B
BUDDSBarnet Unified Document
for Down Syndrome

Constipation

Constipation in Down Syndrome, causes, NICE treatment guidance, toileting support, and related gastrointestinal conditions

Background

Several conditions are more common in Down Syndrome. These include gastro-oesophageal reflux disease (GORD), Hirschsprung's disease, pyloric stenosis, duodenal atresia, aspiration, coeliac disease, constipation and food allergies. This presentation provides an excellent overview and covers everything in considerable detail: A walk through gut dysfunction in Down Syndrome.

In particular, these three conditions need to be highlighted as the most common and also the ones that need to be assessed and managed at every patient review by clinicians:

  • GORD - Signs, symptoms, red flags, investigations, management, when to refer.
  • Coeliac disease - Symptoms, signs, investigations and management, when to refer.
  • Constipation - Recognition, management and behavioural interventions.

Constipation

Stooling Issues and DS

  • Constipation Prevalence: 20%-36% - Increased with hypotonia, communication and behavioural issues, and supplementary feeds. Constipation can happen early on due to low muscle tone, poor mobility, diet and inadequate fluid intake, etc or even short-segment Hirschsprung's. Need to exclude organic disease. Need to check for and manage possible overflow +/- stool withholding, which are common issues.
  • Diarrhoea: often due to overflow. But it could be due to stimulant laxatives. If infective is associated with initial pyrexia. Consider gut dysbiosis associated with lactose intolerance/malabsorption.

Triggers for Constipation

  • Varies between children:
    • Elucidate the history: Age of onset.
    • Parental expectations: Address them in the treatment strategy.
  • Also consider:
    • Pain (e.g. a fissure).
    • Fever/dehydration.
    • Dietary intake (in terms of fibre content).
    • Psychological issues and expression of distress.
    • Toilet training/aversion.
    • Other medicines, other conditions.
    • Family history of constipation.

NICE Recommended Treatment

  • Investigate children with red flags.
  • For faecal impaction - NICE: Polyethene glycol 3350 + electrolytes (e.g. Movicol Paediatric Plain):
    • Escalating dose regimen (= first-line treatment).
    • Adjust the dose of Movicol according to response.
    • Risk of increased overflow (consider impact on school).
    • Review soon.
    • Reduce the dose of Movicol when disimpaction is achieved - Maintenance dose might be half the disimpaction dose.
    • But…
    • Add stimulant (senna/picosulphate) if Movicol alone does not work (but can cause overflow++).
    • Substitute a stimulant laxative if Movicol is not tolerated.
    • Add another laxative such as lactulose (toddlers) or bisacodyl (older children) if stools are hard.
  • Medication may be needed for weeks/months.
  • Children who are toilet training should remain on laxatives until toilet training is well established.
  • Gradually reduce the dose over a period of months in response to stool consistency and frequency, and increase if symptoms relapse.
  • 20-30% children with DS may require laxatives for several years.
  • Also, laxatives are only half the story:
    • Increase fibre content (to normal).
    • Ensure adequate hydration.
    • Increase exercise levels (all evidence-based).
  • Positive behavioural interventions/rewards suited to the child's level.
  • Explain that treatment may take years.
  • Addressing the underlying trigger.
  • Understanding of parents.
  • Fear of toilets in younger children.
  • Access to school toilets among school-age children.
  • Early reassessment and reinforcement of initial messages is also key.
  • Other resources:

Toileting Guidance

Top Tips for Potty Training.

Related Guidance