CORPORATE OFFICE
Level 1
32 Oxford Terrace
Telephone:  0064 3 364 4134
Christchurch Central

               [email address];
CHRISTCHURCH 8011



21 March 2022

Andrew McGregor

Email: [email address]; [email address]; fyi-
[email address]; [email address];

Dear Andrew

RE Official Information Act request CDHB 10777

I refer to your four emails dated 25 November 2021 to the Ministry of Health which they subsequently transferred
to us on 9 December 2021 requesting the following information under the Official Information Act from
Canterbury DHB. Specifically:

1.
Please provide Guidelines/Procedures for the management of postoperative Urinary Retention (POUR)

Guidelines and procedures are in the HHP Acute Urinary Retention pathway on Canterbury Hospital
HealthPathways (Note 1).  Please refer to Appendix 1.

2.
Please provide Guidelines/procedure for the management/prevention of persistent Postsurgical Pain.

The Canterbury DHB does not have guidelines or written procedures for the prevention or management of chronic
post-surgical pain. Specialist staff are educated on acute and chronic pain management as part of their training
and have access to resources such as the ANZCA publication “Acute Pain Management: Scientific Evidence”
https://www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf.”

3.  Please provide Guidelines/procedure in the treatment of patients after a suicide attempt and/or suicidal
ideation

An individualised approach is taken when providing care to a person who has attempted suicide or expresses
suicidal ideation. This is because we need to respond to the diverse reasons people have for attempting suicide,
different life circumstances, levels of whānau support, and their differing needs.
For instance, some suicide attempts occur in the context of a major life event and there may be less ongoing risk
afterwards, compared with someone who has constant symptoms of severe depression or psychosis.
However, in general the following steps are taken:

•
Any potentially life-threatening injuries or conditions are given immediate priority
•
An assessment is then undertaken which includes the person’s clinical presentation, circumstances,
level of risk, and wishes
•
A plan is established in conjunction with the person and their whānau

•
Information on managing mental illness and/or addictions, and support services available, is then
provided.
•

The plan developed for an individual may or may not include follow up by Specialist Mental Health Services
(SMHS), but SMHS will be involved in a person’s ongoing care if they show signs of moderate to severe mental
illness. This could take the form of an inpatient admission, or outpatient care in the community. Care for mild to
moderate mental illness is available through primary care and NGO providers.

4.
Please provide Guidelines/procedure differentiating subtypes of primary (idiopathic) constipation”

Guidelines and procedures are in the Constipation in Adults pathway on Canterbury Hospital HealthPathways
(Note 1). Please refer to Appendix 2.

Guidelines and procedures are in the Constipation in Children pathway on Canterbury Community HealthPathways
(Note 1). Please refer to Appendix 3.

Note 1 Hospital HealthPathways is designed and written for use during a clinical consultation. Each pathway
provides clear and concise guidance for assessing and managing a patient with a particular symptom or condition.
Pathways also include information about making requests to services in the local health system.
Content is developed collaboratively by general practitioners, hospital clinicians, and a wide range of other health
professionals. Each pathway is evidence-informed, but also reflects local reality, and aims to preserve clinical
autonomy and patient choice. HealthPathways serves to reduce unwarranted variation and accelerate evidence
into practice.  The pathways are part of a large suite of clinical and process guidelines and are supported by
background documents. They are intended to be used in that context.  This information is not publicly available.

Information which is publicly available can be found on the Canterbury HealthInfo website.
www.healthinfo.org.nz.

I trust that this satisfies your interest in this matter.

Please note that this response, or an edited version of this response, may be published on the Canterbury DHB
website after your receipt of this response.

Yours sincerely

Ralph La Salle
Senior Manager, OIAs
Canterbury DHB and West Coast DHB

Appendix 1 1
Acute Urinary Retention
See also Urethral Catheterisation.
Red flags
▪
Cauda equina syndrome
▪
Gross haematuria
▪
Postobstructive diuresis
Act
Background
About acute urinary retention
About acute urinary retention
Information
Acute urinary retention refers to the inability to voluntarily pass urine. It is more common
in men, especially those of increasing age.
Offical
Assessment
the
Initial assessment
under
1. History:
•
Ask about symptoms – Always suspect urinary retention in any patient with
unexplained abdominal pain, nausea or vomiting, or confusion.
•
Check urine output.
Released
2. Palpate the lower abdomen.
3. Arrange a bladder scan if available.
4. If patient has no urine output:
•
Confirm the diagnosis by either a palpable, large dull mass in the lower abdomen
or evidence of full bladder via imaging (estimated to contain greater than 500 mL
of fluid).
•
Arrange urgent catheterisation before further clinical evaluation.
Further assessment
1. Look for:

2
•
any underlying causes.
Causes
•
Previous outflow obstruction symptoms and duration
•
Previous or current episodes of haematuria, especially macroscopic with clot
retention
•
Previous prostate disease, e.g. benign prostatic hyperplasia (BPH)
•
Previous surgery or trauma to the pelvis, urinary tract, or spine
•
Any dysuria or flank pain, e.g. urinary tract infection (UTI), pyelonephritis
•
Cauda equina syndrome symptoms – See Low Back Pain.
•
Medications, e.g. anticholinergics or sympathomimetics
•
significant risk factors for urethral damage.
Act
Potential risks for urethral catheterisation
•
Urethroplasty or radical prostatectomy within the preceding 6 weeks
Urethroplasty or radical prostatectomy Information
If it occurred:
•
within the last 6 weeks, this surgery indicates the presence of a urethral
Offical
graft or anastomosis. Catheterisation should therefore be performed by a
Urology Registrar if available. If unavailable, medical staff to insert a
the
suprapubic catheter.
•
more than 6 weeks ago, proceed with urethral catheterisation with care
using 14 Fr catheter. If unsuccessful, insert a suprapubic catheter.
under
•
Urethral trauma in the last 4 weeks
•
Known urethral stricture
•
History of difficult urethral catheterisation
Released
2. Examination:
•
Consider performing a rectal examination to assess prostate size, consistency,
and anal tone.
•
Do a neurological evaluation.
3. Arrange investigations:
•
Urine (once available) for microscopy, culture, and sensitivities
•
Serum creatinine for renal failure
•
Electrolytes (baseline) for postobstructive diuresis with electrolyte disturbance
Postobstructive diuresis

3
Postobstructive diuresis can occasionally occur after relief of a urinary tract
obstruction. It is commonly preceded by bilateral ureteric obstruction. Whilst most
patients will self-resolve in less than 24 hours, it is dangerous because some
patients will continue to lose salt and water, leading to dehydration, electrolyte
imbalances and shock. The clinical definition of postobstructive diuresis is a urine
output of more than 200 mL/hour for 2 consecutive hours or more than 3L/day.
Management
1.  If no urine output or no significant risk factors for urethral damage, catheterise as soon
as possible. If risk factors are present, seek acute urology advice.
2.  If cauda equina syndrome is suspected, request urgent acute neurosurgery review.
3.  If retention is:
•
Act

preceded by gross haematuria, manage as per Macroscopic Haematuria Clinical
Pathway.
•  without haematuria, place size 16 French gauge urethral catheter. Do not attempt
to pass the urethral catheter more than 2 times – If unsuccessful, seek acute
urology advice. Suprapubic catheter may be needed.
Information
4.  Allow bladder to empty, record volume drained, and send urine for microscopy, culture,
and sensitivities.
5.  If serum creatinine is:
Offical
•  less than 200 micromole/L, the patient can be discharged home.
the
•  greater than 200 micromole/L, observe patient for 2 hours. After initial drainage, if
urine output is:
o  greater than 200 mL/hour after initial drainage, begin treatment
under
for postobstructive diuresis.
o  less than 200 mL/hour after initial drainage, encourage oral fluids,
discharge patient, and arrange repeat creatinine with general practitioner
in 2 to 3 days.
Released
6.  If post-obstructive diuresis, arrange hospital admission and:
•  Replace intravenous (IV) fluid at a rate of 50% of the hourly urine output (e.g. if
the patient is passing 240 mL/hour then IV fluids should run at 120 mL/hour).
•  Review rate of urine output and fluid replacement every two hours.
•  Use alternating one litre bags of sodium chloride 0.9% and glucose 4% sodium
chloride 0.18%.
•  Seek acute urology advice.
7.  Treat the underlying pathology if identified from history, examination, or investigation
results.
Discharge and follow-up

4
1.  Provide patient with a take-home supply of equipment, e.g. leg drainage bags and
catheter fix attachments, as well as catheter care information.
2.  Arrange community nursing services for catheter care and further provision of catheter
supplies. Request a home visit the next day.
3.  If serum creatinine was less than 200 micromole/L and urine output dropped to less than
200 mL/hour after initial drainage, arrange repeat creatinine with general practitioner in
2 to 3 days.
If reviewing patient at 2 to 3 days:
•  Check that daily urine output is less than 3 L.
•  Check urea and electrolytes.
If urine output, urea or electrolytes abnormal, seek acute urology advice.
4.  If the patient has a complex urological problem or is recently postoperative,
Act
arrange non-acute urology review for catheter change or removal. Otherwise, arrange
follow up with the patient's general practitioner for catheter change or removal:
•  Remove urinary catheters as soon as possible, although this will vary according
to the circumstances.1
•  If retention was precipitated by an acute event (e.g. constipation, medical illness,
Information
or surgery), remove catheter in 3 to 5 days. See Catheter Change or Trial of
Void pathway.
•  If prior symptoms of benign prostatic hypertrop
Offical hy, treat with an alpha-1-
blocker and arrange a trial of void in 2 to 3 days.
the
Alpha-1-blockers
•  Both doxazosin and terazosin are equally effective and it can be useful to
under
switch to the other if one is ineffective or there are troublesome side-effects.
•  Work by relaxing smooth muscle.
•  Most common side-effects are dizziness and weakness.
•
Released

Postural hypotension is more likely if the patient is already on an
antihypertensive, and this may need reducing.
•  The dose needs to be titrated up over several weeks.
•  In older adults and those with hypotension, start on a low dose.
•  If prescribing doxazosin, start 2 mg at night for 7 days and increase to 4 mg at
night, if required.
•  If the catheter is removed prematurely, consider whether trial of void is
appropriate or if catheter should be reinserted.
•  Organise prophylactic antibiotic supply if indicated for future catheter change.

5
•
If for trial of void, schedule for early in the morning so that reinsertion (if required)
can be done during normal office hours. If the patient is on oxybutynin or
solifenacin succinate, omit dose on the morning of the trial.
5. If in Christchurch emergency department, provide patient with a catheterisation pack.
This contains:
•
Adult Community Referral Centre (ACRC) referral form
•
Catheter information booklet (You and Your Catheter)
•
2 day bags
•
4 night bags
Request
Act
•
Request acute urology advice if:
•
significant risk factors for urethral injury are present.
•
unsuccessful after second attempt at passing catheter.
•
post-obstructive diuresis.
Information
•
If cauda equina syndrome is suspected, request urgent acute neurosurgery
review.
•
If patient is either recently postoperative or known to have complex urological
Offical
problems, request non-acute urology review.
the
•
For all other patients needing catheter change or removal, request general
practitioner follow-up.
•
If discharging a patient with a ca
under theter in situ, request community nursing
services for catheter care and provision of catheter supplies.
Released

Appendix 2 6
Constipation in Adults
See also Constipation in Oncology and Palliative Care.
Red flags
▪
Weight loss
▪
Abdominal mass
▪
Iron deficient anaemia
▪
Blood mixed with stool
Act
▪
Palpable or visible rectal mass
Background
Information
About constipation in adults
About constipation in adults
Offical
Constipation is difficulty passing small hard stools or not passing stool of any
consistency for 3 days or longer. The consistency of the stool rather than the frequency
the
of defecation should be the focus.
Most patients with idiopathic constipation are otherwise asymptomatic.
under
Assessment
1. History – assess constipation and associated features:
Released
•
Frequency and consistency of motions, presence of alternating diarrhoea.
See Irritable Bowel Syndrome (IBS).
•
Difficulty defecating, e.g. straining, sense of incomplete evacuation, inability to
pass stool despite urge
•
Duration of symptoms – lifelong or recent change
•
Blood, lumps, pain, soiling of underwear
•
Constipating drugs
Constipating drugs
Constipating drugs commonly prescribed in hospital patients include:

7
•
opioids, especially codeine.
•
atypical antipsychotics, e.g. clozapine, olanzapine.
•
tricyclic antidepressants.
•
anticholinergics.
•
antiemetics, e.g. ondansetron.
•
calcium channel blockers.
•
aluminium hydroxide.
History will suggest a cause in the vast majority of cases.
2. Consider whether primary constipation. This is most commonly caused by anismus
(failure of normal relaxation of pelvic floor muscles during attempted defecation), and
more rarely by slow colonic transit.
Act
3. Consider secondary causes.
Secondary causes
•
Tumour – colorectal or pelvic mass
•
Hypothyroid
Information
•
Depression
•
Hypercalcaemia
Offical
•
Eating disorder
the
•
Pregnancy
4. Examine abdomen and rectum. If anal tone is increased or pelvic floor muscles fail to
under
relax when the patient is asked to simulate defecation, consider animsus.
5. Arrange investigations if indicated:
•
Plain abdominal X-rays are not automatically indicated for investigating
constipation. If there is suspicion of significant faecal loading or an alternative
Released
diagnosis (e.g. bowel obstruction) an abdominal X-ray is indicated.
•
Blood tests are not usually necessary but will depend on differential diagnosis.
Consider calcium, phosphate, and thyroid function tests if clinically indicated.
•
If red flags or colorectal symptoms suspicious for malignancy are present,
consider further investigations, e.g. colonoscopy or CT colonography.
Red flags
•
Weight loss
•
Abdominal mass
•
Iron deficient anaemia
•
Blood mixed with stool

8
•
Palpable or visible rectal mass
•
If abdominal or rectal mass present, seek general surgery advice.
Management
Specialist assessment is not usually required, unless a specific underlying cause or a
red flag is identified.
1. If animsus is suspected, consider requesting non-acute gastroenterology review for
biomechanical feedback treatment.
2. Provide patient education resources.
3. Avoid giving the patient constipating drugs if possible.
4. Advise simple measures to help relieve and prevent recurrence of idiopathic
Act
constipation.
Simple measures
•
Maintain adequate dietary fibre. Warn the patient that this can worsen abdominal
pain or bloating if constipation is moderate to severe.
Information
•
Avoid dehydration. Excess fluid will be ineffective.
•
Respond rapidly to urge to defaecate
Offical
•
Go to the toilet at least once a day, even if no urge to pass stool.
•
the
Exercise regularly.
5. Consider medications:
•
Initial trial of bulk-forming laxativ
under es.
Bulk-forming laxatives
Increase faecal mass, which stimulates peristalsis.
Released
Only suitable for mild constipation. Avoid in moderate to severe constipation as
may cause abdominal pain and bloating.
Full effect may take some days to develop.
Valuable in patients with small hard stools, if increase in dietary fibre is not
sufficient to relieve constipation.
Adequate fluid intake must be maintained to avoid intestinal obstruction. Avoid in
pre-existing intestinal obstruction.
Common side effects include flatulence and abdominal distension.
Common preparations include:

9
•
psyllium, e.g. Mucilax, Metamucil, Konsyl-D.
•
sterculia, e.g. Normacol, Normacol Plus (also has stimulant action).
•
If constipation is due to opioids, see Canterbury District Health Board Palliative
Care Service Guidelines – Management of Constipation Associated with Opioid
Use flow chart.
•
If hard stool is filling the rectum, or oral treatment is ineffective, consider
suppositories and/or enemas:
o
Glycerol suppositories
o
Bisacodyl suppositories
o
Micolette or Microlax enema
o
Phosphate enema – should usually be avoided in the elderly or those with
chronic kidney disease as there have been cases of phosphate
Act
nephropathy and acute kidney injury, some of which have been fatal.
However, if non-phosphate enema products are not available, phosphate
enema may be used with precautions, including ensuring adequate
hydration and minimising the number of doses used.
•
Other options include:
Information
o
Bulk-forming laxatives
o
Stimulant laxatives
Stimulant laxatives
Offical
These laxatives:
the
•
increase intestinal motility and often cause abdominal cramps.
under
•
should be avoided in intestinal obstruction.
Common preparations include:
•
bisacodyl, e.g. Lax-tabs, Dulcolax, Fleet.
Released
•
dantron (only in terminally ill patients due to potential carcinogenicity).
•
senna, e.g. Laxsol, Coloxyl and senna, Senokot.
•
glycerol suppositories.
o
Osmotic laxatives
Osmotic laxatives
These:
•
increase the amount of water in large bowel, either by drawing fluid
from the body into the bowel or retaining the fluid the laxative was
administered with.
•
should be avoided in intestinal obstruction.

10
Common preparations include:
•
oral lactulose, rectal sodium citrate (e.g. Micolette).
•
second-line option – oral macrogols (e.g. Molaxole). These are
cheaper on prescription rather than over the counter.
o
Stool softening agents
Stool-softening agents
Docusate sodium probably acts as both a stimulant and a softening agent.
They should be avoided in intestinal obstruction.
Combination products with additional stimulants often cause abdominal
cramps.
Act
Common preparations include docusate sodium, e.g. Coloxyl.
6. If the patient is pregnant, and dietary and lifestyle changes fail to control constipation,
advise the patient to use moderate doses of poorly absorbed laxatives.
•
A bulk-forming laxative (e.g. psyllium husks) should be tried first.
Information
•
An osmotic laxative (e.g. lactulose, Molaxole) can also be used.
Request
Offical
the
•
Consider requesting non-acute gastroenterology review if animsus is suspected.
•
Seek general surgery advice if rectal or abdominal mass present.
under
Information
For health professionals
Released
Education
BMJ Learning – The Royal New Zealand College of General Practitioners
Modules [requires registration] – Constipation: A Guide to Diagnosis and Management
For patients
On HealthInfo

11
•  Give your patient a HealthInfo card and encourage them to search using the keyword
"constipation".
•  HealthInfo – Constipation in Adults
Printable Resources
•  HealthInfo – Fibre and Fluid for Healthy Bowels
•  Patient – Constipation
•  Ministry of Health – Constipation
Patient Medication Information
•  My Medicines:
•  Bisacodyl
•
Act

Docusate
•  Lactulose
•  Macrogol
•  Sennoside B
Information
Search My Medicines for patient information leaflets for any medications not listed in this
section.
Contact the HealthInfo team at [email address]
Offical  if you have any resources that
you would like us to consider for this section.
the

under
Released

12
Appendix 3
Constipation in Children
Background
About constipation in children
About constipation in children
•
Constipation is the difficult, delayed, or distressing passage of stools. It is a common
problem, occurring in up to 30% of children.
•
Childhood functional constipation may present with:
•
2 or fewer bowel motions per week
Act
•
Large stools in the rectum palpable on abdominal examination
•
Retentive posturing and withholding behaviour
•
Painful defecation or hard bowel movements
•
Large diameter stools
Information
•
Soiling
•
The child may also be irritable, show malaise or lethargy, and have decreased
appetite or early satiety, symptoms which often resolve after the passage of a large
Offical
stool.
the
•
Constipation can be a significant risk factor for urinary tract infections (UTIs), urinary
frequency and urgency, and recurrent abdominal pain.
•
It can be present despite a daily bow
under el motion – where daily stool is reflective of
overflow from a rectum filled to capacity.
•
Soiling is caused by soft stool leaking around the hard stool of constipation. It is often
referred to as overflow or "sneaky poos".
•
Encopresis occurs when a ch
Released ild is not constipated and is aware of passing stool but
passes stools somewhere other than on the toilet or into a nappy.
•
It is normal for babies aged younger than 1 year to vary greatly in the frequency and
consistency of bowel motions:
•
Breastfed babies may defecate following each feed but some breastfed babies
only defecate every 7 to 10 days.
•
Formula-fed babies will usually defecate at least every 2 to 3 days.
•
Babies can appear distressed for some time prior to a bowel motion. Straining,
facial flushing, or crying for a short period before passing soft stool can be
normal in infants and is not constipation.
•
Children aged older than 1 year usually defecate at least every 2 days.

13
•  Constipation in childhood is almost always functional.
•  Organic problems are rare and are usually only sought if standard treatment fails or in
the setting of obvious abnormality, e.g. anorectal anomaly, neurological abnormality.
Medical causes could include Hirschsprung's disease, slow colonic transit, coeliac
disease, hypothyroidism, and hypercalcaemia.
Assessment
1.  Take a history.
History
•  Symptoms – abdominal pain, distension, nausea, anorexia (loss of appetite), and
presence of any urinary symptoms, secondary nocturnal enuresis, urinary urgency or
frequency, urinary tract infections (UTIs), whether toilet trained or not
Act
•  Duration of problem
•  Onset
Onset
•
Information

Neonatal constipation in a baby with history of delayed passage of meconium is
suspicious for Hirschsprung’s disease (HD).
•  Onset after starting solid food containing gluten may suggest coeliac disease.
Offical
•  History of fearful event, e.g. scared by toilet flushing, at time of toilet training may
lead to retentive behaviour resulting in constipation.
the
•  If following a significant event or clear precipitating factor (e.g. gastroenteritis, anal
fissure, surgery requiring opioids), children may respond quicker to treatment and
under
may not require such an extended course of maintenance laxatives.
•  Stool pattern – frequency, consistency, size of stools, any pain or bleeding
See the Bristol Stool Chart. “Ribbon” stools may suggest anal stenosis.
•
Released

Stooling behaviour – awareness of need to go, straining, withholding or toilet refusal,
soiling
•  Treatments already tried and duration
•  Lifestyle factors – range of foods eaten, dairy and fluid intake, physical activity
•  Dietary factors may include excessive cow's milk intake, but, unlike adults,
lack of fibre is rarely an issue.
•  Formula-fed babies are more at risk of constipation than breastfed babies.
•  Social factors – toilet training, change in family dynamics or routine, especially
starting school
•  Medical history, including neonatal – confirm newborn screen negative, passage of
meconium (within 48 hours of birth)

14
•  Medications, especially iron supplements, antihistamines, ADHD drugs
Drugs can cause constipation
Drugs that can cause constipation in children include:
•  Antacids containing aluminium or calcium
•  Anticholinergics
•  Antidepressants (tricyclics, selective serotonin reuptake inhibitors)
•  Antihistamines (sedating)
•  Antipsychotics (phenothiazines, clozapine, olanzapine, quetiapine)
•  Atomoxetine
•  Calcium supplements
Act
•  5HT3 antagonists, e.g. ondansetron
•  Iron supplements
•  Opioids, including codeine
•  Proton pump inhibitors
Information
•  Sucralfate
•  Vincristine
Offical
•  Family history of coeliac disease, hypothyroidism, or Hirschsprung's disease
the
•  Growth faltering or significant rectal bleeding
2.  Examination:
under
•  Measure weight and height.
•  Palpate abdomen. Examination is often normal, but a palpable stool in the
descending colon is suggestive of faecal impaction.
•  Inspect anus, especially in infants. Rectal examination is not necessary in
Released
general practice.
Inspection of the anus
Check for:
•  normal anatomy.
•  anal fissure.
•  anal skin tag (usually at 6 or 12 o'clock).
•  infection.
•  Check spine for deep cleft or tuft of hair and lower limb neurology.
3.  Consider faecal impaction if:

15
Faecal impaction
•
Occurs when there has been no adequate bowel movement for several days or
weeks, and a large, compacted mass of faeces builds up in the rectum and/or colon
which cannot be easily passed by the child.
•
Symptoms include failing to pass a stool for several days, followed by a large often
painful or distressing bowel motion. Between bowel movements children with faecal
impaction often soil their underclothes.
•
Child may have vomiting and severe pain.
•
palpable mass.
•
soiling or loss of awareness.
•
abdominal pain and vomiting.
•
urinary symptoms, including retention and incontinence.
Act
•
lack of result or increasing abdominal pain when using maintenance laxative
therapy.
4. Ask the parents to complete a bowel record chart, even if they think their child is not
constipated. Ask the child to tell the caregiver when they have done a poo before
flushing the toilet. Also print out a copy of the Bristol Stool Chart to go with the record
Information
chart.
5. Investigations are not necessary as diagnosis is made by history and examination.
Offical
Management
the
Practice point
under
Do not use laxatives alone
Always combine laxatives with general toilet training measures and support.
1. Provide education and arrange support to achieve patient compliance.
Released
Education
•
Reassure the parents and child that there is no organic problem.
•
Explain the reasons for constipation in children.
Constipation in children
Childhood constipation is common.
There are many reasons a toddler might have a hard stool and passing a hard stool
is often painful.
Children don't want that pain and so try to hold on to the stool. This aggravates the
problem as any delay in passing the stool only makes it harder, as the body absorbs
more water from the stool.

16
Usually constipation occurs when this cycle happens:

•  Provide written information or show an educational video.
•  Explain the need to develop normal bowel habit.
•  Ensure the parents and child know from the start that treatment is likely to be
needed for many months, or even years.
•  Develop a plan with the child and the family, including any support needed. This
Act
could include child disability allowance if significant constipation and the family is
struggling to afford unfunded medication.
2.  Advise general measures – consider using a continence toolkit:
•  Adequate fluid intake
Information
Adequate fluid intake
•  Ensure the child has water at each mealtime and extra drinks when weather is
hot.
Offical
•  Reduce milk intake if excessive. For children aged older than 1 year, give no
the
more than 500 mL spread throughout the day.
Normal fluid needs:
under
•  Children aged 1 to 4 years need about 4 cups of fluid a day.
•  Children aged 5 to 13 years need 5 to 6 cups of fluid a day.
•  If the child is very active, they may need to have more fluid.
Released
•  Water is the best fluid.
See also HealthInfo – Fibre & Fluid for Children.
•  Adequate fibre
Adequate fibre intake
•  Ensure the child has at least 3 servings of vegetables and at least 2 servings
of fruit per day (best with peel left on), and 4 to 5 servings of grain foods per
day. Do not use psyllium husk in children.
•  See KidsHealth – Constipation.

17
•  Fruit juice containing sorbitol (e.g. prune, pear, or apple) or kiwifruit (e.g.
KiwiCrush) – This may be sufficient to soften the stool. Do not give fruit juice to
infants aged younger than 1 year.
•  Adequate exercise
•  Regular toileting
Regular toileting
•  Encourage sitting on the toilet, preferably after meals.
•  The child should sit for 5 minutes, twice a day.
•  After breakfast and dinner is often best.
•  Make sure the child is comfortable on the toilet. They may need an inner seat.
•  Get something for the child to rest their feet on to ensure their knees are
Act
higher than their hips.
•  Encourage the child to lean forward and rest their elbows on their knees.
•  Teach the child to push their stomach (abdomen) out when pushing.
•  Consider a star or reward chart to monitor progress. Praise sitting on the
toilet, rather than having clean underwear.  Information
See printable patient information.
3.  If constipated and soiling, the child is likely to be impa
Offical cted. Treat disimpaction first
before prescribing any maintenance laxatives.
the
Disimpaction
Disimpaction may be required initially for many children with severe constipation or
under
impaction.
•  Do not use lactulose if the child is impacted, as it will likely make abdominal pain
worse.
•  Initially, use macrogol 13.8 g sachet (this is the standard dose sachet, not the
Released
half-sachet 6.9 g dose, which is not funded).
•  Give disimpaction dose according to age.
•  Titrate dose up to effect.
•  If there is no response to macrogol, consider PicoPrep, Picosolax, or Dulcolax SP
drops.
•  If severe impaction with pain or urinary retention, consider rectal therapy in
conjunction with oral disimpaction therapy.
•  Follow disimpaction phase with maintenance softening laxatives.
4.  If the patient is symptomatic, has long-standing constipation or abdominal pain and is
not soiling, start maintenance laxatives as well as general measures.

18
Maintenance laxatives
•  Start with lactulose.
•  If lactulose is unpalatable and affects compliance or 3 mL/kg/day is not working,
start macrogol (lactose can be continued).
•  If compliance is an issue, or lactulose and macrogol are ineffective, use Dulcolax
SP drops – note that this is not the same as Dulcolax tablets or suppositories, which
contain bisacodyl as the active ingredient.
•  All may cause abdominal discomfort.
•  Can be unpredictable in their effect.
•  Adjust doses depending on the result. Aim for 1 soft stool per day (minimum – at
least 3 soft stools per week with no pain and no soiling).
Length of use:
Act
•  Will need to be given for a prolonged period, usually at least 6 months, and
sometimes for years to enable the rectum to regain tone and allow bowel retraining.
Laxatives usually need to be given for at least as long as the problem has existed.
•  Osmotic and lubricant laxatives can be safely used for years and do not cause
dependence.
Information
•  Stimulant laxatives should be used when osmotic laxatives have been ineffective.
Once control is regained, or disimpaction achieved, retry osmotic laxatives.
Offical
•  The most common cause of treatment failure is stopping the laxative too early.
the
•  Do not stop laxatives suddenly. Wean slowly.
•  Once the child has been symptom-free for at least 2 months (or longer, depending on
the length of the constipation), consider gradually weaning off the laxative.
under
•  If constipation returns, restart previous effective laxative dose. Warn families in
advance that this is common.
•  See Constipation Therapies in Children for dosing regimens.
Released
5.  Treat anal fissures if present.
Anal fissures
•  Start laxatives.
•  Apply a barrier cream (e.g. castor oil and zinc oxide ointment) or higher-potency zinc
cream (e.g. Secura EPC), or use a topical preparation containing a local anaesthetic
(e.g. Ultraproct, Proctosedyl) for 2 to 3 days only.
6.  Discuss school expectations.
School expectations
Encourage parents to discuss the issue with the child’s teacher and to make a plan to
manage issues at school. Consider requesting continence services from public health

19
nurses to help with this. Teachers can access an educational pathway
on toileting through Leading Lights.
Schools may not change a child who has soiled, and may instead call the parents to do
so. They may ask general practitioners to fill in a form for funding to support teacher
aides to change a soiled child.
Advise parents to consider timing of disimpaction (e.g. weekends, school holidays), as
the child may need to be in easy reach of a toilet.
7.  Arrange follow-up.
Follow-up
•  Plan regular face-to-face or phone review with the family to monitor progress and
adjust medication as needed (maybe 1 to 2 weekly).
•  Encourage compliance and persistence with treatments.
Act
•  The most frequent reasons for failure of treatment are:
•  not getting stool soft enough.
•  not getting enough laxative.
•
Information

duration of treatment being too short.
•  not being used in conjunction with bowel retraining or toileting regime.
•  Ensure dose is adequate.
Offical
Adequate laxative dose
the
E.g., a child aged:
•
under

2 years, weight 12 kg, is likely to need 25 to 36 mL lactulose daily.
•  4 years, weight 18 kg, is likely to need at least 1 sachet macrogol daily
maintenance.
•  Disimpaction doses:
Released
•  start with at least 1 g/kg macrogol daily, and increase to achieve result.
•  start a child aged 8 years, weight 30 kg, with 3 (full) lax-sachets daily and
increase to effect.
•  Aim for "wet cement" or porridge-type stool.
•  Do not stop laxatives suddenly. Wean slowly.
•  Wean medication when the child has been regularly passing soft-formed stools for at
least 2 months (or longer, depending on the duration of the constipation – often the
same amount of time as the constipation has been present for).
•  If constipation returns, restart previous effective laxative dose. Warn families in
advance that this is common.

20
•  Consider further support for the family from the practice nurse, Well Child provider, or
through a continence service.
Continence service
Consider requesting continence assessment for:
•  a child that is soiling and not improving rapidly after disimpaction.
•  support to continue laxatives in the maintenance phase.
•  help with managing constipation at school.
8.  Request non-acute paediatric medical assessment if:
•  suspected underlying medical cause.
•  faecal impaction which has not responded to disimpaction treatments.
•
Act

the child has been receiving appropriate doses of medication but treatment is not
effective.
Request
Information
•  Request non-acute paediatric medical assessment if:
•  suspected underlying medical cause.
•
Offical

faecal impaction which has not responded to disimpaction treatments
above.
the
•  the child has been receiving appropriate doses of medication but
treatment is not effective.
•
under

Consider requesting continence assessment for:
•  a child that is soiling and not improving rapidly after disimpaction.
•  support to continue laxatives in the maintenance phase.
•  help with managing constipation at school.
Released
In your referral, include information on symptoms, duration of symptoms, and treatments
trialled.
Information
For health professionals
Further information
NASPGHAN – Evaluation and Treatment of Functional Constipation in Infants and
Children: Evidence-Based Recommendations

21
For patients

On HealthInfo
•  Give your patient a HealthInfo card and encourage them to search using the keyword
"constipation".
•  HealthInfo:
•  Constipation in Babies
•  Constipation in Children
Act
Printable Resources
•  HealthInfo – How to Sit on the Toilet
•  KidsHealth:
•  Constipation
Information
•  Laxatives
•  Soiling
Offical
Patient Support Information
the
Plunket
Videos
under
Primary Children's Hospital – Constipation in Children: Understanding and Treating This
Common Problem
Search My Medicines for patient information leaflets for any medications not listed in this
Released
section.
Contact the HealthInfo team at [email address] if you have any resources that
you would like us to consider for this section.

Document Outline