Constipation: more than a case of straining

Constipation might not seem like a serious condition but in 2023/24, 63,781 patients were admitted to hospital with a primary diagnosis of constipation. Out of these patients, 13,716 were under 16 and 5,624 were under 5. [2] The number of admissions in children has not seen much change in the past decade.

Table 1 shows the diagnostic criteria for constipation based on the NICE guidelines. [3]

Hydration is also crucial alongside laxatives. The most commonly prescribed laxatives in children are osmotic laxatives, which 'draw water from the rest of the body into your bowel to soften poo and make it easier to pass'. [10] The amount of fluid a child needs to have depends on age, physical activity and the weather, as well as other individual factors. Table 2 shows the guideline amounts from the NICE guidelines. These are not easy to achieve so support should be offered to encourage fluid intake, making drinking routine and fun. Further ideas to achieve good levels of hydration can be found in the infographic in this previous hub article: what you need to know about children and hydration. [11]

When it comes to diet, the NICE guidelines are very generalised. The focus is on ensuring sufficient fibre and following the Eatwell Guide. There are some additional notes added – to avoid recommending unprocessed bran, fibre supplements, or switching formula (unless advised by specialist services) – but in terms of putting this advice into practice for families, there is little guidance. Perhaps this is why families I see in clinic have often just been told to give more fibre without knowing how to do that.

Sudden, drastic increases in fibre can be problematic, so gradually increasing is recommended. Table 3 gives some practical ideas to increase the fibre in a child’s diet, to be offered alongside advice on portion sizes.

In addition to fibre, supporting the family to improve their overall dietary patterns in line with the Eatwell Guide (for age 2 plus) will benefit overall health. Diets which are high in refined and processed foods, and foods which are high in fat can increase the risk of constipation. Particularly in toddlers, checking the amount of dairy which is being consumed is important too. Some toddlers have well over the recommended amount of milk per day, as well as having cheese and yoghurt. Three portions of dairy a day is recommended, with a portion being 200–250ml of milk, a small matchbox-sized piece of cheese or about 100g of yoghurt.

Careful consideration should be given to the family’s current dietary preferences and patterns, as well as their culture, before making recommendations. Including foods in the recommendations that are familiar to them is likely to be more successfully implemented.

Some constipation is due to the presence of other conditions but constipation is often preventable through lifestyle interventions. Encouraging children to go to the toilet when they feel the first urge, rather than withholding and so increasing the stool hardness, is crucial. Withholding often happens around potty training or a change in routine, for example starting school.

In addition, following the same steps of regular physical activity, adequate hydration and good diet in the same way as would be encouraged with the management of constipation is also key to prevention. Where families need extra support, the children’s bowel and bladder charity, ERIC, is a useful place to signpost to. They conduct regular free webinars, have a free helpline and have resources on their website. [14]