Functional constipation is a significant problem in childhood, not only due to its prevalence, but also the impact that it has on quality of life for the affected child and their families. However, the symptoms are often unrecognised by both parents and healthcare professionals, perpetuating the problem. Furthermore, the far-reaching consequences of constipation are too frequently under-estimated, so they continue to increase with associated implications for NHS resources. Prompt recognition and intervention with appropriate laxative therapy, alongside adjustment to diet, fluids and toileting, if required, will prevent the condition becoming chronic. Chronic constipation requires longer and more proactive treatment and support. Healthcare professionals need to raise awareness of this condition to facilitate prevention as well as early, appropriate intervention.  

Constipation is defined by the National Institute for Health and Care Excellence (NICE, 2014) as ‘the inability to pass stools regularly or empty the bowels completely’. Healthcare professionals often view this troubling condition as a minor ailment (NICE, 2010), which is self-limiting for most children. This perspective may be a consequence of it not being considered within most healthcare education programmes. Families presenting with concerns about their child’s bowel actions are often dismissed with minimum interventions, particularly at initial presentation. However, depending on the criteria used for diagnosis, studies report that it affects 0.5–32% of all children, with a pooled prevalence of 9.5% (Koppen et al, 2018). While it is short-lived in many, it becomes a chronic condition in about one-third of affected children; for almost half it remains problematic ten years later (Michaud et al, 2009, cited in Collis, 2019), and some will continue to experience problems as adults (Rajindrajith et al, 2013; Bongers et al, 2010, cited in Collis, 2019).  

The consequences of chronic constipation are significant and pervasive, affecting many areas of the child and family’s life. Under reporting may be due to concerns about negative responses from healthcare professionals (NICE, 2010), leading parents to rely on friends, family and increasingly on social media for support and advice. This can perpetuate myths and under or over-treatment and scepticism about professional advice. Many parents calling a national charity helpline express feelings of frustration, helplessness and isolation as they battle to understand and control the condition against a background of conflicting advice and recommendations. 

Families seeking support often report that their child is lethargic, unhappy, has intermittent or frequent abdominal pain and behavioural issues. The condition affects self-esteem, self-confidence and social integration. The impact of associated soiling may be even more significant. Whale et al (2017) found that children who had difficulty maintaining continence were reluctant to discuss the issue with peers or school staff due to embarrassment and fears of stigma, bullying and isolation. Further, they were at risk of academic under-achievement due to the need for toilet visits during teaching time, difficulties with concentration when they need the toilet, and reduced attendance due to associated symptoms. Collis et al (2019) in their scoping review found that the impact on the child’s quality of life increased as they got older, and that the negative consequences for the family were ‘enduring and extreme’.  

Constipation is under-recognised by families and soiling is rarely identified as a symptom (NICE, 2010). Most parents only realise their child is constipated if they are going several days between bowel actions and/or are passing hard stools. However, some children never experience these indicators. As the NICE guidance for constipation in children (2010) describes, there are several symptoms of constipation, of which only two need to be present for the diagnosis to be made (Box 1). 

In typically developing children, soiling is often thought to be the result of behavioural issues, such as psychological problems, toilet avoidance, laziness or naughtiness, and too frequently parents will only ask for healthcare support when they can no longer cope with the washing or social impact of soiling, by which stage the problem has become chronic.  

Up to 90–95% of childhood constipation is functional or idiopathic (Tabbers et al, 2014; Madani et al, 2016; Collis et al, 2019). This means that there is no identifiable underlying anatomical, histological or physiological condition. However, it is likely to be the result of a complex interplay of several factors. Walter et al (2019) identify that constipation often emerges early in life with a median age of onset at 2.3 years, with Steutel et al (2020) finding that 9.6% of 1053 children aged 13–48 months had functional constipation. Suggested causes are changes from breast to formula feeding, weaning and potty training (Walter et al, 2019). In the author’s clinical experience, this is the case for many children, with other triggers being dehydration associated with illness, medication, or reluctance to use an unfamiliar toilet, or one that is perceived as unpleasant (such as some school toilets). The situation may also be caused or compounded by withholding of stool in response to previous painful defecation, family history of constipation (Koppen et al, 2015). Walter et al (2019) cite studies that suggest psychological stress and maltreatment as possible causes of constipation for older children.  

Von Gontard (2015) found that incontinence was more prevalent in children with additional needs and was more likely to continue into adolescence and beyond, rightly concluding that all children are entitled to assessment and appropriate individualised treatment according to needs. Chaidez et al (2014) found an increased risk of constipation and other gastrointestinal problems for children with autism and developmental disabilities. Constipation in children with disabilities may be linked to differences in muscle tone or mobility, but issues may be diagnosed late due to assumptions that any incontinence is related to the disability, rather than to an underlying bowel problem, such as constipation (Rogers and Patricolo 2014). 

Little et al (2019) found that children aged 3–5 years old with chronic constipation were more responsive to sensory stimuli in the areas of oral and visual processing, sensory sensitivity and sensory avoidance than similar children without constipation; while Von Gontard et al (2011) found that 30–50% of children with soiling had sufficient symptoms to meet the criteria for diagnosis of a psychological or psychiatric condition. 

Tambucci et al (2019) highlight a link between obesity in childhood and constipation. They present the hypotheses that habits around food consumption, or differences in the gut microbiome, as well as psychosocial issues that are acknowledged to affect weight in children, may be implicated in the development of constipation and other functional gastrointestinal disorders in those with obesity. Conversely, Yousefi et al (2019) found that constipation resulted in reduced height and weight in a sample of Iranian children.  

Whatever the cause and individual effect, constipation has a significant impact on the healthcare economy, as well as the child and family. The Cost of Constipation Report (Bowel Interest Group, 2020) demonstrates that the cost of constipation for the NHS continues to increase and that children aged 0–14 years spent a total of 13,000 bed days in hospital in 2018–19 for constipation. A longitudinal study of a large cohort of children found that 5.9% had consulted a doctor at least once between the ages of four and nine years of age (Heron et al, 2018), and it is reported to be responsible for up to 25% of paediatric gastroenterology referrals (Nurko and Zimmerman, 2014). A study in Pittsburgh found that 20% of children attending an emergency department with acute abdominal pain were diagnosed with functional constipation (Caperell et al 2013). There are also healthcare costs arising from community continence clinic appointments, general paediatric referrals and laxative prescriptions. 

Children usually present to the healthcare professional when the family become concerned about symptoms. In addition to those listed by NICE (Box 1), in the author’s clinical experience, parents may also complain about day or night time wetting, difficulty with toilet training, or their child actively withholding faeces.  

The aim for all children should be:  

• Prevention  
• Early identification  
• Effective treatment.  

If information about the signs and symptoms of constipation were included in all parent-held child health records and discussed at all routine contacts by health visitors and school nurses, there would be less stigma and embarrassment, and families would recognise the problem earlier and know how and when to seek help. Crucially, prompt proactive treatment with laxatives would reduce the incidence of the condition becoming chronic.  

FAECAL IMPACTION  

Once constipation is present the child will almost inevitably experience the passage of at least one large hard stool that is painful to pass. Their natural reaction will be fear of further bowel motions, which triggers withholding. As they become more practised at contracting the pelvic floor in response to signals to open their bowels, their ability to withhold improves and, for many, perpetuates the formation of large hard stools that cause further pain when they cannot be held in any longer, and a vicious circle develops. As the mass in the rectum builds, impaction may result, but withholding becomes more difficult. At this point, the child may hide, to concentrate on preventing evacuation. They may recruit other muscles in the body, which parents may interpret as straining (Cohn, 2010).  

Faecal impaction is a large mass of stool in the bowel that the child is unlikely to be able to pass without laxative treatment. Soiling may occur due to the child being unable to hold any longer, or because liquid or softer faeces leak around the hard lump; or it may be due to anatomical changes caused by the large mass of stool, allowing pieces to escape into the underwear. The child is not in control of the soiling and is often unaware of it until alerted by another. This is because the mass of retained stool may cause over-distension of the rectum (megarectum), reducing both contractility and sensitivity (Cohn, 2011). Adults often find this difficult to understand, not recognising that the child has reduced awareness of rectal stretch due to faeces always being present in an area of the bowel that should usually be empty. Furthermore, the child is unaware of the smell, despite this often being very offensive.

Faecal impaction is not an inevitable result of chronic constipation. Some children continue to pass soft stools most days or several times a day. However, as they never or rarely fully empty the rectum, they are constipated. They may or may not display withholding behaviour, which parents often interpret as straining. Bladder symptoms (Clayden and Wright, 2007; Cohn, 2011; Chung et al, 2014), offensive smelling wind, or any of the other symptoms listed in Box 1 may be evident. The wide variation in symptoms may make recognising constipation difficult.    

DIAGNOSIS  

Diagnosis of constipation is primarily by careful history-taking. Red flags should actively be considered (Box 2), with prompt referral to an appropriate specialist if present or suspected. Careful questioning about bowel history, duration of the condition, details of the onset of symptoms, diet and fluid intake, medication (including over-the-counter preparations), and any other health conditions will help to confirm functional constipation.  

A two-week bowel diary kept by the family, where possible and practicable, is often helpful. Tests and investigations, such as abdominal radiograph (X-ray), ultrasound, transit studies, digital rectal examination (DRE), bloods for coeliac disease or hypothyroidism, are only needed if there are concerns about an underlying cause, or on specialist request (NICE, 2010), although visual inspection of normal spine and anus may help to exclude an organic cause.  

TREATMENT  

Once the diagnosis of functional constipation is made, treatment with laxatives should be initiated. NICE (2010) recommends this as firstline for all children and gives doses of medication from infancy, with macrogol being the treatment of choice, including in children younger than two years old. However, families need to understand the mode of action as well as how to mix and administer it and the need to continue with treatment once symptoms improve if they have been present for more than a few days. Furthermore, they need to be advised that some symptoms, particularly soiling, may initially deteriorate. Clinical experience shows that failure to explain this results in cessation of treatment or premature reduction in dose of laxatives and consequent lack of sustained improvement.  

Macrogols are osmotic laxatives that work by retaining the water they are mixed with in the bowel. The water then softens the stool making it more difficult to withhold and easier to pass. The addition of water may also increase stool volume, stimulating peristalsis. Therefore, if the macrogols are not mixed with water as directed, they are unlikely to achieve a full effect.  

Increasing doses of macrogols can be used for disimpaction if required. The disimpaction regimen is fully described in NICE guidance (2010) and families should be advised to continue until their child is passing liquid stools (type 7 on the Bristol stool chart, Figure 1; Lewis and Heaton, 1997). At that point, the dose is usually reduced to a maintenance dose of about half the disimpaction dose. Families can be directed to the video at www.thepoonurses.uk to help them titrate doses. Bowel diaries may help the family to keep track of progress and assist healthcare professionals in making appropriate recommendations.  
 

Not all children require disimpaction. The indication for this is soiling or a faecal mass being present in the abdomen or rectum. Children who do not need disimpaction should be started on a maintenance dose of macrogol, titrated every few days until they are passing a soft stool most days. Sodium picosulfate or senna, both stimulant laxatives, should be introduced if a child has not disimpacted within two weeks of starting macrogol, or if macrogol on its own is ineffective.

In the author’s clinical experience, the key to success is the child having sufficient laxative to overcome withholding and convince them that stools are easy to pass. Therefore, it is important to offer an alternative if the child will not take the macrogol, either because of the volumes involved or sensitivity to the taste. Other alternatives besides the stimulant laxatives include lactulose, which has an osmotic effect. This is an undigestible sugar, so parents do need to be advised to pay attention to their child’s dental hygiene if it is to be used. Docusate sodium is also an option and has both a mild stimulant and softening effect. The disadvantage of this option is that it should be given three times a day.

NICE states: ‘Do not use dietary interventions alone as first-line treatment for idiopathic constipation’. Rather, these should be an adjunct after initiation of laxative therapy. It is important to encourage fibre in the form of fruit and vegetables, wholegrain breakfast cereals and high fibre bread, as well as appropriate fluid intake according to age and activity levels (Table 1).
 

Age	Sex	Total drinks per day
1-3 years	Female  Male	900-1000ml  900-1000ml
4-8 years	Female  Male	1000-1400ml  1000-1400ml
9-13 years	Female  Male	1200-2100ml  1400-2300ml
14-18 years	Female  Male	1400-2500ml  1400-3200ml

Table 1: Suggested intake of water-based drinks per 24 hours by age and gender (adapted from NICE, 2010). 

Toileting programmes are also helpful. Consideration should be given to toilet training if required, as once the child is passing soft stools as the position on the potty is ideal for relaxing puborectalis and facilitating the correct anorectal angle for complete emptying (Figure 2). For older children who use the toilet, a step so that their feet are fully supported on a firm surface with their knees higher than their hips and an insert seat, if required, to ensure that they are sitting with their bottom well supported, are recommended (Collins and Bradshaw, 2016; RCN, 2019). Children should be encouraged to sit on the toilet at least once a day after a meal, to utilise the gastro-colic reflex.  



Figure 2. Correct position for opening your bowels (Royal College of Nursing [RCN], 2019). 

For any treatment programme to be successful, families need to understand the problem and the suggested intervention. Clinicians need to recognise that parents are the experts in their child, as well as their family situation, and the child is the expert in their own feelings and behaviour. Therefore, all should be involved in negotiating and agreeing the treatment plan. The family should be provided with reliable information that they can refer to after the consultation (see Resources) and details for follow up. NICE (2010) recommends that children commencing disimpaction should be reviewed within a week and within six weeks for those starting maintenance. Intervals between further contacts should be agreed, depending on individual need. 

Families whose children have a short-lived episode of constipation should be warned to be alert for a recurrence and to use laxatives again promptly. For children who have chronic functional constipation (lasting more than eight weeks [NICE, 2010]), laxatives are likely to be needed for several months or longer. This is to allow the child to learn that bowel motions are not painful and therefore overcome habitual withholding, and to give an overstretched bowel the chance to recover. Therefore, families should be advised to continue with maintenance doses of laxatives until their child develops loose stools (type 5–7 on the Bristol stool chart, Figure 1), at which point they can cautiously be reduced.  

Clinical experience shows that many children never develop loose stools. For these children, cautious and very gradual reduction in laxatives can be started after three to six months with no symptoms. Families should be advised to reduce the daily dose by half or one sachet of macrogol or 2.5mls of other osmotic or stimulant laxatives. This reduced dose should be maintained for at least four to six weeks before any further reduction. Information should be provided that relapses are common and can happen for a variety of reasons, such as:  

• Reduction of maintenance dose  
• Change of routine or diet  
• Reduced fluid intake, or illness.  

They should respond promptly by giving sufficient extra laxatives to overcome symptoms. If extra laxatives are needed more than once a week, the family should return to the dose at which their child was last symptomatic and continue this for a minimum of four to six weeks before trying a further reduction. It is of note that a small proportion of children do not respond well to optimum medical management and NICE (2014) therefore recommends that children who have not responded to initial treatment within three months be referred to a healthcare professional with expertise in the problem.  

CONCLUSION  

Constipation is a common problem in children and young people with peak incidence in toddlers (Walter et al, 2019). However, in the author’s clinical experience, this condition is rarely discussed with parents. Routine provision of information to all families about the signs and symptoms of constipation, including explanations of withholding behaviours and soiling would reduce ignorance, stigma and embarrassment and lead to earlier presentation. Further, if healthcare professionals were appropriately educated about the significance of this distressing condition, effective treatment could be offered more promptly, which might reduce overall incidence, as well as the impact of the condition becoming chronic. Once constipation has developed, parents need support and appropriate evidence-based information to understand and adhere to treatment routines and for sustained improvement. Quality of life is significantly negatively impacted by childhood constipation. Treatment can be straightforward for many, but if the condition is not resolving within three months, the child should be referred on to someone with more specialised knowledge. Things will not improve until healthcare professionals become more adept at identifying and addressing constipation before it has significant impact on daily life and resources for the child, family and healthcare economy. In the author’s clinical opinion, constipation should be included in all healthcare education programmes and within public health surveillance, with written and verbal advice being given at key contact times throughout childhood.