Management of Constipation

Stage 1

• Dietary management of constipation

High-fibre foods

• Avoid excessive white bread
  
• Encourage wholewheat bread or bran
  
• High-fibre cereals

Stool softeners

• Fruit (particularly the peel), vegetables
  
• Beans and nuts
  
• Drink 6–8 glasses of water or juice per day
  
• Have a bottle of water available during school time
  
• Fluids of any sort, especially fresh orange or prune juice
  
• In babies, try boiled water or fresh orange juice between milk feeds

Stage 2: Disimpaction (for 1–2 Weeks or Until Symptoms Resolve)

• Laxatives:
  
  
  
  • Iso-osmotic agents such as polyethylene glycol (e.g. Movicol) carry water to the stool, softening and lubricating it. Increase the dose until the stools become liquid, then reduce,
    
  • Stimulant laxatives such as sodium picosulfate, bisacodyl, senna or ducosate sodium should be added if polyethylene glycol is ineffective.
    
  • Osmotic laxatives (e.g. lactulose) draw fluid into the bowel and can be used if polyethylene glycol is not tolerated.
  
  
• Bulking agents: absorb water and make stool softer (e.g. Fybogel).
  
• Glycerin suppositories are useful in babies.
  
• Enemas: may rarely be required in severe constipation if oral treatment has failed.
  
• Manual evacuation under general anaesthetic: occasionally required in extreme cases, usually in children with other problems such as severe learning difficulties.

Stage 3: Maintenance

• Stools should be kept soft by either diet (see box) or laxatives (polyethylene glycol ± stimulant )for 3–6 months.
  
• Encourage daily bowel movements by sitting the child on the toilet at a fixed time once or twice each day for 5–10 min. If done after eating this makes use of the gastrocolic reflex.

Stage 4: Vigilance

• Start or escalate treatment at the first indication of recurrence of hard stools.