🔑 Key Learning
- Affects up to 20% of UK children; common in primary care.
- Red flags include delayed meconium, abnormal anus, and neuro signs.
- Macrogol is 1st line for both disimpaction and maintenance.
- Overflow soiling + palpable mass = faecal impaction.
- Consider perianal strep if red, painful perianal area.
👀 Clinical Features
Suggestive of constipation:
- < 3 stools per week (unless exclusively breastfed - may be less frequent)
- Large, hard, or pellet-like stools, 'rabbit droppings'
- Straining, pain or bleeding
- Overflow soiling
- Poor appetite
Suggestive of faecal impaction:
- Severe constipation history
- Overflow soiling
- Palpable faecal mass on examination
🚩 Red Flags (Urgent Referral to Paediatrics)
- Onset of symptoms in first weeks of life
- Delayed meconium (>48 hrs)
- Family history of Hirschsprung’s disease
- Ribbon stools (suggesting anal stenosis)
- Neuro signs or motor delay
- Abnormal lumbosacral, gluteal, or anal anatomy
🟠 Amber Flags (Refer + start treatment)
- Failure to thrive or delayed development
- Suspected maltreatment
- Symptoms began after introduction of cow’s milk
🧴 Perianal Streptococcal Dermatitis
- Bright red perianal erythema ± oedema
- May be associated with painful defecation and withholding
💊 Management
Faecal Impaction
- 1st line: Macrogol (e.g. Movicol) with escalating dose:
- 1–5 yrs: start at 2 sachets/day, increasing to max 8/day
- 2nd Line:
- If unresolved after 2 weeks, add stimulant laxative (e.g. senna)
- If macrogol not tolerated: use senna ± lactulose
Maintenance Therapy
1st Line:
- Macrogol until soft, regular stools achieved
2nd Line:
- Add stimulant laxative (senna) if response inadequate
- If macrogol not tolerated, switch to senna ± lactulose
- Continue treatment for several weeks after resolution
🍽️ Diet & Lifestyle
- Scheduled toilet times with reward systems
- Encourage fibre-rich diet and increased fluid intake
📝 Exam Clues & Clinchers
-
Overflow soiling + palpable mass = faecal impaction
- 1st line: Disimpaction regimen with escalating dose of macrogol
- Ribbon-like stools in an infant = think anal stenosis
- Bright red perianal rash = perianal strep
- Delayed meconium = consider Hirschsprung's or CF