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defaecation is variable but on average 3/day <6/12 to daily by 3yrs

||Stool patturn|Sx|Hx|
| <1yr|<3/wk type 3-4 (not apply to breast fed >6/52), hard large stool, rabbit droppings|distress on passing stool, bleeding, straining|previous episode, anal fissure|
| >1yr|<3/wk type 3-4, hard large stool that won't flush, rabbit droppings, overflow (smelly, loose, no sensation)|poor appetite, pain waxes and wanes, straining, anal pain, retentive posture - straight legged, arched back, tiptoe|plus hard painful stool with bleeding|

Mostly idiopathic ... possibly
dehydration
low fibre diet
medication (eg opiate)
anal fissure
over enthusiastic potty training
hypothyroid
Hirschprungs
learning disability
hypercalcaemia

''Red flags''
Timing - starts at birth or without ppt factors
Meconium after >48hrs
Ribbon stool
faltering growth (amber)
Neuro - leg weakness
Abdo - distension
remember diet and NAI

''Faecal impaction ''
Movicol (escalate dose)
add stimulant
If movicol not tolerated - stimulant plus osmotic (lactulose)
Note - initially pain and soiling increase

''Maintenance''
Movicol
Add stimulant
then docusate or lactulose if still hard
keep at dose for few weeks then decrease slowly

Fluid and fibre impt but not 1st line alone
regular toilet and non-punitive behaviour
Health visitor or paed continence advisor to help

''Infants''
Bottle fed - extra water and bicycle legs / massage tummy
breast fed - unusual - think organic
if weaned - fruit juice, water, ??lactulose