An introduction to managing constipation and soiling in childhood

1
An introduction to managing constipation and
soiling in childhood

• June Rogers MBE
• Paediatric Continence Advisor
• RN,RSCN,BA(Hons),MSc,ENB216,ENB 978
• Director of PromoCon
• Disabled Living, Manchester
• October 2004

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Constipation in childhood

• Childhood constipation is said to account for
• 3 of outpatient visits
• (Loening-Bauke 1982)
• 25 of gastroenterological referrals
• (Agnersson 1990)

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Constipation

• Difficulty or delay in passage of stool
• lt 3 per week
• may be associated with pain / discomfort
• stools not necessarily hard
• rectum usually full

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Soiling

• Often referred to as constipation with overflow
• inappropriate passage of stool in underwear
  associated with chronic constipation
• faeces often loose and smelly
• involuntary action over which child has no control

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Encopresis

• Term first used in 1926 to suggest similarity
  with enuresis for wetting
• Inappropriate passage of normal stool
• Stool passed in pants or deposited elsewhere
  (where it can be found!)
• Normal bowel sensation
• Often associated with other behavioural problems

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Managing constipation in general practice
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Causes of constipation in childhood

• Holding on - often initiated by passage of
  large / painful stool
• delay in passage of normal stool
• anal fissure
• group A hemolytic streptococcal anal infection
• toilet phobias / fears
• Child sexual abuse

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Causes of constipation (continued)

• Functional faecal retention -usually associated
  with soiling
• follows from holding on unless managed
  appropriately
• child forgets mechanics of normal defaecation
• May require long term treatment and follow up

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Functional faecal retention

• Symptoms begin after first year
• passage of enormous stools
• symptoms of increasing faecal loading -
  soiling/irritability/abdo pain/anorexia
• symptoms resolve on passage of stool
• seemingly irrational coping skill behaviour
• nonchalant attitude / hiding underwear

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Constipation environmental issues

• School toilets!
• Toilet cold/dark
• Toilets dirty
• Uncomfortable
• Lack of privacy
• Lack of toilet paper
• inaccessible

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Constipation psychological factors

• Fear / anxiety
• Precipitating family stress
• Learned behaviour
• ? Coercive potty training
• Cry for help

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Assessing constipation

• Red flag symptoms include
• gt 48 hours before passing meconium as a neonate
• Abdominal distension esp if failing to thrive
• Infrequent small or ribbon stools
• Constant leaking especially if linked with
  urinary leaking too
• Failed management with appropriate standard
  intervention (with compliance)

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General health profile

• Check for
• daytime urinary problems
• nocturnal enuresis
• appetite / fibre intake
• fluid intake - how much milk?
• any medical problems
• any current medication

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Bowel profile

• Check passage of meconium
• description of stools
• - frequency
• - consistency
• - size
• - any pain /discomfort/blood/mucus
• may utilise Bristol Stool Form Chart developed
  by Heaton
• use of toilet / potty
• any previous treatments /interventions

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Toilet training profile

• Age toilet training commenced
• age acquired bladder control
• age acquired bowel control
• (if appropriate )
• any significant changes / problems / events
  occurring at this time

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Constipation and soiling Management Overview

• Education
• Evacuation
• Maintenance

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Constipation - management

• Demystification child and family need to be
  aware of
• Normal variation in bowel habits
• Protracted course of treatment
• Relapses common
• Long term laxatives often required -only to be
  stopped on advice
• Symptoms may get worse initially

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Treatment of constipation

• Demystification with written information
  (available from ERIC, NELH Treatment notes,
  perhaps locally from bowel clinic)
• structured toileting programme
• consistent scheduled toileting
• positive reinforcement
• diet / fluid adjustment
• oral laxatives
• Suppositories/enemas only as very last resort and
  if tolerated by child

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How much fluid?

• ensure adequate fluid intake
• e.g. 4 year old weighing 16 kg -
• needs 85ml/kg 1360 ml
• aim for 6-8 cups throughout the day
• encourage water based drinks

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How much fibre ?

• There are no DRA for fibre for children
• the daily recommended intake is the amount
  required to produce a soft stool
• suggested daily intake is age 5g fibre

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Medication

• Local protocol may be available from paediatric
  service
• Traditional medications include
• Lactulose (stool softener)
• Senna ( bowel stimulant)
• More recent additions
• Movicol paediatric plain (flavourless version of
  movicol half)

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Starting treatment

• Often need to start by evacuating accumulated
  stool
• Local protocol may suggest what medication to
  use, what dose and when specialist advice should
  be sought

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Evacuation

• Traditionally softened stools first using osmotic
  laxative e.g. lactulose/docusate
• Then introduced stimulant e.g. senna
• Added Sodium picosulphate or similar if poor
  result
• Enema or EUA if above failed
• Problems with above as often poor compliance and
  may involve protracted treatment time

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Evacuation - Single step Approach

• Following introduction of Movicol Paediatric
  Plain majority of children can undergo single
  line treatment with appropriate dose titration
  Eliminates need for powerful stimulants and use
  of enemas
• Children find enemas very distressing and
  therefore should only be given to children as a
  very last resort

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Disimpaction

• Movicol Paediatric Plain 2-4years 2-8 sachets,
  5-11 years 4-12 sachets to start with minimum
  number of sachets for age and increase every
  other day until evacuation complete (usually
  within 7 days). Sachets can be taken in divided
  doses but total daily dose should be taken within
  12 hours.
• (refer to SmPC for further details)
• Movicol Adult dose 8 sachets per day for 3 days

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Laxative Dosage

• Lactulose lt1 year, 2.5ml bd 1-5 years 5ml bd
  5-10 years 10ml bd adult 15 ml bd
• Docusate (oral solution) 6 months to 2 years
  12.5 mg tds 2-12 years 12.5 25 mg tds adult
  up to 500 mg/day in divided doses
• Senna (syrup) 2-6 years 2.5 5ml in morning,
  over 6 years 5-10 ml adult 10-20 ml usually at
  bedtime.
• Movicol Paediatric Plain 2-6 years 1-4 sachets,
  7-11 years 2-4 sachets per day (titrate dose as
  necessary)
• Movicol adults 1-3 sachets per day

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Maintenance therapy

• Aim to prevent relapse
• On going advice and support
• Continue with diet/fluid advice
• Long term laxative therapy
• Consider cautious reduction 6mthly
• Behaviour modification

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Maintenance

• Use adequate doses to pass stool one every 1-2
  days
• May need to use a combination of stool
  softener/bulking agent and bowel stimulant (e.g.
  lactulose and senna) or Movicol Paediatric Plain
• Will need at least 6 months treatment and often
  much longer to learn/re-learn bowel habit

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Finishing treatment

• Gradual reduction, dont stop suddenly
• Reduce bowel stimulant (if using) first
• Treat early if relapse

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Managing soiling and encopresis
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Aetiology of soiling

• Usually due to longstanding constipation (and
  therefore may be preventable with early treatment
  of constipation)
• loss of anorectal angle due to retained stool
• over secretion of mucus
• decreased rectal sensation
• continued peristalsis higher up
• reflex relaxation of the anal
• sphincter provoked by retained stool

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Soiling and encopresis

• Often more complex problems
• May be associated with behaviour problem
• May benefit from a specialist assessment from
  paediatric, specialist nurse clinic and/or CAMHS
• If referring, should start treating any
  constipation while awaiting appointment

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Assessing the soiling problem

• Is the child soiling because of
• Delayed bowel control
• Overflow soiling with underlying constipation
• Encopresis

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Assessment

• Need to take into account whole child approach
• How the child perceives the problem important
• Family dynamics need to be taken into account
• Need to be aware of external factors

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Effect on child

• Issues around childs beliefs regarding soiling
• Shame / embarrassment
• Denial non compliance
• Having a secret
• Bullying / name calling
• Social isolation
• Low self esteem

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Effect on family

• Issues around parents beliefs regarding cause of
  soiling
• Often resort to punitive management
• Perceived poor parenting skills
• Risk of abuse
• Financial cost - 34 per wk / 1,768 per yr
• (ERIC Annual review 2001/2002)

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Soiling profile

• Age at onset of soiling
• duration of soiling
• frequency of soiling
• description of soiling
• - consistency
• - volume
• - location

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Behaviour / school profile

• Temperament style
• general behaviour at home
• general behaviour at school
• any reported problems associated with the toilets
• any reported soiling
• any reported bullying

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Childs feelings

• What are childs feelings about using the toilet
  - at home and school?
• does child willfully hold on to stool?
• what are childs feelings about the soiling?
• what does the child think is the cause of the
  soiling?

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Family feelings

• How do parents view soiling?
• How do they manage when it happens?
• What do they do when it doesnt happen?

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Treatment -whole child approach

• Families often perceive the main problem is the
  soiling
• constipation secondary issue
• emphasis needs to be made on poos in the toilet
  NOT clean pants
• engaging the child to sit on the toilet and
  perform often most difficult part of treatment

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Medication

• Need to treat any underlying constipation first
• Fine tune treatment to avoid constipation, but
  prevent diarrhoea
• Maintain for at least 6 months
• Then consider cautious dose reduction
• Advice family appropriately if relapse occurs

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Management whole child approach

• Overcome helplessness
• No blame approach
• Short term goals
• Achievable outcomes
• Positive reinforcements