Red flags: When to be concerned- Delayed passage of meconium (after 48 hours of age in a term infant)
- Onset in the neonatal period
- Abnormal neurology
- ‘Ribbon’ stools: suggests Hirschsprung’s disease
- Steatorrhoea: suggests malabsorption, e.g. cystic fibrosis
- Disclosure/history or signs of child abuse
- Gross abdominal distension or with vomiting: suggests obstruction
- Anaemia
- Faltering growth
Management
Information and explanation
A central part of management is to demystify the process of defaecation and toileting behaviour, and to understand the psychosocial context. Parents’ and child’s expectations need to be understood and met to be able to agree a management strategy that can be maintained over a long time period. Re-iteration during follow-up is often required.
Dietary management
- Oral fluid intake should be adequate, but not excessive
- Dietary fibre manipulation is rarely useful, and increasing dietary insoluble fibre, e.g. bran, may worsen symptoms by increasing stool bulk without softening, and causing flatulence
- There is no evidence of benefit from probiotics
Toileting
A routine of sitting on the toilet after meals in the morning and evening encourages regular bowel movements, which is central to managing functional constipation. Stool withholding increases the likelihood of colonic loading, therefore impaction and overflow soiling. Thus, withholding should be addressed by encouraging toiling when the ‘call to stool’ is recognised. This routine is established using positive reinforcement of behaviours, appropriate to developmental stage, in a non-confrontational manner. Colonic motility is promoted by physical activity.
Biofeedback training with anorectal manometry is rarely used in children.
Medical management
Laxative medications are used to support behavioural modifications.
Disimpation
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