Changes

August 2025 — reviewed. A literature search was conducted in August 2025 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No changes have been made to the recommendations.

Update

Goals

To support primary healthcare professionals to:

• Identify and treat children with constipation and faecal impaction promptly.
• Manage idiopathic constipation effectively in primary care, if appropriate.
• Refer for specialist assessment if there are identified red or amber flags suggesting a potentially serious underlying cause.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Constipation in children and young people

• Children and young people with constipation receive a full assessment before a diagnosis of idiopathic constipation is made.
• Children and young people with idiopathic constipation receive oral macrogols as first-line treatment.
• Children and young people with idiopathic constipation starting disimpaction therapy have their treatment reviewed by a healthcare professional within 1 week.
• Children and young people with idiopathic constipation starting maintenance therapy have their first treatment review by a healthcare professional within 6 weeks.
• Children and young people with idiopathic constipation starting laxative treatment, or their parents or carers, receive written information about laxatives.
• Children and young people with idiopathic constipation that does not respond to initial treatment within 3 months are referred to a healthcare professional with expertise in the problem.

[NICE, 2014]

What is it?

• Constipation is a decrease in the frequency of bowel movements characterized by the passing of hard stools, which may be large, and associated with straining and pain. Soiling of the clothes (the involuntary passage of fluid or semi-solid stool) may result from overflow from the overloaded bowel, and stool retention (faecal impaction) may occur. 
• In the UK, the normal stool frequency in children ranges from an average of four per day in the first week of life to two per day at 1 year of age. The normal adult range (between three stools per day and three stools per week) is usually attained by 4 years of age. 
• Constipation is termed idiopathic (functional) if it cannot currently be explained by a known cause (any anatomical, physiological, radiological, or histological abnormality). 
• Chronic constipation is constipation lasting longer than 8 weeks. 

[NICE, 2023]

What causes it?

• Functional constipation, where there is no organic cause, is the most common type of constipation in children and adolescents, accounting for 95% of cases. 
• Only 5% of constipation cases in children and adolescents can be attributed to an underlying aetiology, such as:
  • Anorectal malformations.
  • Coeliac disease.
  • Cystic fibrosis.
  • Down's syndrome.
  • Hirschsprung disease.
  • Neuromuscular disorders.
  • Spinal cord abnormalities.
• Contributing factors for constipation include: 
  • A family history of constipation. 
  • Drugs such as sedating antihistamines or opioids.
  • Fever.
  • Inadequate fluid intake.
  • Pain.
  • Psychosocial issues.
  • Reduced dietary fibre intake.
  • Toilet training issues.
• Constipation is more common in children: 
  • Who are physically inactive.
  • With impaired mobility (for example, children with cerebral palsy).
  • With a neurodevelopmental disorder (such as Down's syndrome or autism spectrum disorder). 

[Auth, 2012; Mulhem, 2022; NICE, 2023]

How common is it?

• Childhood constipation accounts for 3–5% of general paediatric consultations [Mutyala, 2020] and up to 25% of paediatric gastroenterology referrals [Madani, 2016; Mulhem, 2022].
• The prevalence of childhood constipation is 10–20% in the UK, depending on the criteria used for diagnosis [Auth, 2012].
  • In the UK, 30% of children aged 4–11 years will have constipation lasting less than 6 months, and 5% will have constipation lasting more than 6 months.
• Constipation is equal in both sexes below 5 years old, and is more common in girls aged over 13 years. Peak incidence of constipation is at the time of toilet training (typically around 2–3 years of age) [Afzal, 2011].
• Constipation is largely under-reported as the signs and symptoms frequently go unrecognized. It may manifest with withholding behaviours to prevent the painful passage of stools; these are often confused with straining. Parents may not be aware of the link between soiling and constipation. 

[NICE, 2023]

What are the complications and prognosis of idiopathic constipation?

• Complications of idiopathic constipation include:
  • Anal fissure, which may exacerbate a vicious cycle of pain leading to stool withholding, hard stool, and ongoing constipation.
  • Haemorrhoids. 
  • Rectal prolapse. 
  • Megarectum. 
  • Faecal impaction and soiling.
  • Volvulus. 
  • Behavioural and social problems. 
• The prognosis of idiopathic constipation varies with each child and family:
  • Outcomes are improved when constipation is identified and treated promptly — in children referred to a gastroenterologist, a delay in initial medical treatment of over 3 months from symptom onset correlates with a longer duration of symptoms.
  • In a systematic review of 14 prospective observational studies (n = 1752), a mean of 49.3% of children had recovered and were taken off laxatives after 6–12 months follow up, and overall 60.6% of children were free from symptoms, regardless of laxative use, after 6–12 months follow up [Pijpers, 2010].
  • In the UK, 5% of children between the ages of 4 and 11 years suffer from constipation lasting more than 6 months. Chronic constipation (duration longer than 8 weeks) generally develops in children aged between 1 and 4 years of age (the pattern of bowel movement tends to be established by 4 years of age).
  • A Dutch prospective follow-up study of 401 children with functional constipation who were referred to a tertiary hospital clinic found symptoms improved in 80% of children by 16 years of age (median follow-up duration of 11 years), but the remainder continued to experience symptoms into adulthood [Bongers, 2010].

[Afzal, 2011; Auth, 2012; Tabbers, 2014; COMPASS, 2016; NICE, 2023]

How should I assess a child with suspected constipation?

• Take a medical history and ask about:
  • The timing of the onset of constipation and possible precipitating factors.
    • For newborns, ask if the passage of meconium was normal (within 48 hours after birth in a term baby). 
  • The frequency of bowel movements.
  • The size and consistency of stools.
  • Soiling (in toilet-trained children).
  • Pain with bowel movements.
  • Bleeding or mucus passed with stools.
  • Retentive posturing (typical straight-legged, tiptoed, back-arching posture).
  • Straining. 
  • Distress on stooling. 
  • Abdominal distension or pain. 
  • Vomiting. 
  • Appetite and fluid intake.
  • Dietary changes. 
  • A previous history of constipation. 
  • A previous or current anal fissure. 
  • A family history of Hirschsprung disease. 
  • The presence of withholding behaviours.
  • Medication history.  
  • Urinary symptoms.
• Perform an examination to exclude red flags:
  • Inspect the perianal area for appearance, position and patency.
  • Perform an abdominal examination.
  • Inspect the spine/lumbosacral and gluteal regions.
  • Conduct a lower limb neuromuscular examination (including tone and strength).
• Do not undertake digital rectal examination in primary care unless competent to interpret features of anatomical abnormality or Hirschsprung’s disease. 

When should I diagnose constipation in a child?

• Diagnose constipation in a child presenting with two or more of the following: 
  • Stool patterns:
    • Fewer than three complete stools a week (unless exclusively breastfed, when stools may be infrequent) — stools are typically semi-soft (type 3 or 4 on the Bristol Stool Form Scale).
    • Hard, large stool (may block the toilet in children older than 1 year of age).
    • 'Rabbit droppings' stools (type 1 on the Bristol Stool Form Scale).
    • Overflow soiling in children older than 1 year of age (typically very loose, smelly stools that are passed without sensation or awareness; may also be thick and sticky, or dry and flaky).
  • Symptoms associated with defecation in a child at any age:
    • Distress or pain on passing stool.
    • Bleeding associated with hard stool.
    • Straining.
  • Symptoms associated with defecation in a child older than 1 year of age:
    • Poor appetite that improves with passage of large stool.
    • Waxing and waning of abdominal pain with passage of stool.
    • Evidence of 'retentive posturing' — typical posture is straight-legged, on tiptoes with an arched back.
    • Anal pain.
  • Past history of constipation.
  • Previous or current anal fissure.
• Diagnose faecal impaction (a large faecal mass in the rectum) in a child presenting with a combination of:
  • A history of severe symptoms of constipation. 
  • The presence of overflow soiling. 
  • Faecal mass palpable on abdominal examination. 
• If constipation is diagnosed, exclude red or amber flags before making a working diagnosis of idiopathic constipation. 
• Digital rectal examination is not routinely recommended for the diagnosis of constipation or faecal impaction. 

What clinical features are suggestive of idiopathic constipation in a child?

Exclude an underlying disorder or condition causing constipation by assessing for the presence of red and amber flags. If there are no red or amber flags:

• Features in the history that are suggestive of idiopathic constipation, including:
  • Meconium passed within 48 hours of birth (in a full-term baby). 
  • Onset of constipation at least a few weeks after birth. 
  • Presence of precipitating factors:
    • Dietary factors (for example, changes to infant formula or weaning, poor diet, or insufficient fluid intake). 
    • Acute illness, such as infection.
    • Anal fissure. 
    • Use of drug treatments such as sedating antihistamines or opiates.
    • Timing of potty or toilet training.
    • Psychosocial factors such as moving house, starting nursery or school, other major changes in family circumstances, and fears and phobias. 
• In a physical examination of a child with idiopathic constipation: 
  • There is a normal appearance of the anus and surrounding area.
    • Digital rectal examination is not routinely required to make the diagnosis. 
  • The abdomen is soft and flat, or distended only to a degree consistent with age or excess weight.
  • They are generally well with normal development, and height and weight are within normal limits. 
  • The appearance of the skin and anatomical structures of the lumbosacral/gluteal regions are normal. 
  • Motor and neurodevelopment are within normal limits (including normal gait, tone, and power in lower limbs). 
• Note: in some children, constipation may be associated with perianal streptococcal infection. 
• No specific investigations (such as abdominal X-ray or ultrasound scan) are required in primary care to diagnose idiopathic constipation. 

What are the red and amber flags for constipation in a child?

• Red flags suggest a serious underlying cause or condition. If any of the following are detected, refer the child urgently to an appropriate specialist, and do not initiate treatment for constipation in primary care. They include:
  • Symptoms of constipation appearing from birth or during the first few weeks of life — may indicate Hirschsprung's disease (congenital aganglionic megacolon).
  • Delay in passing meconium for more than 48 hours after birth, in a full-term baby — may indicate Hirschsprung's disease or cystic fibrosis.
  • Family history of Hirschsprung's disease. 
  • Abdominal distention with vomiting — may indicate Hirschsprung's disease or intestinal obstruction. 
  • Gross abdominal distension.  
  • Ribbon stool pattern — may indicate anal stenosis (more likely to present in a child younger than 1 year of age). 
  • Leg weakness or motor delay — may indicate a neurological or spinal cord abnormality.
    • Examination may reveal unexplained lower limb deformity or abnormal neuromuscular signs, including abnormal reflexes.
  • Abnormal appearance of the anus (including fistulae; bruising; fissures; tight or patulous [widely patent] anus; anteriorly placed anus; or an absent anal wink [a reflex contraction of the external anal sphincter when the skin around the anus is stroked, may indicate spinal or neurological pathology]). 
  • Abnormalities in the lumbosacral and gluteal regions (such as asymmetry of the gluteal muscles, evidence of sacral agenesis, scoliosis, discoloured skin, naevi, hairy patch, sinus or central pit). 
• Amber flags also require specialist referral for assessment, but children with these signs may be treated for constipation in primary care whilst awaiting specialist assessment. They include:
  • Evidence of faltering growth, developmental delay, or concerns about wellbeing, which may indicate a systemic condition — liaise with a specialist to arrange testing for possible coeliac disease, hypothyroidism, cystic fibrosis, and electrolyte disturbance, if appropriate. See the CKS topics on Coeliac disease and Hypothyroidism for more information.
  • Constipation triggered by the introduction of cows' milk — see the CKS topic on Cows' milk allergy in children for more information.
  • Concern of possible child maltreatment — follow local child safeguarding procedures. See the CKS topic on Child maltreatment - recognition and management for more information.

Scenario: Management of constipation in children

From birth to 18 years.

Choice of laxatives

The choice of laxative will depend on the age of the child, the formulation preferred (liquid or tablet), and individual preference.

• Osmotic laxatives increase the amount of fluid in the large bowel, thereby softening the stool and stimulating peristalsis. They include:
  • Macrogols.
  • Lactulose.
• Stimulant laxatives cause peristalsis by stimulating the colonic and rectal nerves. They include:
  • Senna.
  • Docusate sodium.
  • Bisacodyl.
  • Sodium picosulfate.

Bisacodyl

Docusate sodium

Lactulose

Macrogol

Senna

Sodium picosulfate

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on the primary care management of constipation in children.

Search dates

June 2020 - June 2025

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 17th June 2020). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S7    S3 AND S6 
S6    S4 OR S5 
S5    AB ( child* or schoolchild* or infant* or infancy OR adolescen* or pediatr* or paediatr* or neonat* or boy or boys or girl or girls or youth or youths or baby or babies or toddler* or teen or teens or teenager* or newborn* or puberty or young people ) OR TI ( child* or schoolchild* or infant* or infancy OR adolescen* or pediatr* or paediatr* or neonat* or boy or boys or girl or girls or youth or youths or baby or babies or toddler* or teen or teens or teenager* or newborn* or puberty or young people)
S4    (MH "Child+") OR (MH "Infant+") OR (MH "Adolescent") 
S3    S1 OR S2 
S2    AB ( constipat* or faecal impaction or fecal impaction ) OR TI ( constipat* or faecal impaction or fecal impaction ) 
S1    (MH "Constipation") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.