and young people who have had an ACE procedure.

# Information and support
Provide tailored follow-up to children and young people and their parents or carers according to the child or young person's response to treatment, measured by frequency, amount and consistency of stools. Use the Bristol Stool Form Scale to assess this (see appendix B). This could include:
telephoning or face-to-face talks
giving detailed evidence-based information about their condition and its management, using, for example, NICE's information for the public for this guideline
giving verbal information supported by (but not replaced by) written or website information in several formats about how the bowels work, symptoms that might indicate a serious underlying problem, how to take their medication, what to expect when taking laxatives, how to poo, origins of constipation, criteria to recognise risk situations for relapse (such as worsening of any symptoms, soiling etc.) and the importance of continuing treatment until advised otherwise by the healthcare professional.
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.
Healthcare professionals should liaise with school nurses to provide information and support, and to help school nurses raise awareness of the issues surrounding constipation with children and young people and school staff.
Refer children and young people with idiopathic constipation who do not respond to initial treatment within 3 months to a practitioner with expertise in the problem.

# Terms used in this guideline

## Chronic constipation
Constipation lasting longer than 8 weeks.

## Digital rectal examination
Examination of the lower rectum using a gloved, lubricated finger to check for abnormalities.

## Idiopathic constipation
Constipation that cannot (currently) be explained by any anatomical, physiological, radiological or histological abnormalities.

## Intractable constipation
Constipation that does not respond to sustained, optimum medical management.

## Optimum management
Management as set out in this guideline.

## Specialist
Healthcare professional with either interest, experience and/or training in the diagnosis and treatment of constipation in children and young people. Examples: specialist continence nurse, community paediatrician with an interest in the diagnosis and treatment of constipation.

## Specialist services
Services for children and young people that include constipation management.
A larger glossary of terms can be found in the full guideline.# Recommendations for research
The Guideline Development Group (GDG) has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The GDG's full set of recommendations for research are detailed in the full guideline.

# Polyethylene glycol 3350 + electrolytes in children under 1
What is the effectiveness of polyethylene glycol 3350 + electrolytes in treating idiopathic constipation in children younger than 1 year old, and what is the optimum dosage?

## Why this is important
There is some evidence that treatment of constipation is less effective if faecal impaction is not dealt with first. Disimpaction with oral macrogols is recommended for children and their use avoids the need for rectal treatments.
Rectal treatments are used more commonly in hospital than at home. Although relatively few infants are admitted to hospital, there would be savings if initially all children were disimpacted at home.
Polyethylene glycol 3350 + electrolytes, an oral macrogol, is licensed for disimpaction in children older than 5 years. Increasing experience has shown that it is effective in infants younger than 1 year old, but evidence is limited to small case series. If dosage guidelines and evidence on macrogol use in infants were obtained and published, more healthcare professionals might be encouraged to try macrogols in this age group. It would also allow the guideline to be applicable across the whole paediatric age group.

# Age-specific information
Is age-specific information more effective than non-age-specific information in increasing children's knowledge and understanding of constipation and its treatment, and what information should be given?

## Why this is important
When treating idiopathic constipation it is helpful if children and young people understand how the bowel works, what can go wrong and what they can do about it. Younger children (pre toilet training) need to allow stools to come out. Older children and young people have a more active role and need to develop a habit of taking all prescribed medication, sitting on the toilet each day and pushing stools out. Volition from the child or young person is vital to establish and sustain a regular toilet habit. Intended learning outcomes are similar for all age groups.
Theory-based research has led to the development of some materials such as 'Sneaky-poo' that are not appropriate for young children. To help clinicians and parents motivate children and young people to fully participate in managing their constipation it is important to discover how best to communicate information to them, what materials are most effective and, specifically, what works at different ages.

# Specialist services
Do specialist nurse-led children's continence services or traditional secondary care services provide the most effective treatment for children with idiopathic constipation (with or without faecal incontinence) that does not respond fully to primary treatment regimens? This should consider clinical and cost effectiveness, and both short-term (16 weeks) and long-term (12 months) resolution.

## Why this is important
By the time children reach tertiary care they have often suffered years of constipation with or without faecal incontinence and have intractable constipation.
Findings from one trial have suggested that children referred to a tertiary gastroenterology service and diagnosed as having idiopathic constipation are managed as effectively by nurse-led follow-up as by a consultant paediatric gastroenterology service. Parent satisfaction was improved by the nurse-led service. However, the nurse-led service may require increased resources because many more contacts are made. Several services with a similar model of care have been established but cost effectiveness has not been formally assessed.
For coherent services to develop across the UK, the cost effectiveness of specialist nurse-led services provided as first referral point if primary treatment regimens have not worked needs to be examined.

# Colonic washouts
What is the effectiveness of different volumes and types of solutions used for colonic washouts in children who have undergone an antegrade colonic enema (ACE) procedure for intractable chronic idiopathic constipation?

## Why this is important
The ACE procedure has a role in the management of people with treatment-resistant symptoms. Close follow-up is integral to the effectiveness of this technique to allow safe and effective administration of washout solutions.
The choice of washout solutions and frequency of administration differs between centres. Outcomes may be improved by evaluating how experienced centres choose washout solutions and by comparing techniques.
Centres offering the ACE procedure as treatment for children with chronic idiopathic constipation should be surveyed for their choice of washout solution. To determine the perceived strengths and weaknesses of each solution, the survey should cover enema, choice of washout fluid, volumes and frequency of administration.

# Models of service
What is the impact of specific models of service on both clinical and social outcomes to deliver timely diagnosis and treatment interventions in children with chronic idiopathic constipation and their families?

## Why this is important
There has been no research to explore the social impact on children with constipation and their families, and many of the clinical studies have been of mediocre quality. A comprehensive study is needed that investigates the effectiveness of specific models of care, and that takes into consideration both the clinical and social impact of this complex condition.# Appendix A: The algorithms
A care pathway can be found on page 22 to 32 of the full guideline.# Appendix B: Bristol Stool Form Scale
The Bristol Stool Form Scale can be found on page 32 of the full guideline.