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Constipation

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Principles of Management

Infrequent passage of stool for whatever reason often leads to constipation and faecal impaction with secondary problems of faecal soiling, anorexia, abdominal pain, behavioural problems and low self-esteem. The management of constipation involves:

  1. Education and explanation.
  2. High fibre diet and high fluid intake (consider dietician review during admission).
  3. Retraining children to sit regularly on the toilet after meals.
  4. Laxative medications to soften the stool (e.g. Lactulose) and increase stool expulsion (e.g. Senokot® - Note: non-formulary at Auckland DHB - suggest use docusate / senna combination). Other options include MgOH 8%, or movicol.
  5. Faecal disimpaction (e.g. colonic lavage or phosphate enema). Note the former should be used with caution under the age of 1 year and the latter is contraindicated under the age of 3 years.

Faecal Disimpaction

Some consultants will recommend a trial of Picoprep (sodium picosulphate) at home in order to try and prevent an admission to hospital for Klean-Prep™

Picoprep Dose  
 <2 yr olds  ¼ sachet BD for 2/7 
 2-4 yr olds ½ sachet BD for 2/7 
>4 yrs   1 sachet BD for 2/7

This is not funded (cost ~$25), but may prevent an admission. Adequate fluid intake during treatment is very important. Restarting laxatives after treatment course is vital. This treatment should only be instituted by an authorising consultant and the caregivers have the ability to phone for advice if required.

Movicol has also been used as a disimpaction agent in the outpatient setting. The dose for this is 1-1.5g/kg/day for 3 days (1 packet of movicol contains 13g). The limitation of this treatment is the volume of fluid (125mL/packet) to be used. Special authority required.

Colonic Lavage (age > 1 year)

Poor response to outpatient therapy may necessitate an admission in selected cases for colonic washouts. Large volumes (5-10L) of a balanced electrolyte solution, Klean-Prep™, is given orally to 'dissolve' the faecal lump.

Most children will require a nasogastric tube to achieve the desired intake per hour. Involve the Play Therapists. Oral Midazolam 0.5mg/kg to a maximum of 15mg may be required. Abdominal x-rays are at the discretion of the admitting consultant. All patients should be seen and assessed by a paediatric consultant prior to admission. That individual is responsible for outpatient follow up following discharge.

Once the child is admitted to the ward, a large nasogastric tube should be inserted and vital signs and weight recorded. Begin the nasogastric infusion at the lowest rate and increase by 100ml/hour until the desired rate is reached or symptoms develop. Most children need 10-40ml/kg/hr. Normal diet should continue if tolerated.

A input/output fluid balance chart is required, adequate fluid intake is required to prevent dehydration and/or hypo/hypernatraemia. For young children (i.e <24 months) daily electrolytes testing may be required.

SUGGESTED FLOW RATES FOR KLEAN-PREP™

Age (Years) Weight (kg)   Initial (ml/hr) Maximum (ml/hr) 
1-5   10-20 100   500
6-9   20-30  200   800 
9-12   30-40 300  1000 
Over 12   40+  400 1200 

If symptoms develop (usually nausea &/or vomiting), reduce the flow rate to the previous rate at which the child was asymptomatic. Metoclopramide may be given to reduce nausea and reduce transit time. Discontinue at 8pm at night to allow rest as 'catharsis' may continue late into the evening. Restart at 6am.

Important: Success of treatment is judged by a clear effluent (SOMEONE NEEDS TO LOOK IN THE PAN!). The commonest reason for failure of treatment is insufficient volume of Klean-Prep™. Abdominal x-ray and rectal examination at the end of treatment are unnecessary (frequently uninterpretable) if clear effluent is achieved.

Phosphate Enemas (Age > 3 Years)

Phosphate enemas can be used in the outpatient or Emergency Care setting to disimpact the rectum. They should not be administered by parents and are contra-indicated in children < 3 years. If there is no result they should not be repeated on the same day. Dosage: 30-60mls. One to three enemas may be required, ideally 48 hours apart. Refer to the Paediatric Nursing Service.

Discharge and Follow-up

A discharge plan should be discussed with the patient's primary paediatrician, with outpatient follow-up needs arranged within one month.

All children need to go home on laxative therapy, options include:

  • Lactulose - 1-3ml/kg/day in two divided doses (softener only)
  • Need to brush teeth after dose.
  • Senokot - 1 tablet OD for <5 yrs, 2 tablets daily for > 5yrs
    Not funded. Stimulant laxative.
  • Magnesium Hydroxide 8% - 1ml/kg/day in two divided doses
    Not funded. Available from hospital pharmacy or Cox's Pharmacy, Glen Innes. Advantage of low dose for young children and palatability. Stool softener and stimulant. Not advisable for children <18 months old.
  • Movicol (Macrogol 3350) - 1g/kg/day. One packet contains 13g. Special authority required. Not as well tolerated in children <4yrs because of palatability (bitter) and volumes required for dilution (125mL/packet). Stool softener and stimulant.

For children with very difficult to manage constipation or significant behavioural problems associated with this, referral to consult liaison may be indicated.

Consideration and investigation where appropriate for organic disease (ie hypothyroidism, spinal dysraphism, Hirschprung's disease etc) always required, especially in difficult to treat constipation.

Primary Care Referral Pathway

Northern Region Clinical Pathway for the assessment and management of constipation in children http://www.healthpointpathways.co.nz/northern/paediatric-a-z/constipation-paediatric/

Information for Families

Kidshealth website - factsheets on constipation and laxatives

Acknowledgement

This guideline was developed by KidzFirst, South Auckland Health. Starship appreciates being able to include this guideline.

References

  1. Clinical Practice Guideline. Evaluation and Treatment of constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. JPGN 2006; 43: e1-e13.
  2.  Pashankar DS. Childhood constipation: evaluation and management. Clin Col Rect Surg 2005; 18 (2): 120-127.
  3. http://www.kidshealth.org.nz/constipation
  4. http://www.kidshealth.org.nz/laxatives

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Document Control

  • Date last published: 01 February 2012
  • Document type: Clinical Guideline
  • Services responsible: General Paediatrics, KidzFirst
  • Author(s): Anne Tait
  • Editor: Greg Williams
  • Review frequency: 2 years

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