- Constipation from birth or within first few weeks
- Failure to pass meconium in first 48 hours
- Ribbon stools (more likely in <1 yr)
- Undiagnosed or new weakness in legs
- Motor delay
- Abdominal distension with vomiting, or gross abdominal distension even without vomiting mentioned
- Abnormal appearance, position, or patency of anus. Look for fistulae, bruising, tight anus or patulous anus, anteriorly placed anus, absent anal wink.
- Abnormalities of the spine, lumbosacral region, or gluteal muscles – flattened or asymmetrical glutei, naevus/discoloured skin, hairy patch, lipoma, central pit (dimple with base not visible), evidence of sacral agenesis, scoliosis.
- Unexplained neuromuscular abnormalities – talipes or other lower limb abnormalities, neurological signs unexplained by existing conditions
- Abnormal reflexes (no need to check routinely – only if red flags already on history/examination)
- Evidence of possible maltreatment on history/examination
Refer urgently if:
- any red flags present
- non-response to optimum treatment in a child <1yr.
Refer if no response to treatment within three months.
If constipation is associated with faltering growth, test for coeliac disease and hypothyroidism.
If a patient cannot tolerate the escalating regime of PEG as treatment for constipation, second-line treatment is a stimulant such as sodium picosulfate either on its own or in combination with a softener such as lactulose. This can also be used for impaction, rather to my surprise.
Continue maintenance after disimpaction. Try starting with half the disimpaction dose. When treating constipation, continue laxatives until several weeks after regular bowel habit is achieved – which may take several months – and tail off gradually over a further period of months. Also make sure that behavioural interventions are instituted (regular toileting, encouragement and rewards).
(BMJ learning module)