constipation (children & young people)

• Most constipation is functional, but always screen for red flags (delayed meconium, faltering growth, severe abdominal distension, abnormal anus/spine/neuro signs).
• First-line disimpaction: macrogol (PEG) with electrolytes, escalating daily; add stimulant if response inadequate.
• Maintenance: continue macrogol at a maintenance dose once disimpacted; expect months of treatment (not “a week and stop”).
• Behavioural plan is non-optional: toileting after meals, footstool, reward system, education for parent/child.
• Encopresis/soiling: treat as constipation with overflow; avoid blaming—focus on disimpaction + maintenance + support.

• History: stool frequency/consistency (Bristol), painful defecation, withholding behaviours, rectal bleeding, soiling, urinary symptoms, diet/fluids, psychosocial stressors, medications.
• Examination: abdominal mass/distension, perianal inspection (fissure/skin tags), growth parameters, back/spine/neuro (lower limb tone/reflexes) if concern.
• Red flags for organic disease: delayed passage of meconium, failure to thrive, persistent vomiting, severe distension, abnormal anal position/appearance, neurological signs, systemic illness.

Step 1 — start PEG/macrogol with electrolytes (age-appropriate dosing per BNFC/local protocol):

• Use a graduated, escalating daily regimen until stool output becomes loose and the rectum is cleared.
• Warn families: stool volume may be large; transient soiling is common during clearance.

Step 2 — if inadequate response:

• Add a stimulant laxative (e.g., senna or sodium picosulfate), especially if stool remains hard/impacted.
• Escalate/seek paediatric advice if severe pain, no response, or significant red flags.

Rectal interventions (suppositories/enemas) are generally second-line and often need specialist direction, especially in younger children or where safeguarding/trauma concerns exist.

• Once disimpacted, continue macrogol as maintenance for a prolonged period (often several months), then taper slowly.
• Set expectations: relapse is common if treatment stops early or the toileting plan is weak.
• Consider comorbidities: neurodevelopmental conditions, anxiety, bullying, painful fissures.

Behavioural plan:

• Toileting 5–10 minutes after meals (gastro-colic reflex)
• Foot support (knee flexion improves evacuation)
• Reward for sitting and effort, not only “results”
• School plan if needed (access to toilet, privacy, hydration)

References (Harvard):

• NICE (2017) Constipation in children and young people: diagnosis and management (CG99). https://www.nice.org.uk/guidance/cg99