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Constipation

About

What is covered

This interactive flowchart covers the diagnosis and management of idiopathic childhood constipation in primary and secondary care in newborns, infants and children younger than 18 years and possible treatments for constipation in adults.
Constipation is common in childhood. It affects around 5–30% of the child population, depending on the criteria used for diagnosis.
Symptoms become chronic in more than one third of patients, and constipation is a common reason for referral to secondary care.

Updates

Updates to this interactive flowchart

21 July 2015 Adult section of overview divided into chronic idiopathic constipation and opioid-induced constipation. Naloxegol for treating opioid-induced constipation (NICE technology appraisal guidance TA345) added to opioid-induced constipation.
23 September 2014 Assessing motility of the gastrointestinal tract using a wireless capsule (NICE interventional procedure guidance 502) added to overview.
22 July 2014 Lubiprostone for treating chronic idiopathic constipation (NICE technology appraisal guidance 318) and prucalopride for the treatment of chronic constipation in women (NICE technology appraisal guidance 211) added to overview.
12 May 2014 Constipation in children and young people (NICE quality standard 62) added.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on constipation in an interactive flowchart

What is covered

This interactive flowchart covers the diagnosis and management of idiopathic childhood constipation in primary and secondary care in newborns, infants and children younger than 18 years and possible treatments for constipation in adults.
Constipation is common in childhood. It affects around 5–30% of the child population, depending on the criteria used for diagnosis.
Symptoms become chronic in more than one third of patients, and constipation is a common reason for referral to secondary care.

Updates

Updates to this interactive flowchart

21 July 2015 Adult section of overview divided into chronic idiopathic constipation and opioid-induced constipation. Naloxegol for treating opioid-induced constipation (NICE technology appraisal guidance TA345) added to opioid-induced constipation.
23 September 2014 Assessing motility of the gastrointestinal tract using a wireless capsule (NICE interventional procedure guidance 502) added to overview.
22 July 2014 Lubiprostone for treating chronic idiopathic constipation (NICE technology appraisal guidance 318) and prucalopride for the treatment of chronic constipation in women (NICE technology appraisal guidance 211) added to overview.
12 May 2014 Constipation in children and young people (NICE quality standard 62) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Naloxegol for treating opioid-induced constipation (2015) NICE technology appraisal guidance 345
Lubiprostone for treating chronic idiopathic constipation (2014) NICE technology appraisal guidance 318
Prucalopride for the treatment of chronic constipation in women (2010) NICE technology appraisal guidance 211
Assessing motility of the gastrointestinal tract using a wireless capsule (2014) NICE interventional procedure guidance 502
Constipation in children and young people (2014) NICE quality standard 62

Quality standards

Constipation in children and young people

These quality statements are taken from the constipation in children and young people quality standard. The quality standard defines clinical best practice for constipation in children and young people and should be read in full.

Quality statements

Assessment

This quality statement is taken from the constipation in children and young people quality standard. The quality standard defines clinical best practice for constipation in children and young people and should be read in full.

Quality statement

Children and young people with constipation receive a full assessment before a diagnosis of idiopathic constipation is made.

Rationale

Children and young people with constipation can present to different types of healthcare professionals in primary, community and secondary care. Once constipation in children and young people has been recognised it is important to ensure that underlying causes of constipation and ‘red flag’ symptoms are excluded. A diagnosis of idiopathic constipation, in which the constipation cannot be explained by anatomical or physiological abnormalities, can only be made through a full assessment, including detailed history-taking and a physical examination by a healthcare professional.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with constipation receive a full assessment before a diagnosis of idiopathic constipation is made.
Data source: Local data collection.
Process
Proportion of children and young people with constipation who receive a full assessment.
Numerator – the number in the denominator who receive a full assessment.
Denominator – the number of children and young people with constipation.
Data source: Local data collection. NICE Constipation in children and young people: audit support tool, criteria 1, 2, 5 and 7.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that staff are trained to perform a full assessment (including detailed history-taking and physical examination to exclude ‘red flag’ symptoms) for children and young people with constipation before making a diagnosis of idiopathic constipation.
Healthcare professionals perform a full assessment for children and young people with constipation (including detailed history-taking and physical examination to exclude ‘red flag’ symptoms) before making a diagnosis of idiopathic constipation.
Commissioners ensure that they commission services from providers whose staff perform a full assessment (including detailed history-taking and physical examination to exclude ‘red flag’ symptoms) for children and young people with constipation before making a diagnosis of idiopathic constipation.

What the quality statement means for patients, service users and carers

Children and young people with constipation have a detailed assessment, which includes asking about their symptoms and other problems, and a physical examination. This will help to check that the constipation is not caused by anything serious.

Source guidance

  • Constipation in children and young people (NICE clinical guideline 99), recommendation 1.1.2 (key priority for implementation) and 1.1.3 (key priority for implementation).

Definitions of terms used in this quality statement

Full assessment
A combination of history-taking and physical examination should be used to diagnose idiopathic constipation. Key components of assessment can be found in tables 1–3 in NICE clinical guideline 99.
A positive diagnosis of idiopathic constipation can be established by excluding underlying causes. If a child or young person has any ‘red flag’ symptoms identified from history-taking or physical examination, do not treat them for constipation. Instead, refer them urgently to a healthcare professional with experience in the area of concern.
‘Red flag’ findings and diagnostic clues that indicate an underlying disorder or condition (not idiopathic constipation) are detailed in full in table 2 of NICE clinical guideline 99 for history-taking and in table 3 for physical examination.
Assessment can be undertaken by healthcare professionals such as GPs, school nurses, health visitors, practice nurses, continence advisors and paediatricians. [NICE clinical guideline 99 and expert opinion]
Idiopathic constipation
Constipation that cannot (currently) be explained by any anatomical, physiological, radiological or histological abnormalities. [NICE clinical guideline 99, Introduction]

Equality and diversity considerations

Certain groups of children and young people are more prone to idiopathic constipation than others, such as those with Down’s syndrome or autism, and some children and young people with physical disabilities, such as cerebral palsy. There is also a higher prevalence of idiopathic constipation in children and young people in local authority care. These children and young people may have additional needs that should be considered when assessing them for idiopathic constipation.

First-line treatment with laxatives

This quality statement is taken from the constipation in children and young people quality standard. The quality standard defines clinical best practice for constipation in children and young people and should be read in full.

Quality statement

Children and young people with idiopathic constipation receive oral macrogols as first-line treatment.

Rationale

Laxatives are an effective treatment for constipation; oral macrogols are the first-line laxative of choice unless otherwise indicated. Oral macrogols are easily administered at home and in the community, and may avoid the need for invasive hospital treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with idiopathic constipation receive oral macrogols as first-line treatment.
Data source: Local data collection.
Process
Proportion of diagnosed cases of idiopathic constipation in children and young people for which oral macrogols are prescribed as first line treatment.
Numerator – the number in the denominator for which oral macrogols are prescribed as first line treatment.
Denominator – the number of diagnosed cases of idiopathic constipation in children and young people.
Data source: Local data collection. NICE Constipation in children and young people: audit support tool; criteria 9 and 18.
Outcome
Rates of unplanned hospital attendance for idiopathic constipation.
Data source: Hospital episode statistics from The Health and Social Care Information Centre. Child health indicator profiles including data on hospital admissions for constipation in those aged 0 24 years are also available from Public Health England's Child and maternal health intelligence network.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that staff prescribe oral macrogols as first-line treatment for children and young people with newly diagnosed idiopathic constipation and that oral macrogols are included on prescribers' lists.
Healthcare professionals prescribe oral macrogols as first-line treatment for children and young people with newly diagnosed idiopathic constipation.
Commissioners ensure that they commission services from providers that can demonstrate that staff prescribe oral macrogols as first-line treatment for children and young people with newly diagnosed idiopathic constipation.

What the quality statement means for patients, service users and carers

Children and young people with constipation receive a medicine called a laxative to mix with water and drink as their first treatment.

Source guidance

  • Constipation in children and young people (NICE clinical guideline 99) recommendations 1.4.2 and 1.4.3 (key priority for implementation), 1.4.4 and 1.4.11.

Definitions of terms used in this quality statement

Idiopathic constipation
Constipation that cannot (currently) be explained by any anatomical, physiological, radiological or histological abnormalities. [NICE clinical guideline 99, Introduction]
Macrogol
A type of laxative (also called polyethylene glycol). [British National Formulary]

Reviewing disimpaction therapy

This quality statement is taken from the constipation in children and young people quality standard. The quality standard defines clinical best practice for constipation in children and young people and should be read in full.

Quality statement

Children and young people with idiopathic constipation starting disimpaction therapy have their treatment reviewed by a healthcare professional within 1 week.

Rationale

Review of treatment within 1 week of starting disimpaction therapy should establish whether the treatment has worked and help prevent relapse. Children and young people with faecal impaction are at high risk of relapse and should be closely monitored. Faecal impaction should be resolved before maintenance therapy is started.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with idiopathic constipation starting faecal disimpaction therapy have their treatment reviewed by a healthcare professional within 1 week.
Data source: Local data collection.
Process
Proportion of children and young people with idiopathic constipation starting disimpaction therapy who receive a review of their treatment from a healthcare professional within 1 week.
Numerator – the number in the denominator who receive a review of their treatment from a healthcare professional within 1 week.
Denominator – the number of children and young people with idiopathic constipation starting disimpaction therapy.
Data source: Local data collection. NICE Constipation in children and young people: audit support tool, criterion 14.
Outcome
a) Rates of reimpaction.
Data source: Local data collection.
b) Production of regular soft stools.
Data source: Local data collection.
c) Rates of unplanned hospital attendance for constipation.
Data source: Hospital episode statistics from The Health and Social Care Information Centre. Child health indicator profiles including data on hospital admissions for constipation in those aged 0 24 years are also available from Public Health England's Child and maternal health intelligence network.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that staff perform a review of laxative treatment for disimpaction in children and young people with idiopathic constipation within 1 week.
Healthcare professionals review treatment within 1 week for children and young people with idiopathic constipation who are starting laxative treatment for disimpaction.
Commissioners ensure that they commission services from providers that can demonstrate that they provide treatment reviews within 1 week for children and young people with idiopathic constipation who are starting laxative treatment for disimpaction.

What the quality statement means for patients, service users and carers

Children and young people starting laxative treatment for a blockage in the bowel caused by constipation (called faecal impaction) should have their treatment reviewed by a healthcare professional within a week.

Source guidance

  • Constipation in children and young people (NICE clinical guideline 99) recommendation 1.4.8.

Definitions of terms used in this quality statement

Disimpaction therapy
Treatment with laxative stimulants for the evacuation of impacted faeces. [NICE clinical guideline 99]
Idiopathic constipation
Constipation that cannot (currently) be explained by any anatomical, physiological, radiological or histological abnormalities. [NICE clinical guideline 99, Introduction]
Healthcare professional
The review of laxative treatment can be undertaken by a number of healthcare professionals such as GPs, school nurses, health visitors, practice nurses, continence advisors and paediatricians. [Expert opinion]

Reviewing maintenance therapy

This quality statement is taken from the constipation in children and young people quality standard. The quality standard defines clinical best practice for constipation in children and young people and should be read in full.

Quality statement

Children and young people with idiopathic constipation starting maintenance therapy have their first treatment review by a healthcare professional within 6 weeks.

Rationale

It is important to review maintenance therapy in children and young people with idiopathic constipation to prevent faecal impaction, and to assess for possible issues, such as problems with taking medicine and toileting.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with idiopathic constipation starting maintenance therapy receive their first treatment review from a healthcare professional within 6 weeks.
Data source: Local data collection.
Process
Proportion of children and young people with idiopathic constipation starting maintenance therapy who receive a review of their treatment from a healthcare professional within 6 weeks.
Numerator – the number in the denominator who receive their first treatment review from a healthcare professional within 6 weeks.
Denominator – the number of children and young people with idiopathic constipation starting maintenance therapy.
Data source: Local data collection.
Outcome
a) Rates of reimpaction.
Data source: Local data collection.
b) Production of regular soft stools.
Data source: Local data collection.
c) Rates of unplanned hospital attendance for constipation.
Data source: Hospital episode statistics from The Health and Social Care Information Centre. Child health indicator profiles including data on hospital admissions for constipation in those aged 0 24 years are also available from Public Health England’s Child and maternal health intelligence network.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that staff perform the first treatment review of maintenance therapy for children and young people with idiopathic constipation within 6 weeks of treatment starting.
Healthcare professionals perform the first treatment review for children and young people with idiopathic constipation who are starting maintenance therapy within 6 weeks.
Commissioners ensure that they commission services from providers that can demonstrate that they perform the first treatment review for children and young people with idiopathic constipation who are starting maintenance therapy within 6 weeks.

What the quality statement means for patients, service users and carers

Children and young people starting laxatives for the ongoing treatment of constipation (either as their first treatment or after treatment to clear a blockage) receive a treatment review from a healthcare professional within 6 weeks.

Source guidance

  • Constipation in children and young people (NICE clinical guideline 99) recommendation 1.4.10.

Definitions of terms used in this quality statement

Idiopathic constipation
Constipation that cannot (currently) be explained by any anatomical, physiological, radiological or histological abnormalities. [NICE clinical guideline 99, Introduction]
Maintenance therapy
Treatment with laxatives, either following disimpaction for the ongoing treatment of idiopathic constipation or for the initial treatment of idiopathic constipation if the child or young person does not have faecal impaction. [NICE clinical guideline 99]
Review during maintenance treatment
Review during maintenance treatment includes ensuring that the child or young person’s faeces do not become impacted and assessing for possible issues in maintaining treatment, such as problems with taking medicine and toileting.
The timing of review during maintenance treatment will depend on the individual needs of the child or young person and their parents or carers. It could range from daily contact to every few weeks.
After the first review, ongoing review and reassessment should be tailored to treatment response. Maintenance therapy should continue until regular bowel habits are established, which may take several months. Some children and young people may need maintenance therapy for several years.
A pragmatic timeframe for review of maintenance treatment within 6 weeks of starting treatment is proposed for measuring the quality statement. [Adapted from NICE clinical guideline 99, recommendations 1.4.10 and 1.4.11, and expert opinion]
Healthcare professional
The review of laxative treatment can be undertaken by a number of healthcare professionals such as GPs, school nurses, health visitors, practice nurses, continence advisers and paediatricians. [Expert opinion]

Written information

This quality statement is taken from the constipation in children and young people quality standard. The quality standard defines clinical best practice for constipation in children and young people and should be read in full.

Quality statement

Children and young people with idiopathic constipation starting laxative treatment, or their parents or carers, receive written information about laxatives.

Rationale

It is important that children and young people, or their parents or carers, are provided with clear, written information about how to take their medication and what to expect when taking laxatives. This will help to enable self-management and adherence to therapy. Providing evidence-based information that can be referred to later will help as a reminder of key advice and to answer any queries.

Quality measures

Structure
Evidence of local arrangements for children and young people with idiopathic constipation starting laxative treatment, or their parents or carers, to receive written information about laxatives.
Data source: Local data collection.
Process
Proportion of children and young people with idiopathic constipation starting laxative treatment, or their parents or carers, who receive written information about laxatives.
Numerator – the number in the denominator receiving written information about laxatives at the start of treatment.
Denominator – the number of children and young people with idiopathic constipation starting laxative treatment, or their parents or carers.
Data source: Local data collection. NICE Constipation in children and young people: audit support tool, criterion 21.
Outcome
Satisfaction of children and young people, or their parents or carers, with the provision of information on laxatives to help them to manage the condition.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that staff provide children and young people with idiopathic constipation who are starting laxative treatment, or their parents or carers, with written information about laxatives.
Healthcare professionals provide written information about laxatives to children and young people with idiopathic constipation who are starting laxative treatment, or their parents or carers.
Commissioners ensure that they commission services from providers that can demonstrate that they provide written information about laxatives for children and young people with idiopathic constipation who are starting laxative treatment, or their parents or carers.

What the quality statement means for patients, service users and carers

Children and young people with constipation who are starting laxative treatment, or their parents or carers, receive written information about laxatives, including how to take them and what to expect from the treatment.

Source guidance

  • Constipation in children and young people (NICE clinical guideline 99) recommendation 1.8.1.

Definitions of terms used in this quality statement

Written information about laxatives
This may include the following:
  • Information on possible responses to laxative treatment that can be measured by the frequency, amount and consistency of stools using the Bristol Stool Form Scale and on how to adjust laxative doses in response.
  • Information about how bowels work, symptoms that might indicate a serious underlying problem, how to take their medication, what to expect when taking laxatives, how to poo, origins of constipation, criteria to recognise risk situations for relapse (such as the worsening of any symptoms or soiling) and the importance of continuing treatment until advised otherwise by the healthcare professional. [Adapted from NICE clinical guideline 99, recommendation 1.8.1]

Equality and diversity considerations

All information provided about idiopathic constipation and its management, including laxative treatment, should be accessible to children and young people, and their parents or carers, with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English. Children and young people with idiopathic constipation, and their parents or carers, should have access to an interpreter or advocate if needed.

Referral if no response to treatment

This quality statement is taken from the constipation in children and young people quality standard. The quality standard defines clinical best practice for constipation in children and young people and should be read in full.

Quality statement

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.

Rationale

For the majority of children and young people, idiopathic constipation responds well to laxative treatment delivered within primary care. However, children and young people with constipation that has not responded to initial treatment may need specialist help and support, and further investigations may be needed.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that 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.
Data source: Local data collection.
Process
Proportion of children and young people with idiopathic constipation that does not respond to initial treatment within 3 months who are referred to a healthcare professional with expertise in the problem.
Numerator – the number in the denominator who are referred to a healthcare professional with expertise in the problem.
Denominator – the number of children and young people with idiopathic constipation that does not respond to initial treatment within 3 months.
Data source: Local data collection.
Outcome
Rates of recurrent presentation to general practice.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that staff refer children and young people with idiopathic constipation that does not respond to initial treatment within 3 months to a healthcare professional with expertise in the problem.
Healthcare professionals refer children and young people with idiopathic constipation that does not respond to initial treatment within 3 months to a healthcare professional with expertise in the problem.
Commissioners ensure that they commission services from providers who can demonstrate that 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.

What the quality statement means for patients, service users and carers

Children and young people whose constipation does not improve after 3 months of laxative treatment are referred to an expert in constipation in children and young people.

Source guidance

  • Constipation in children and young people (NICE clinical guideline 99) recommendation 1.8.4.

Definitions of terms used in this quality statement

Idiopathic constipation
Constipation that cannot (currently) be explained by any anatomical, physiological, radiological or histological abnormalities. [NICE clinical guideline 99, Introduction]
Healthcare professional with expertise in the problem
A healthcare professional with interest, experience and/or training in the diagnosis and treatment of constipation in children and young people. This may be, but is not limited to, a specialist continence nurse, community paediatrician or GP with a special interest. [Adapted from NICE clinical guideline 99]
Respond to initial treatment
Progress and improvement in symptoms from the point of initiation of maintenance treatment when treatment has been adhered to, based on the clinical judgement of a health professional and informed by the child, young person or the parents or carers. The Bristol Stool Form Scale may also be used in determining whether symptoms have improved. [Expert opinion]

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Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Key components of history-taking to diagnose constipation

Key components
Potential findings in a child younger than 1 year
Potential findings in a child or young person older than 1 year
Stool patterns
Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks of age)
Hard large stool
'Rabbit droppings' (type 1, see Bristol Stool Form Scale)
Fewer than three complete stools per week (type 3 or 4, see Bristol Stool Form Scale)
Overflow soiling (commonly very loose [no form], very smelly [smells more unpleasant than normal stools], stool passed without sensation. Can also be thick and sticky or dry and flaky.)
'Rabbit droppings' (type 1, see Bristol Stool Form Scale)
Large, infrequent stools that can block the toilet
Symptoms associated with defecation
Distress on stooling
Bleeding associated with hard stool
Straining
Poor appetite that improves with passage of large stool
Waxing and waning of abdominal pain with passage of stool
Evidence of retentive posturing: typical straight legged, tiptoed, back arching posture
Straining
Anal pain
History
Previous episode(s) of constipation
Previous or current anal fissure
Previous episode(s) of constipation
Previous or current anal fissure
Painful bowel movements and bleeding associated with hard stools

Key components of history-taking to diagnose idiopathic constipation

Key components
Findings and diagnostic clues that indicate idiopathic constipation
'Red flag' findings and diagnostic clues that indicate an underlying disorder or condition: not idiopathic constipation
Timing of onset of constipation and potential precipitating factors
In a child younger than 1 year:
  • Starts after a few weeks of life
  • Obvious precipitation factors coinciding with the start of symptoms: fissure, change of diet, infections
In a child/young person older than 1 year:
  • Starts after a few weeks of life
  • Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking medicines
Reported from birth or first few weeks of life
Passage of meconium
Normal (within 48 hours after birth, in term baby)
Failure to pass meconium/delay (more than 48 hours after birth, in term baby)
Stool patterns
'Ribbon stools' (more likely in a child younger than 1 year)
Growth and general wellbeing
In a child younger than 1 year:
  • Generally well, weight and height within normal limits
In a child/young person older than 1 year:
  • Generally well, weight and height within normal limits, fit and active
No 'red flag' but see 'amber flag' below
Symptoms in legs/locomotor development
No neurological problems in legs (such as falling over in a child/young person older than 1 year), normal locomotor development
Previously unknown or undiagnosed weakness in legs, locomotor delay
Abdomen
Abdominal distension with vomiting
Diet and fluid intake
In a child younger than 1 year:
  • Changes in infant formula, weaning, insufficient fluid intake
In a child/young person older than 1 year:
  • History of poor diet and/or insufficient fluid intake
'Amber flag': possible idiopathic constipation (see investigate possible underlying causes)
Growth and general wellbeing: Faltering growth
Personal/familial/social factors: Disclosure or evidence that raises concerns over possibility of child maltreatment

Key components of physical examination to diagnose idiopathic constipation

Key components
Findings and diagnostic clues that indicate idiopathic constipation
'Red flag' findings and diagnostic clues that indicate an underlying disorder or condition
Inspection of perianal area: appearance, position, patency, etc
Normal appearance of anus and surrounding area
Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal wink
Abdominal examination
Soft abdomen. Flat or distension that can be explained because of age or excess weight
Gross abdominal distension
Spine/lumbosacral region/gluteal examination
Normal appearance of the skin and anatomical structures of lumbosacral/gluteal regions
Abnormal: asymmetry or flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi or sinus, hairy patch, lipoma, central pit (dimple that you can't see the bottom of), scoliosis
Lower limb neuromuscular examination including tone and strength
Normal gait. Normal tone and strength in lower limbs
Deformity in lower limbs such as talipes
Abnormal neuromuscular signs unexplained by any existing condition, such as cerebral palsy
Lower limb neuromuscular examination: reflexes (perform only if 'red flags' in history or physical examination suggest new onset neurological impairment)
Reflexes present and of normal amplitude
Abnormal reflexes

Glossary

Paths in this pathway

Pathway created: January 2013 Last updated: May 2017

© NICE 2017

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