Comparison of the guidelines
| NICE CG99, NICE CKS62 guidelines | Joint ESPGHAN/NASPGHAN guidelines | |
|---|---|---|
| Diagnosis | ‘Idiopathic’ constipation Diagnosis based on history and physical examination | ‘Functional’ constipation, using Rome III criteria Diagnosis based on history and physical examination |
| Investigations | Plain abdominal radiography, abdominal ultrasound and colonic transit studies only by specialist services in intractable idiopathic constipation Testing for coeliac disease and hypothyroidism only suggested in intractable constipation or with evidence of faltering growth | Plain abdominal radiography when faecal impaction is suspected but physical examination unreliable/not possible Colonic transit study may help discriminate between functional constipation and functional non-retentive faecal incontinence and in situations when the diagnosis is not clear Testing for hypothyroidism, coeliac disease and hypercalcaemia only in presence of red flag symptoms |
| Role of diet and physical activity | A balanced diet and daily physical activity is recommended, but not sufficient as first-line treatment | Normal fibre and fluid intake is recommended along with normal physical activity |
| Laxatives | PEG orally using an escalating dose regimen as first-line for faecal disimpaction Add a stimulant laxative (or in combination with an osmotic laxative) if PEG alone does not work | PEG orally for 3–6 days as first-line treatment for faecal impaction. Lactulose may be used if PEG is not available Milk of magnesia, mineral oil and stimulant laxatives may be considered as additional or second-line treatment |
| Enema | Sodium citrate enemas to be used only if all oral medications for disimpaction have failed. Phosphate enemas for disimpaction only to be used under specialist supervision | An enema once per day for 3–6 days is recommended for children with faecal impaction, if PEG is not available. PEG and enema are equally effective for treatment of faecal disimpaction |
ESPGHAN, European Society for Paediatric Gastroenterology, Hepatology and Nutrition; NASPGHAN, North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition; NICE, National Institute for Health and Care Excellence; PEG, polyethylene glycol.