History and Examination

History

A diagnosis of constipation can be made if two or more of the following:

• Three or fewer defecations in the toilet per week
• At least one episode of faecal incontinence per week
• History of retentive posturing or excessive volitional stool retention
• History of painful or hard bowel movements
• Presence of a large faecal mass in the rectum palpable on abdominal examination

Examination

• Plot height and weight in red book.
• The faecal mass of impaction can be difficult to palpate.
• Inspect anus to check normal anatomical placement or presence of anal fissures.
• Digital rectal examination is not recommended in primary care.
• Inspect spine and check normal lower limb neurology.

Faecal incontinence

Typically the child with 'overflow' faecal incontinence due to constipation will pass small amounts of stool into their pants and seem unaware that they have done so. See constipation management below. Disimpaction is usually required before starting maintenance laxative.

Bloody diarrhoea, faecal urgency or nocturnal diarrhoea suggests colitis. Refer to paediatrics.

Constipation from birth, passage of meconium after 48 hours old, passage of 'ribbon like' stools or chronic severe abdominal distension suggest Hirschsprungs or anal stenosis. A period of normal bowel habit makes Hirschsprungs or anal stenosis unlikely.

Child under 1 year that doesn't respond to laxatives after 4 weeks.

Abnormal growth, weight loss or chronic vomiting suggests coeliac disease or other chronic disorders.

Abnormal lower limb neurology or cutaneous lesion over spine suggests spinal cord lesion.

Suspicion of abuse (sexual, emotional, physical or neglect).

For advice on the management of constipation in children refer to the formulary chapter 1 "Management of constipation in children"

Provide reassurance for the following infants who do not require referral or treatment

• Breast fed infants who only defaecate every few days but have no other symptoms of constipation or red flags.
• Do not treat infant dyschezia' (characterised by at least 10 minutes of straining and crying before successful passage of soft stools in healthy infants aged under 6 months) with laxatives.

Referral Criteria

Children whose constipation doesn't improve after 3 months of laxative treatment refer to health visitor (pre-school child) or school nurse via single point of access VCL.DevonSpa@nhs.net

Children whose constipation doesn't improve despite input from health visitor or school nurse refer to bladder and bowel care nurses via Northern Devon Health Care Trust.

If red flags or concern about organic cause refer to paediatric gastroenterology.

Referral Instructions

Referral to Paediatric Bladder & Bowel Care

This service is not available on e-Referrals therefore send an email with attached referral letter to:

• E-mail: ndht.bladderandbowel@nhs.net
• Franklyn House, Franklin Drive, Exeter, EX2 9HS
• Tel: 01392 208044

Referral to paediatric gastroenterology

e-Referral Service Selection:

• Specialty: Children & Adolescent
• Clinic Type: Gastroenterology
• Service: DRSS-South Devon & Torbay-Children's & Adolescent Services- Devon ICB - 15N

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

Patient Information

Parental resources

ERIC (Education and Resources for Improving Childhood Continence)

Evidence

NICE clinical guideline 99. NICE guideline on constipation in children and young people. May 2010

Pathway Group

This guideline has been signed off by South Devon and Torbay CCG

Publication date: August 2017
Updated: December 2018