Cases/Patient < 19 years old

Hard Stools Since Starting Solids — Free SCA Practice Case

Mother of a baby with hard stools since starting solids

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12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

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Patient Profile

Full Name

Wilf Pettigrew

Age

0 years

Consultation Type

Telephone

Age

7 months

Situation

Telephone Consultation. Routine call booked by his mother.

Reason for Encounter

"Wilf has been straining and passing hard little poos since he started solids. Should I give him prune juice or something stronger?"

Medical Records (Wilf Pettigrew)

●PMH: Born at term, uncomplicated. Newborn bloodspot screening normal. Primary immunisations up to date.
●Medications: None.
●Allergies: NKDA.
●Growth: Red Book weight 8.3 kg at the health visitor weighing 3 weeks ago, on the 50th centile, as at previous weighings.
●Social: Lives with both parents. Formula fed.

Patient Script

For the friend playing the patient role

Character Overview: You are Kezia Pettigrew, a 33 year old secondary school geography teacher on maternity leave, due back in about two months. You are phoning about your son Wilf, who is 7 months old and your first baby. You live with your husband Dominic, a sixth form college lecturer who is home by five most days and takes the evening bottle. His mother Maureen visits on Saturdays and has firm views on feeding. You are cheerful, chatty and self deprecating, and you tend to tell things in the order they happened, with a joke at your own expense. You trust your new mums' group chat more than you probably should, and you like to say what your friends told you. You are more worried than you sound. You read about a bowel condition some babies are born with, and it has frightened you, although you will not mention it unless asked what is worrying you. You would much rather use food than medicine for a baby. You use a baby tracking app on your phone for feeds and nappies.

Opening Sentence: "Hello, doctor, thanks for ringing. It's about my son Wilf, he's seven months old. Since we started him on solids about a month ago he's been straining and doing hard little poos. I wondered whether I should give him some prune juice, or whether he needs something stronger."

History if Asked (Data Gathering Phase)

●The poos before solids: "They were soft and mustard coloured, like a paste, once or twice a day. It's all in my app. No trouble at all until we started solids."
●The poos now: "Hard, dark little balls, like rabbit droppings. One every two or three days now. It used to be daily."
●Straining: "He goes bright red, pulls his knees up and cries for a few minutes before anything comes. Then it comes out and he's fine again. No pain between times."
●Blood: "About a week ago there was one thin streak of bright red blood on the outside of a hard poo. Just the once. There's been no blood mixed through it and no mucus or jelly."
●Duration: "It's been about four weeks, getting a bit worse in the last fortnight."
●Milk feeds: "He's on a standard first infant formula, four bottles a day of about 180 millilitres. He takes them well. Same brand since he was a few weeks old."
●Solids: "We began at about six months. Baby rice for the first week, then purees of carrot, sweet potato, parsnip, banana and apple, and now some porridge and toast fingers, twice a day, a few spoonfuls to half a small pot."
●Water: "Sips of water from a cup with meals, only about thirty millilitres a day, honestly. He mostly plays with the cup."
●Wet nappies: "Five or six a day, the same as always."
●How he is: "He's himself. Happy, grabbing at everything, feeding and sleeping the same. The health visitor weighed him three weeks ago, 8.3 kilograms, 50th centile like always."
●What I've tried: "Only the sips of water. I bought a carton of prune juice but haven't opened it, because I wanted to check first. In my new mums' group chat someone said a teaspoon of honey in his water works, and another said her baby had lactulose from the pharmacy. I haven't done either. I did wonder about switching to one of the constipation formulas from the supermarket."

Ideas, Concerns, Expectations

Gating note: Kezia does not raise these herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks the solids have been too much for his tummy, or that she introduced baby rice too quickly, and that prune juice is a natural, gentle fix. She sees medicine as a last resort for a baby. "I think I've upset his tummy by starting solids. Prune juice is natural, isn't it? I'd rather not give a baby medicine if I can help it."
●Concerns: She is frightened that this is more than ordinary hard poos. She read that some babies are born with a problem in the nerves of the bowel that causes severe constipation, and she cannot stop thinking about it. She also feels guilty. "I read something in the middle of the night about a bowel condition babies are born with, and I haven't been able to put it out of my head. Is that what this is? And did I cause it by starting solids?"
●Expectations: She hopes for a clear plan she can follow, and reassurance that nothing serious has been missed. She is open to medicine if it is explained, but wants to know it is safe at his age. "I'd like to know what to do, and I'd like to know it's nothing serious. If he does need medicine I'd want to understand it first."

If Asked: Birth, Development and Family History

Gating note: Kezia answers each of these plainly when the doctor asks about it.

●Birth: "He was born at 39 weeks, a normal delivery, 3.4 kilograms. No problems."
●First stool: "He passed his first poo, the black sticky one, in the first day in hospital. The midwife wrote it down."
●Newborn screening: "The heel prick test came back normal. We got the letter."
●Bowels in the first six months: "Completely normal until solids. No constipation, no diarrhoea."
●Development: "He rolls both ways, sits with a bit of support, takes his weight on his legs when I hold him up, and kicks both legs equally. He is reaching for toys and babbling."
●Medicines and vitamins: "None. No iron drops, no antibiotics, nothing from the pharmacy."
●Family history: "Nobody has had a bowel condition as a baby. Dominic had a lot of constipation as a toddler, his mum says. Nobody has cystic fibrosis or thyroid problems."

If Asked: Associated Symptoms

Gating note: Kezia answers these only when asked. Every one is negative unless stated.

●If asked about a swollen or hard tummy: "No, his tummy is soft and looks normal. He's not been bloated."
●If asked about vomiting, including green vomit: "He brings up a tiny bit of milk now and then, same as he always has, but no proper vomiting and nothing green."
●If asked about the shape of the poo, such as thin, flat or ribbon like: "No, they're round little balls."
●If asked about fever or being unwell: "No temperature and no illness. He had a mild cold about six weeks ago."
●If asked about a rash, eczema, wheeze, or milk allergy features: "No rash, no eczema, no wheeze. He has had a bit of yoghurt without any trouble."
●If asked about floppiness, weak legs or unusual movements: "No, he's strong and kicks both legs."
●If asked about a sore bottom: "He's a bit sore after a hard one, but it's not red or swollen."

Social History and Household

●Household: Kezia, Dominic and Wilf. Dominic does the evening bottle, but Kezia does most daytime feeds and nappies and would give any medicine.
●Work: Back at work in about two months, with nursery planned for Wilf.
●Support: The health visitor is helpful and she has her number. Maureen visits on Saturdays. The new mums' group chat is useful and also unsettling.
●Her wellbeing: Tired but coping, no low mood.
●Availability to bring him in: She is free any day this week, mornings are best because Wilf naps after lunch. She has a car.

Responses to Management (The Negotiation Phase)

●
If the doctor says Wilf needs to be examined in person:
- ●Reaction: Relieved to be taken seriously. "Yes, please. Nobody has actually looked at him. I can bring him any morning this week. Will you weigh him again?" "What are you checking for?"
●
If the doctor explains what is likely going on and addresses her fear:
- ●Reaction: Listens closely, then asks directly. "So it's not that bowel condition I read about? How can you tell?" She is reassured by specific facts such as his first poo on day one, normal bowels for six months and thriving. If told it is not her fault: "I did wonder if I'd started solids too early."
●
If the doctor advises food and drink changes, or answers the prune juice question:
- ●Reaction: Practical. "So how much prune juice, and should I put it in his bottle?" If told babies under a year do not need juice, or that it should be well diluted and given with meals: "Right, I'll keep it for his meals then." She asks which foods help. If the doctor does not mention formula she asks, "Should I switch him to one of the constipation formulas?" and accepts advice not to. If the doctor does not mention honey, she does not raise it herself. If asked directly about the honey suggestion, she is surprised to hear it is unsafe: "Oh. I'm glad I didn't."
●
If the doctor suggests a laxative:
- ●Reaction: Hesitant, then curious. "A medicine for a baby? Is it safe at seven months? Will he get used to it and not go without it?" Once the doctor explains that it is an osmotic laxative that softens the stool, how much to give, how long it may take and that the dose is adjusted to his stools: "So it's not addictive, and I can turn it down if he gets loose? How do I give it to him?"
●
If the doctor asks her to keep a diary, or arranges a review:
- ●Reaction: Enthusiastic. "I'm already logging his poos in the app, I'll add the consistency. How long until I should expect it to improve?" If told it can take weeks to a few months and not to stop suddenly: "So I shouldn't stop it as soon as he's better?"
●
If the doctor gives safety netting:
- ●Reaction: Wants specifics. "What would mean I should come straight in, rather than wait for the review?" If the advice is vague, she asks again which symptoms. She repeats back clearly if given specific signs and what to do.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Kezia rings about Wilf, 7 months old, who has strained and passed hard pellets since starting solids about four weeks ago. He is feeding and growing well and has had one streak of blood on a hard stool. She asks whether to give prune juice or "something stronger". The station tests whether the candidate separates simple constipation from a rarer underlying cause, gives age appropriate dietary advice, and uses a laxative when advice alone is not enough, while answering a frightened first time mother.
●The model plan has six parts. Take a focused history that screens for red flags. Arrange an examination in person within days to inspect the anus, abdomen, lower back and legs and to weigh him. Give fluid and diet advice and answer the juice, honey and formula questions. Offer a macrogol laxative alongside the diet advice. Explain how to adjust and for how long to continue it. Review in one to two weeks, with escalation if there is no response and specific safety netting.
●Acceptable alternatives: examining first and starting the laxative at the in person visit, or prescribing after the telephone history and examining within days, are both reasonable. Offering lactulose first is a weaker choice because macrogol is the first line, but it is accepted where macrogol is not tolerated. Arranging the review at one week or two weeks both fit the guidance.

Recognising Idiopathic Constipation in an Infant

●NICE guideline CG99 (Constipation in children and young people) and NICE CKS Constipation in children (revised August 2025) say that two or more findings establish constipation. In a child under 1 year these include fewer than three complete stools a week (not in exclusively breastfed babies after 6 weeks), hard large stools or rabbit droppings, distress on stooling, bleeding with hard stool, and straining.
●Idiopathic constipation, meaning no underlying cause found, is suggested when onset comes after the first few weeks of life, with an obvious precipitant such as a fissure, a change of diet or an infection, and a child who is generally well with weight and height normal. In infants, changes of formula, weaning and low fluid intake are typical triggers.
●Wilf fits this pattern. Soft daily stools became hard pellets when solids began, he strains but recovers, his only water intake is about 30 millilitres a day, and he has had a single streak of fresh blood from a hard stool.

Red Flags and Why They Are Asked

●CG99 says that a child with a red flag should not be treated for constipation but referred urgently to a clinician with the relevant expertise. Red flags in the history include a first stool later than 48 hours after term birth, constipation reported from birth or the first weeks of life, ribbon stools, abdominal distension with vomiting, previously unknown leg weakness or locomotor delay, and faltering growth.
●Examination red flags include an abnormal appearance, position or patency of the anus (fistulae, bruising, multiple fissures, a tight or patulous anus, an anteriorly placed anus), gross abdominal distension, a sacral dimple or hairy patch, and abnormal tone, strength or reflexes in the legs.
●Hirschsprung disease usually presents with delayed first stool, abdominal distension and vomiting, often in the first weeks. Wilf passed his first stool on day one, had normal bowels for six months, is thriving and has a soft abdomen, which makes it very unlikely. Explaining this to Kezia is what reassures her.

Why Examine Him in Person

●CG99 asks for a physical examination to exclude red flags before labelling idiopathic constipation. This cannot be done by telephone: perianal inspection, abdominal palpation, the spine and gluteal region, and lower limb tone and strength all need hands and eyes. The blood streak is a further reason to look.
●A digital rectal examination should not be done in primary care unless the clinician is competent to interpret anatomical abnormalities and Hirschsprung features. It is not needed at this visit.

Fluids, Diet, Juice, Honey and Formula

●Dietary change alone is not first line treatment (CG99 1.5.1). It is given alongside a laxative. Advise a balanced diet with enough fibre for babies who have started solids, such as fruit, vegetables, wholegrain cereal and pulses, and not bran or fibre supplements.
●For fluids, the reference intake for 7 to 12 months is about 800 millilitres a day from milk and food, of which about 600 millilitres is assumed to be water from drinks. These are guides, not requirements. Wilf takes about 720 millilitres of formula and 30 millilitres of water, so offering more water in an open cup with meals is sensible.
●The prune juice question: NHS advice is that babies under 12 months do not need fruit juice, and that if it is given it should be well diluted (about one part juice to ten parts water), served with meals in a cup, not in the bottle. Puréed prunes or pears are an easy alternative. Juice is not a treatment in its own right.
●Honey is not given to babies under 12 months because of the risk of infant botulism (NHS: do not give honey until over 1 year old).
●CKS advises not switching formula or starting a cows' milk exclusion diet unless advised by specialist services. Anti constipation formulas are not needed for Wilf, who has no allergy features.

Laxative Treatment

●Macrogol (polyethylene glycol 3350 with electrolytes) is the first line laxative in children (CG99 1.4.11, CKS). In the BNFC and CKS prescribing information, the paediatric plain sachet for ages 1 to 11 months is half to one sachet daily for maintenance, adjusted to produce regular soft stools. The product is mixed in a drink and may be given in a bottle or cup.
●Licensing varies. CKS and NICE note that not all macrogol preparations are licensed in children under 12, and the licensed starting age differs by product, so the prescriber should check the summary of product characteristics and tell the parent how the medicine is being used at his age.
●Assess for faecal impaction first (overflow soiling, a palpable abdominal or rectal mass). If impacted, disimpaction uses an escalating macrogol regimen, reviewed within one week, and the dose is halved for maintenance. Wilf has no features of impaction, so maintenance dosing is appropriate. Do not use rectal treatments unless oral medicines have failed and the family consents.
●A stimulant laxative, sometimes with lactulose, is a later line step if macrogol fails or is not tolerated, not a first choice for a baby.
●Macrogol is not habit forming and does not stop the bowel working. Continue for weeks to months, even after stools improve, and stop gradually. Too much causes loose stools, so reduce the dose if this happens.

The Blood Streak and the Sore Bottom

●A single streak of fresh red blood on the outside of a hard stool, with a sore but not swollen bottom, is most likely from a small anal fissure. Softening the stool allows healing. Multiple fissures or an abnormal anus on examination are red flags that need urgent assessment, including consideration of child maltreatment (CKS), and are not present in this history.

Follow Up, Referral and Safety Netting

●Reassess frequently while on maintenance treatment. Ask the parent to keep a diary of stools, consistency and the laxative dose.
●If a child under 1 year does not respond to optimum treatment within four weeks, CG99 1.2.2 and CKS say to refer urgently to a clinician competent to perform a rectal examination and consider Hirschsprung disease or other underlying pathology.
●Safety netting should be specific: green or persistent vomiting, a swollen or hard abdomen, blood mixed through stools, fever, refusing feeds, drowsiness or floppiness, fewer wet nappies or poor weight gain need prompt assessment. Offer written information and the ERIC helpline, as CKS suggests.

Consulting With a Worried First Time Mother

●Kezia hides a fear of a bowel condition present from birth, plus guilt about weaning. Ask what she thinks and what worries her, then answer the fear with Wilf's own facts and say plainly that solids did not harm him. She prefers food to medicine, so explain why diet alone is not enough and answer her questions about safety and dependence.

Common Mistakes in This Station

●Recommending prune juice or honey without a thought for his age, or agreeing to a constipation formula.
●Prescribing a laxative with no plan to examine him, or referring urgently despite a reassuring history.
●Never asking about the first stool, vomiting, abdominal swelling or leg movement.
●Missing the low water intake as a trigger, or omitting any fibre advice.
●Using stimulant laxatives, suppositories or high dose disimpaction for a baby with no impaction.
●Giving no plan for adjusting, continuing and stopping the laxative.
●Offering reassurance without naming her fear of a bowel condition, or using terms such as Hirschsprung disease or idiopathic without explaining them.
●Safety netting with "come back if it gets worse" and no named symptoms.

Mapped to the RCGP curriculum topic: Patient < 19 years old.

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