A 6-Year-Old Boy with Abdominal Pain

A 6-year-old boy is bought in by his mother. She is concerned as he has been complaining about tummy pain for the last week. She has noticed that he has had some soiling in his pants for the last few days. She also reports that he sometimes goes to stand in the corner by himself with his legs crossed.

There has been some family disruption recently and the boy’s parents are going through quite a hostile divorce. Up until this point the boy’s medical history has been unremarkable, and he has reached all of his developmental milestones on time.

1. What is the most likely diagnosis?

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The child has a history that is very consistent with a diagnosis of constipation.

Constipation in childhood is common and studies have shown that it can affect anywhere between 5% and 30% of children. The vast majority of cases are functional constipation, but it is always important to be alert for any unusual causes.

Trigger factors in older children, such as in this case, are often associated with psychological problems such as major life events. Younger children can commonly experience symptoms during potty training, or when they newly start school.

2. You perform an examination of the child, which is normal. What would your management include?
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The management of constipation in children includes the following:

  • Reassurance that this is a common problem, and that treatment can take weeks or months to take effect.
  • Acknowledgement of the family’s difficult situation with the divorce and explanation that this can be a precipitating factor.
  • Diet and lifestyle recommendations, including explanations of how exercise is beneficial, and that a high fibre diet and being well hydrated is also sensible.
  • Disimpaction, if needed, with an osmotic laxative, followed by maintenance laxatives. Clear explanations should be given that this can take a while to have effect. Regular follow up should also be organised.
3. List the red flag symptoms or signs that would alert you to a more serious diagnosis?
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Red flag symptoms and signs that would indicate a more serious diagnosis include:

  • Symptoms starting from birth, or in the first few weeks of life.
  • Delay or failure to pass meconium.
  • Abdominal distension and vomiting
  • Neurological signs such as leg weakness, abnormal reflexes.
  • Limb deformity.
  • Abnormal appearance of anus.
  • Abnormal gluteal muscles.
  • Presence of scoliosis.

 

The NICE guidelines on constipation in children and young people can be read in full here:

https://www.nice.org.uk/guidance/CG99