Intended for healthcare professionals

Practice 10-Minute Consultation

Childhood constipation

BMJ 2021; 375 doi: (Published 02 December 2021) Cite this as: BMJ 2021;375:e065046
  1. Olivia Bradshaw, paediatric junior clinical fellow1,
  2. Robbie Foy, professor of primary care2,
  3. Arnab K Seal, consultant paediatrician, honorary senior lecturer34,
  4. Jonathan C Darling, clinical associate professor in paediatrics and child health and medical education and honorary consultant paediatrician5
  1. 1Leeds Teaching Hospitals NHS Trust, Leeds, UK
  2. 2Leeds Institute of Health Sciences, University of Leeds, Leeds
  3. 3Leeds Community Healthcare NHS Trust, Leeds
  4. 4University of Leeds, Leeds
  5. 5Division of Women’s and Children’s Health, School of Medicine, University of Leeds, Leeds
  1. Correspondence to O Bradshaw o.bradshaw{at}

What you need to know

  • Prompt initiation and titration of laxatives, active support, and adequate duration of maintenance treatment are cornerstones of management

  • Disimpaction is complete once the child starts to have watery stools

  • Maintenance treatment may be required for at least as long as the child has suffered from constipation, to allow for return of regular bowel habit

The parents of a 2 year old boy are concerned that he is struggling to open his bowels and appears to be straining. They tried macrogol for two weeks but stopped because it caused soiling and distress.

Constipation, the passage of fewer than three complete stools per week,1 affects approximately one in 10 children worldwide.2 It occurs most commonly in toddlers,3 often presenting at the time of weaning, toilet training, or starting school.4 Laxatives are safe and effective.5 Early intervention and support for parents with dosing and duration can prevent problems such as chronicity, withholding behaviours, overstretched bowels with decreased motility, and overflow soiling. This article offers an approach to childhood constipation in primary care, especially where initial treatment has been unsuccessful.

What you should cover

Take or revisit the history and examination to differentiate idiopathic constipation from other underlying conditions. Box 1 lists red flags.

Box 1

Red flag features6


  • Onset from birth or first few weeks of life

  • >48 hour delay in passing meconium

  • Undiagnosed weakness in legs, locomotor delay

  • Abdominal distension with vomiting

  • Persistent blood in stool

  • Ribbon (thin, stringy) stools


  • Faltering growth

  • Gross abdominal distention

  • Abnormalities of spine, lumbosacral region, or gluteal muscles

  • Abnormal position, patency, or appearance of the anus (eg, laxity)

  • Lower limb deformities

  • Abnormal neuromuscular signs unexplained by any existing condition

  • Persistent anal issues such as fissures or skin tags



Identify the stool patterns and timing of onset. Hard large stool, “rabbit dropping” stool, and overflow soiling are all common. A paediatric Bristol …

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