For Providers: Constipation Guidelines
This clinical tool is intended to be used as a training tool for providers and also as a resource for primary care physicians during clinic.
Treating Constipation
This toolkit is designed to help clinicians clearly evaluate and manage constipation in children older than one year. This includes guides through history and physical examination, identification of red flags, assessment for fecal impaction or fecal incontinence, disimpaction when needed, maintenance therapy and follow-up.
Constipation management in a pediatric practice may be common, but identifying patients who may need pediatric gastroenterology consultation or referral may be more complex. This guide includes age- and weight-based disimpaction protocols, maintenance medication guidance, family education and an appendix with diagnostic criteria for fecal impaction and recommended history questions.
How Can Primary Care Providers Screen for Constipation?
Assessment begins with a history and physical examination, including a perianal examination and consideration of a digital rectal exam. Clinicians should ask about bowel movement frequency, stool consistency and size, pain or straining with stool passage, blood in the stool, stool accidents and the sensation of incomplete evacuation.
Fecal impaction is defined as a significant amount of stool in the rectum and colon in the setting of constipation-associated fecal incontinence or encopresis, or incomplete or infrequent evacuation. Evidence of impaction may include a hard mass in the lower abdomen, a dilated rectum filled with stool on rectal examination or excessive stool in the distal colon on abdominal radiography.
What Are the Signs and Symptoms of Constipation?
Children with constipation may have infrequent or incomplete bowel movements, hard or large stools, straining, pain with stool passage or stool accidents. Clinicians should ask families whether stools are large enough to clog the toilet, whether blood is present and whether the child feels completely emptied after a bowel movement. Stool accidents may include small streaks or smears in underwear or full bowel movements outside the toilet.
Certain findings may suggest an underlying condition rather than uncomplicated constipation. History red flags include:
- Constipation beginning in the first month of life
- Delayed passage of meconium
- Ribbon or thin stools
- Unexplained blood in the stool
- History of poor feeding or failure to thrive
- Fever and bilious vomiting
Physical examination concerns include:
- Severe abdominal distension
- Abnormal perianal findings
- Decreased lower-extremity strength or reflexes
- Sacral abnormalities
- Evidence of bowel obstruction
How Is Constipation Treated?
Treatment depends on whether fecal impaction or soiling is present. Children with impaction should undergo a disimpaction or bowel clean-out protocol, followed by maintenance therapy. Guidelines should be used for age- and weight-based regimens using PEG 3350 and senna. An enema may be considered when a large stool mass is present.
Maintenance therapy should include:
- A balanced diet with whole grains
- Fruits and vegetables
- Age-appropriate fluid intake
- Daily toilet sitting
- Daily laxative therapy at an appropriate dose
- PEG 3350 or lactulose may be used as osmotic laxatives, with doses adjusted to achieve one to two soft bowel movements per day. A stimulant laxative may be added if stool-softening therapy alone is ineffective.
Families should use positive reinforcement, establish regular toilet sitting and continue therapy consistently. Follow-up within several weeks is recommended to assess progress. Once the child is doing well, maintenance therapy should continue for at least six months.
When to Refer and Laboratory Testing
Consider pediatric gastroenterology consultation or referral when:
- A red flag (identified in the Signs and Symptoms section) is identified in the history or physical examination.
- The patient does not respond to an appropriate disimpaction regimen.
- Constipation persists despite the recommended daily dose of laxative therapy.
- Symptoms continue despite appropriate maintenance treatment and good adherence.
- Additional evaluation is needed because an underlying gastrointestinal condition is suspected.
If disimpaction is unsuccessful, clinicians should review adherence and social determinants of health and repeat or intensify the clean-out protocol when appropriate. After repeated unsuccessful attempts, clinicians should obtain laboratory studies and contact pediatric gastroenterology for consultation.
For patients who are not improving, suggested laboratory evaluation may include :
- CBC
- BMP
- Thyroid studies
- Tissue transglutaminase IgA
- Total IgA
- Lead testing when risk factors are present
When referring, clinicians should send relevant growth curves, laboratory and radiology results, the reason for referral and details of previous treatment regimens.
