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This guidance has been developed from NICE CG99: Constipation in children and young adults (July 2017) and in collaboration with local specialists.
Treat a child for constipation in primary care only if a working diagnosis of idiopathic constipation has been made and red flags have been excluded.
When considering specialist referral see: South Devon and Torbay Referral Guideline: Constipation and faecal incontinence in children and adolescents
There is currently no referral guidance for Western Devon although Specialist paediatric bladder and bowel care service (Franklyn House, Exeter) covers the whole of Devon except for Plymouth facing referrals, who should be referred to Plymouth Children's Continence Service at the Child Development Centre (CDC).
Dietary interventions alone should not be used as first-line treatment for idiopathic constipation.
See 1.6.2 Stimulant laxatives and 1.6.4 Osmotic laxatives
Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain.
Review children and young people undergoing disimpaction within 1 week.
Consider seeking specialist advice or arranging urgent referral if all oral laxative regimens below fail or the child is very distressed.
NICE recommends that suppositories or enemas should not be used routinely in primary care. However, it should be noted that the specialist paediatric bladder and bowel care team may recommend the use of bisacodyl and lecicarbon C suppositories for use in individual patients.
NICE state that sodium citrate enemas should only be administered if all oral medications for disimpaction have failed.
If faecal impaction has been diagnosed offer:
Notes
If this fails to lead to disimpaction after 2 weeks, add a stimulant laxative. If a macrogol is not tolerated, substitute with a stimulant laxative either on its own or, if stools are hard, in combination with lactulose or another stool softener such as docusate:
Notes
Or
If stools are hard consider adding:
Or
Start maintenance laxative treatment as soon as the bowel is disimpacted.
See 1.6.2 Stimulant laxatives and 1.6.4 Osmotic laxatives
Maintenance treatment should be used alongside diet and lifestyle advice (see above).
If impaction is not present or has been treated, start maintenance laxative treatment promptly (even if constipation is reported for only a few days), aiming for regular soft formed stools. Ensure the child has easy access to a toilet.
Notes
If constipation persists despite optimal doses of the macrogol, add a stimulant laxative. If the macrogol is not tolerated, substitute with a stimulant laxative and, if stools are hard, consider combining with lactulose or another stool softener laxative such as docusate:
Notes
Or
If stools are hard consider adding:
Or
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.