Consider referring a child with constipation to a specialist if there are red flag symptoms or signs, such as delayed passage of meconium, constipation since the first few weeks of life, chronic abdominal distension plus vomiting, family history of Hirschsprung's disease, or faltering growth, which require urgent referral to a healthcare professional competent to perform a digital rectal examination and interpret features of underlying pathology NICE CKS.
For children older than 1 year, if there is no response to laxatives after 3 months of optimal treatment, refer to a practitioner with appropriate expertise, such as a paediatrician or specialist nurse-led children's continence service NICE CKS.
Children with persistent or refractory symptoms despite optimal management should also be referred for further assessment NICE CKS.
Children with suspected underlying conditions like coeliac disease or hypothyroidism, or ongoing constipation not responding to treatment, should be referred for further tests NICE CKS.
Children with signs suggestive of anatomical abnormalities or Hirschsprung's disease, such as delayed meconium passage or family history, should be urgently referred for specialist assessment NICE CG99.