Approach to constipation

• Constipation is common, occurring in 30 % of children

• Red flags
• constipation presents early in life < 6 weeks
• functional constipation is the most common cause of constipation in childhood 

• Some other less common causes 
• Medical: cow milk allergy, coeliac disease, hypercalcaemia, hypothyroidism 
• Surgical: hirschsprung disease, meconium ileus, anatomic malformations of anus and spinal cord abnormalities

• History
• Timing of meconium passage
• Painful/frightening precipitant
• Straining 
• Toilet refusal, hiding while defecting, crossing legs or other withholding behaviour 
• Faecal or urinary incontinence, day or night 
• Weight loss, vomiting or PR blood loss - suggests possible organic disease
• Stool description 

• Examination 
• Height and weight -- failure to thrive
• Abdomen - palpable faeces
• Spine - deep sacral cleft or tuft of hair 
• Neurology - assessment of lower limbs 
• Anal area - visually examine for fissures, internal examination not required

• Management 

• Behaviour modifications
• Toilet sits - 5 minutes 3 times a day, preferably after meals 
• use chart or diary 
• Diet 
• Medication
• Titrate medicaion aiming for one soft, easy to pass bowel action per day 
• children: stool softener or iso-osmotic laxative 
• infants 6-12 months: colocyl drops or lactulose 
• infants < 6 months: coloxyl drops 

References: 

• RCH 
• John Murtagh