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QuestionComment
The answers on this mock have been incredibly confusing and inconsistent. How do we know the duration is 4 weeks???
59513
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iona
QuestionComment
if in the bnf it has said maximum 4 sachets, how do you know what frequency to put down ? 
59538
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Hypertension Kinase
QuestionComment
and for duration - does it matter if you write down 1 month or 4 weeks
59539
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Hypertension Kinase
QuestionComment
Why not "to be reviewed" 

59654
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Recessive Dominant
QuestionComment
13.8g is an adult dose for a 4 year old. Paediatric sachets not an option on drop down list
61044
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GEORGIA
Concept
Chapter
# Summary
 

Constipation in children is defined as a condition where the child defaecates less than three times per week or experiences significant difficulty in passing stool. The typical signs and symptoms include hard, pellet-like stool that is difficult to pass, and in some cases, overflow diarrhoea. It's primarily diagnosed through patient history and abdominal examination. Management includes a Movicol disimpaction regimen followed by maintenance Movicol, a high-fibre diet, and fostering good toileting habits. 
 

# Definition
 

Constipation in children is a clinical condition where the child defecates fewer than three times per week or experiences significant difficulty in passing stool. Chronic constipation in this population is often characterised by hard, pellet-like stool that is difficult to pass.
 

# Epidemiology
 

Constipation in children is a common occurrence, affecting 30% of children aged 4-11 years, however, the peak incidence is around age 2-3 when the child undergoes toilet training. It is likely under-reported as symptoms such as overflow diarrhoea may not be recognised as constipation by parents. 
 

# Aetiology
 

The most common cause of chronic constipation in children is dietary factors, with other contributing factors including:
 

- Fever
- A low-fibre diet and poor fluid intake 
- Family history of constipation 
- Avoidance of using the toilet
- Pain upon passing stool, e.g., secondary to an anal fissure or very hard stool
- Unrecognised sensation of needing to pass stool
- Sedentary behaviour or impaired mobility 

There is often a trigger for constipation:

- Dietary changes 
- Toilet training 
- Social changes (starting nursery, moving house, fears, family changes)
- Medications 
- Anal fissure 
 

# Signs and symptoms
 

In children, chronic constipation often presents as:
 

 -  Hard, pellet-like stool that is difficult to pass
 -  Possible overflow diarrhoea due to fluid moving past the hard stool in the rectum
 -  Less than 3 stools passed per week 
 -  The child may have pain and straining during defaecation

For idiopathic constipation, the following red flags must be ruled out:

- Delayed passage of meconium 
- Onset of constipation within first few weeks of life 
- Failure to thrive (faltering weight gain and growth)
- "Ribbon stools"
- Neurologic problems in lower limbs 
- Anal abnormalities 


# Differential diagnosis
 

 -  **Hirschsprung's disease**: Presents with a delay in passing meconium (>48 hours), a distended abdomen, forceful evacuation of meconium after digital rectal examination, and a history of chronic constipation with poor response to Movicol disimpaction regimens and poor weight gain.
 -  **Irritable Bowel Syndrome (IBS)**: May cause chronic constipation and is associated with abdominal pain, bloating, and altered bowel habits. Pain is typically relieved by defecation.
 -  **Hypothyroidism**: Can lead to constipation, along with other symptoms such as weight gain, fatigue, cold intolerance, and slow growth in children.
 -  **Celiac Disease**: While more commonly associated with diarrhoea, it can sometimes cause constipation. Other symptoms include failure to thrive, abdominal pain, and bloating.
 -  **Lead poisoning**: Constipation is one of the symptoms along with learning difficulties, irritability, loss of developmental skills in children, and possibly anaemia.
 -  **Anal fissure**: Pain during and after bowel movements can lead to constipation due to the child's fear of experiencing pain again.
 -  **Functional constipation**: Characterised by normal anorectal and colonic physiology but the passage of hard stools, infrequent stools, or painful defecation.
 -  **Neurological disorders** like Spina Bifida and Cerebral Palsy: These conditions may impact the nerves that control bowel function, leading to constipation.
 

# Investigations
 

-  Chronic constipation is generally diagnosed from history and examination
    -  Abdominal examination may reveal impacted faeces (hard, depressible masses) 
    -  Examination to exclude neurologic impairment in lower limbs or abnormal appearance of the anus which may indicate a diagnosis other than idiopathic constipation 
 
If a specific diagnosis is queried or if the constipation is not responding to treatment, referral for further investigations by a specialist paediatrician is indicated. These include:

- A rectal suction biopsy for Hirschsprung's disease.
 

# Management
 

-  The initial treatment of chronic constipation is with a Movicol (polyethylene glycol 3350) disimpaction regimen.
     -  If the child does not have faecal impaction, the child can be started on maintenance therapy first. 
     -  If the child does not respond to Movicol, a stimulant laxative can be added after 2 weeks. 
-  This is followed by maintenance Movicol 
-  Lifestyle management:
     -  Encourage a high-fibre diet with sufficient fluid intake 
     -  Provide advice about encouraging good toileting habits (i.e. regular toilet times) 
     -  Regular physical activity 
-  In the case of Hirschsprung's disease, definitive management is through the surgical removal of the section of the aganglionic colon. The healthy bowel is then pulled through.

 
#  Complications

Constipation in children may lead to:

 - Anal fissures
 - Haemorrhoids 
 - Rectal prolapse
 - Faecal impaction and overflow soiling 
 - Psychological distress to the child 
 
 
#  Prognosis 

Earlier detection and management of constipation in children is associated with an improved prognosis. For approximately 1/3 of children, the constipation becomes chronic. Following treatment, 60% of children become free from constipation by 1 year and 80% of children have no symptoms by age 16. 

Comorbidities such as psychological disorders and psychosocial issues are associated with a generally poorer prognosis. 
 

# NICE Guidelines 
 

[NICE Guidelines on Constipation in Children](https://www.nice.org.uk/guidance/cg99)
 
#  References

[NHS Constipation in children](https://www.nhs.uk/conditions/baby/health/constipation-in-children/) 

[Patient info Constipation in children](https://patient.info/digestive-health/constipation/constipation-in-children)
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3590
Constipation in children
Topic
91
Paediatrics
## Drug choice feedback
This child is suffering from constipation. There are no signs of faecal impaction and so a regular maintenance laxative should be prescribed.

Osmotic (stool softening) laxatives are the first-line drug prescribed in children with constipation. The macrogol 'Movicol' (Polyethylene glycol 3350 plus electrolytes) or Lactulose are recommended as first-line treatment.

Stimulant laxatives such as Senna and sodium picosulphate should be used as second-line and so would not be appropriate in this instance.

## Dose/Route/Frequency/Duration feedback
Movicol is prescribed in sachets. The maintenance dose for a 4-year-old is 1 sachet daily.

Lactulose is a liquid prescribed in mL, the dose for a 4-year-old is 2.5-5mL twice daily.
10058
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1 sachet
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macrogol '3350' paediatric oral powder sachets
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4 weeks
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daily (OD)
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oral (PO)
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1 sachet
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macrogol '3350' paediatric oral powder sachets
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4 weeks
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daily (OD)
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oral (PO)
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2 mL
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lactulose 10 g/15 mL oral solution
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4 weeks
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twice daily (BD)
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oral (PO)
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5 mL
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lactulose 10 g/15 mL oral solution
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4 weeks
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twice daily (BD)
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oral (PO)
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10 mL
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lactulose 10 g/15 mL oral solution
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4 weeks
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twice daily (BD)
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oral (PO)
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1 sachet
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macrogol '3350' paediatric oral powder sachets
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4 weeks
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daily (OD)
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oral (PO)
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1 sachet
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macrogol '3350' paediatric oral powder sachets
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4 weeks
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daily (OD)
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oral (PO)
Case Presentation: A 4-year-old boy is brought to the GP by his mother with abdominal pain and infrequent bowel movements. He has been passing 1-2 hard stools per week. His mother reports that he experiences pain when passing stools. He has a good diet and good fluid intake. He has reached all of his developmental milestones. 


## PH
None

## DH
None

NKDA

## On examination
The patient looks well.

On palpation of the abdomen, there is generalised tenderness with no guarding and no palpable faecal mass.

Height: 100cm

Weight: 16kg

# Prescribing Request

Write a prescription for one drug that is most appropriate to treat his condition.