1. The parents of a 2-year old boy are concerned about his constipation and straining to open his bowels. Initial treatment with macrogol for 2 weeks was stopped due to soiling and distress. 2. Constipation is common in toddlers and early intervention with laxatives can prevent problems. Explanation of constipation and supported treatment would help this child and family. 3. Laxatives like macrogol are recommended to treat constipation. Treatment may initially worsen soiling but aims to restore normal bowel function. Parents require education on use and expected duration of treatment.

1. Kurdistan Board GEH/GIT Surgery J Club 2021
Supervised by Professor Dr. Mohamed Alshekhani.

2. Introduction:
 The parents of a 2 year old boy are concerned that he is struggling to open
his bowels&appears to be straining.
 They tried macrogol for two weeks but stopped from soiling& distress.
 Constipation, the passage of fewer than three complete stools per week,
affects 1/10 children worldwide.
 It occurs most commonly in toddlers, often presenting at the time of
weaning,toilet training, or starting school.
 Laxatives are safe&effective.
 Early intervention & support for parents with dosing / duration can
prevent problems such as chronicity, withholding behaviours,
overstretched bowels with decreased motility&overflow soiling.

3. What to cover:
 Take or revisit the history & examination to differentiate idiopathic
constipation from other underlying conditions.

4. History:
 Identify the stool patterns&timing of onset.
 Hard large stool,“rabbit dropping” stool& overflow soiling are common.
 A paediatric Bristol stool chart help parental descriptions.
 Reduced appetite, abd discomfort that improves with defecation, straining,
anal pain may all feature in idiopathic constipation.
 Blood streaked stool often indicates an acute anal fissure.
 Constipation may also present with urine infections or wetting owing to
pressure on the bladder.
 Idiopathic constipation rarely starts within the first few weeks of life.
 Onset from birth, including failure or delay in passing meconium, may
indicate obstruction or Hirschsprung’s disease.
 “Ribbon stools” occur in Hirschsprung’s dis or with AR malformation.
 Exclusively breastfed infants’ stools can vary widely, from type 6-7 in the
first few days of life to weekly bowel movements Inquire about diet&fluid
intake, including changes in formula, weaning&intake of fruits-vegetables.

5. History:
 Explore parents’ concerns about causes & how the problem is affecting the
child and family.
 Children may hide soiled underwear to avoid shame.
 Constipation can be distressing for families; parents may feel isolated &
have concerns about possible underlying medical causes.
 It can be difficult to differentiate between overflow soiling&behavioural
soiling related to emotional distress.
 In children who have already received treatment, explore the reasons why
it hasn’t worked.
 Parents may prematurely stop laxative after perceiving macrogol induced
stool as “diarrhoea.”
 Concerns about use of medications,inconvenience of treatment&conflict
between child & parents over treatment may also reduce adherence.

9. Exam:
 Children with idiopathic constipation are generally well.
 Examine with red flags in mind.
 Include growth , abdominal&focused neurological examination.
 Examine the spine, buttocks,anus&legs for deformities, muscle tone, or
wasting.
 DRE should not be done in primary care &rarely indicated.

11. Investigations:
 Investigations are seldom warranted in primary care.
 Avoid routine abdominal radiography or ultrasound.
 If the child has faltering growth or poor response to adequate treatment,
testing for coeliac disease & hypothyroidism may be considered in
secondary care.

12. Management:
 The child in the vignette had no red flag features of constipation&initial
treatment failed because he could not tolerate the unpleasant side effects.
 Explanation of idiopathic constipation&supported treatment would help
this child & his family.
 Explain:Constipation is distressing&painful; soiling causes anxiety.
 Explain to children, if possible&their carers what happens to the bowel
during constipation.
 Explain how overflow incontinence occurs & how this can be perceived as
diarrhoea when the child is still constipated.
 A diagram can aid this discussion.

13. Management:
 Encourage helpful behaviours:
 Emphasise that constipation is not the child’s fault.
 Reprimands make things worse.
 Encourage parents&carers to use positive reinforcement to help the child
establish a regular bowel habit.
 Toileting reward charts can encourage a regular routine.
 Reward behaviours rather than achievements, accepting that accidents
occur.
 This can help re-establish a regular bowel pattern.

16. Explaining overflow
incontinence. “When
old poo becomes hard
&stuck in the intestine,
new poo can leak
around the edges. It
may leak onto
underwear& cause
accidents. Sometimes
children do not know
this is happening as
the old poos stop them
feeling that they need
to poo. Treatment aims
to help move the old
poo out, so the
intestine can start to
function properly again

17. Management:Non-pharma
 Guidance from NICE recommends non-pharmacological management in
conjunction with laxatives, as dietary interventions alone are unlikely to
work.
 Recommend a balanced fibrous diet & see if drinking more fluids helps.

18. Management:Pharma
 Laxatives:
 NICE recommends commencing treatment with macrogols initially: two
paediatric macrogol preparations are licensed for use in children under 12.
 An osmotic alternative such as lactulose may sometime be preferred,
depending on the patient, as it is very sweet&can be given with water.
 Stimulant laxatives may be required in addition; many children find liquid
senna unpalatable but tablets can be taken by ped >2 (off-label <6).
 Explain to parents&carers how laxatives work.
 Ped macrogol laxatives can be flavoured (chocolate, lemon, lime) or plain.
 Other laxatives may need to be prescribed off-licence, eg, different
flavoured macrogols, if these are the most appropriate for the patient.
 Once prepared, the liquid can be mixed with anything the child likes, such
as hot chocolate or cordial.
 Offer further resources to parents / carers&allow sufficient time to explain
the treatment: many parents do not expect side effects &may not realise
the length of treatment required.

20. Management:dis-impaction
 Considered for children who do not open their bowels effectively for seven
or more days.
 Impaction may present with or without hard stool palpable on abd exam.
 Explain that disimpaction treatment can initially increase soiling, gaseous
distension&abdominal pain.
 Suggest paracetamol for pain.
 If feasible, time the regimen for when the child is not at school or nursery,
such as in the holidays& If this is not possible, the child may require a
letter of absence.
 Use an increasing dose regimen of a macrogol laxative as Movicol
paediatric plain.
 Add a stimulant laxative, as senna, if required after two weeks.
 If macrogol is not tolerated, substitute with a stimulant laxative singly or
use in combination with an osmotic laxative lactulose.
 Review children undergoing disimpaction within one week.

21. Management:maintenance
 Start maintenance treatment as soon as the child is disimpacted.
 Describe this to parents as when the child has “watery poo.”
 Continue maintenance treatment after regular bowel habit is established,
usually for at least as long as the child has been constipated,may take
several months& some require ongoing laxative treatment.
 Adjust the regimen to achieve one soft, formed stool every day.
 Do not stop treatment abruptly; gradually reduce the dose in response to
stool consistency/frequency.
 Emphasise that stopping treatment too early will often result in recurrence
/ chronicity,particularly important for children who re-present after
attempting treatment.
 Reassess children according to their progress & needs,done after six weeks,
to ensure that re-impaction does not occur , to review adherence& toileting
behaviours.

22. Management:Referral
 Refer to paediatrics for any red flag features.
 Consider referring children <1 year? with probable idiopathic constipation
unresponsive to treatment within four weeks.
 Refer children >1 year? not responding to treatment, despite appropriate
dosage&good treatment compliance, within three months&any child
unable to wean from laxatives after 12 months.