Pre-referral guidelines for primary care providers

Constipation is a common condition in all ages, being defined by the consistency and size of stool, along with frequency of stool and associated symptoms (encopresis, blood or pain with passage of stools).

Infant stool patterns are often described as being normal when a bowel action occurs at a frequency of seven times per day through to once every seven days (or three times per day to once every three days in formula fed babies). They are often of variable consistency. Colour changes are common and generally do not represent an underlying abnormality. Straining in babies before passing a normal stool also does not represent an underlying problem.

For the diagnosis and management of constipation, please refer to the Royal Children’s Hospital clinical practice guidelines.

Practice Points

  • Note that is is normal for infants to defecate only every 7 days (or every 3 days if formula fed), providing consistency of stool is normal
  • Healthy infants will often strain and cry before/during passing normal stools, requiring no management
  • Abdominal x-rays are generally not useful in the diagnosis or management of constipation
  • Management of constipation should use oral medications when required, avoiding per rectal medications (incl. enemas) in most circumstances
  • Failure of constipation management is common when medications are weaned too quickly
  • Management of constipation takes a long period of time and requires a consistent approach over prolonged periods of time.

Referral pathways

  • Paediatrician
    • Most cases of constipation can be adequately managed in the general practice setting. Referral to paediatric outpatient services can be considered in the management of constipation when management steps above are failing to contain symptoms adequately.
    • Severe constipation resulting in significant abdominal distention that is unresponsive to adequate outpatient therapy may require inpatient care for further investigation and management.
  • Continence clinic
    • Management in conjunction with a referral to continence services is reasonable in children with significant constipation