Peds GI

Constipation in children
The frequency at which children open their bowels varies widely but generally
decreases with age from a mean of 3 times per day for infants under 6 months old to
once a day after 3 years of age.
NICE produced guidelines in 2010 on the diagnosis and management of constipation in

children. A diagnosis of constipation is suggested by 2 or more of the following:
Stool Pattern:
Child <1 year:

Fewer than 3 complete stools per week (type 3 or 4 on Bristol stool form scale)
(doesn't apply to exclusively breastfed babies after 6 weeks of age)
Hard large stool
Rabbit droppings (T1)
hild >1 year:

Fewer than 3 complete stools per week (3 or 4)
Overflow soiling (commonly very loose, very smelly, stool passed without
sensation)
'Rabbit droppings' (type 1)
Large, infrequent stools that can block the toilet
Symtpoms associated with defecation:
Child<1 yr:
Distress on passing stool

Bleeding associated with hard stool
Straining
Child >1 yr:

Poor appetite that improves with passage of large stool waxing and waning of
abdominal pain with passage of stool
Evidence of retentive posturing: typical- straight legged, tiptoed, back arching
posture
Straining
Anal pain
Hx:
Child<1 yr:
Previous episode of constipation
Previous or current anal fissure
Child>1 yr:
Previous episode(s) of constipation
Previous or current anal fissure
Painful bowel movements and bleeding associated with hard stools
The vast majority of children have no identifiable cause - idiopathic constipation.

Other causes of constipation in children include:
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung's disease
hypercalcaemia
learning disabilities
After making a diagnosis of constipation NICE then suggesting excluding secondary

causes. If no red or amber flags are present then a diagnosis of idiopathic
constipation can be made:
The following indicate Idiopathic constipation:
Timing:
Starts after a few weeks of life
Obvious precipitating factors coinciding with the start of symptoms: fissure,
change of diet, timing of potty/toilet training or acute events such as infections,
moving house, starting nursery/school, fears and phobias, major change in family,
taking medicines
Passage of meconium:
<48 hours
Stool pattern ----
Growth:
Generally well, weight and height within normal limits, fit and active
Neuro/locomotor:
No neurological problems in legs, normal locomotor development
Abdomen: -----
Diet: Changes in infant formula, weaning, insufficient fluid intake or poor

diet
Red flag suggesting underlying disorder:
Timing:
Reported from birth or first few weeks of life
Passage of meconium:
>48 hrs
Stool pattern: Ribbon stool
Growth: Faltering growth is an amber flag
Neuro/locomotor: Previously unknown or undiagnosed weakness in legs, locomotor

delay
Abdomen: Distension
Diet: ----
Other: Amber flag: Disclosure or evidence that raises concerns over possibility of
child maltreatment
Prior to starting treatment, the child needs to be assessed for faecal impaction.
Factors which suggest faecal impaction include:
symptoms of severe constipation
overflow soiling
faecal mass palpable in the abdomen (digital rectal examination should only be
carried out by a specialist)
NICE guidelines on management
If faecal impaction is present

polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an
escalating dose regimen as the first-line treatment
add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction
after 2 weeks
substitute a stimulant laxative singly or in combination with an osmotic laxative
such as lactulose if Movicol Paediatric Plain is not tolerated
inform families that disimpaction treatment can initially increase symptoms of
soiling and abdominal pain
Maintenance therapy
very similar to the above regime, with obvious adjustments to the starting dose,
i.e.
first-line: Movicol Paediatric Plain
add a stimulant laxative if no response
substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add
another laxative such as lactulose or docusate if stools are hard
continue medication at maintenance dose for several weeks after regular bowel habit
is established, then reduce the dose gradually
General points
do not use dietary interventions alone as first-line treatment although ensure the
child is having adequate fluid and fibre intake
consider regular toileting and non-punitive behavioural interventions
for all children consider asking the Health Visitor or Paediatric Continence
Advisor to help support the parents.
The NICE guidelines do not specifically discuss the management of a very young
child. The following recommendations are largely based on the old Clinical
Knowledge Summaries recommendations.
Infants not yet weaned (usually < 6 months)

bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage
and bicycling the infant's legs
breast-fed infants: constipation is unusual and organic causes should be considered
Infants who have or are being weaned

offer extra water, diluted fruit juice and fruits
if not effective consider adding lactulose
Threadworms:
Infestation with threadworms (Enterobius vermicularis, sometimes called pinworms)

is extremely common amongst children in the UK. Infestation occurs after swallowing
eggs that are present in the environment.
Threadworm infestation is asymptomatic in around 90% of cases, possible features

include:
perianal itching, particularly at night
girls may have vulval symptoms
Diagnosis may be made by the applying Sellotape to the perianal area and sending it
to the laboratory for microscopy to see the eggs. However, most patients are
treated empirically and this approach is supported in the CKS guidelines.
Management
CKS recommend a combination of anthelmintic with hygiene measures for all members
of the household
mebendazole is used first-line for children > 6 months old. A single dose is given
unless infestation persists
Dose of mebendazole should be repeated 2 weeks after initial dose. All household
contacts should be treated, and general measures closely stuck to (washing bedding
daily for the first few days, washing as soon as rising in the morning, keeping
nails very short and clean
Gastro-oesophageal reflux in children
Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. Around 40%

of infants regurgitate their feeds to a certain extent so there is a degree of
overlap with normal physiological processes.
Risk factors
preterm delivery
neurological disorders
Features
typically develops before 8 weeks
vomiting/regurgitation
milky vomits after feeds
may occur after being laid flat
excessive crying, especially while feeding
Diagnosis is usually made clinically
Management (partly based on the 2015 NICE guidelines)

advise regarding position during feeds - 30 degree head-up
infants should sleep on their backs as per standard guidance to reduce the risk of
cot death
ensure infant is not being overfed (as per their weight) and consider a trial of
smaller and more frequent feeds
a trial of thickened formula (for example, containing rice starch, cornstarch,
locust bean gum or carob bean gum)
a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same
time as thickening agents
NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in
infants and children occurring as an isolated symptom. A trial of one of these
agents should be considered if 1 or more of the following apply:
unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth
ranitidine was previously used as an alternative to a PPI but was withdrawn from
the market in 2020 as small amounts of the carcinogen N-nitrosodimethylamine (NDMA)
were discovered in products from a number of manufacturers.
prokinetic agents e.g. metoclopramide should only be used with specialist advice
Complications
distress
failure to thrive
aspiration
frequent otitis media
in older children dental erosion may occur
If there are severe complications (e.g. failure to thrive) and medical treatment is
ineffective then fundoplication may be considered
Diarrhoea and vomiting in children
Diarrhoea and vomiting is very common in younger children. The most common cause of
gastroenteritis in children in the UK is rotavirus. Much of the following is based
around the 2009 NICE guidelines (please see the link for more details).
Clinical features
NICE suggest that typically:

diarrhoea usually lasts for 5-7 days and stops within 2 weeks
vomiting usually lasts for 1-2 days and stops within 3 days
When assessing hydration status NICE advocate using normal, dehydrated or shocked
categories rather than the traditional normal, mild, moderate or severe categories.
Clinical Dehydration:
Appears to be unwell or deteriorating
Decreased urine output
Skin colour unchanged
Warm extremities
Altered responsiveness (for example, irritable, lethargic)
Sunken eyes
Dry mucous membranes
Tachycardia
Tachypnoea
Normal peripheral pulses
Normal capillary refill time
Reduced skin turgor
Normal blood pressure
Clinical Shock:
Decreased level of consciousness
Cold extremities
Pale or mottled skin
Tachycardia
Tachypnoea
Weak peripheral pulses
Prolonged capillary refill time
Hypotension
The following children are at an increased risk of dehydration:

children younger than 1 year, especially those younger than 6 months
infants who were of low birth weight
children who have passed six or more diarrhoeal stools in the past 24 hours
children who have vomited three times or more in the past 24 hours
children who have not been offered or have not been able to tolerate supplementary
fluids before presentation
infants who have stopped breastfeeding during the illness
children with signs of malnutrition
Features suggestive of hypernatraemic dehydration:

jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
Diagnosis
NICE suggest doing a stool culture in the following situations:

you suspect septicaemia or
there is blood and/or mucus in the stool or
the child is immunocompromised
You should consider doing a stool culture if:

the child has recently been abroad or
the diarrhoea has not improved by day 7 or
you are uncertain about the diagnosis of gastroenteritis
Management:
If clinical shock suspected - admit for IV rehydration
For children with no evidence of dehydration:

Continue BF and other milk feeds
Encourage fluid intake
Discourage fruit juices and carbonated drinks
If dehydration is suspected:
give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours,
plus ORS solution for maintenance, often and in small amounts
continue breastfeeding
consider supplementing with usual fluids (including milk feeds or water, but not
fruit juices or carbonated drinks)
An infant that has reflux who is not distressed and is growing well - required
observation but no treatment initially

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Constipation in children

NICE produced guidelines in 2010 on the diagnosis and management of constipation in

Child <1 year:

hild >1 year:

Symtpoms associated with defecation:

Distress on passing stool

Child >1 yr:

The vast majority of children have no identifiable cause - idiopathic constipation.

After making a diagnosis of constipation NICE then suggesting excluding secondary

The following indicate Idiopathic constipation:

Stool pattern ----

Diet: Changes in infant formula, weaning, insufficient fluid intake or poor

Red flag suggesting underlying disorder:

Stool pattern: Ribbon stool

Growth: Faltering growth is an amber flag

Neuro/locomotor: Previously unknown or undiagnosed weakness in legs, locomotor

NICE guidelines on management

If faecal impaction is present

Infants not yet weaned (usually < 6 months)

Infants who have or are being weaned

Infestation with threadworms (Enterobius vermicularis, sometimes called pinworms)

Threadworm infestation is asymptomatic in around 90% of cases, possible features

Gastro-oesophageal reflux in children

Gastro-oesophageal reflux is the commonest cause of vomiting in infancy. Around 40%

Diagnosis is usually made clinically

Management (partly based on the 2015 NICE guidelines)

Diarrhoea and vomiting in children

NICE suggest that typically:

The following children are at an increased risk of dehydration:

Features suggestive of hypernatraemic dehydration:

NICE suggest doing a stool culture in the following situations:

You should consider doing a stool culture if:

If clinical shock suspected - admit for IV rehydration

For children with no evidence of dehydration:

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