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A - MSRA Paediatrics [15] > [27] Constipation > Flashcards

[27] Constipation Flashcards

1
Q

What can constipation in children be defined as?

A

The infrequent passage of dry, hardened faeces, often accompanied by straining or pain and bleeding associated with hard stools

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2
Q

What is the problem with defining ‘normal’ frequency of defecation?

A

Highly variable, and varies with age

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3
Q

What is the average frequency of defecation in the 1st week of life?

A

4 stools per day

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4
Q

What happens to the frequency of defecation by 1 year?

A

It falls to an average of 2/day

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5
Q

How long may it take for breastfed infants to pass stool?

A

Several days

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6
Q

What are the causes of constipation in children?

A
  • Underlying conditions
  • Lack of high-fibre foods
  • Difficulties with potty training
  • Anxiety
  • Anal fissure
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7
Q

Are primary causes for constipation common?

A

No, rare

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8
Q

What underlying conditions should be considered in a child with constipation?

A
  • Hirschsprung’s disease
  • Lower spinal cord problems
  • Anorectal abnormalities
  • Hypothyroidism
  • Coeliac disease
  • Hypercalcaemia
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9
Q

Give an example of when anxiety may lead to constipation

A

Anxiety about opening bowels in school or in unfamiliar toilets

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10
Q

What are the risk factors for constipation?

A
  • Sedentary lifestyle
  • Certain medications
  • Medical conditions affecting anus or rectum
  • Family history of constipation
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11
Q

What are the symptoms of constipation in children?

A
  • Infrequent defecation
  • Large stool that is difficult to pass
  • ‘Rabbit dropping’ stools
  • Abdominal pain, which waxes and wanes with passage of stool
  • Overflow soiling
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12
Q

What is found on examination in constipation?

A

Normally reveals a well child, with normal growth, soft abdomen, and normal examination of back and perineal area

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13
Q

Should you do a DRE in children with constipation?

A

No, refer to specialist if required

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14
Q

What are the amber flag signs in constipation?

A
  • Faltering growth
  • Signs of possible maltreatment
  • Perianal streptococcal infection
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15
Q

What should be done when faltering growth is present with constipation?

A

Test for coeliac disease and hypothyroidism

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16
Q

Give two examples of signs of maltreatment in constipation

A
  • Perianal bruising

- Multiple fissures

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17
Q

What should be done when there is perianal streptococci infection in constipation

A

Treat for constipation and infection

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18
Q

What should be done if there are any red flag symptoms in constipation?

A

Do not treat constipation, and refer urgently to relevant HCP

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19
Q

What are the red flag symptoms of constipation?

A
  • Failure to pass meconium in first 24 hours of life
  • Gross abdominal distention
  • Abnormal lower limb neurology or deformity
  • Sacral dimple over natal cleft/spine
  • Abnormal appearance/patency of anus
  • Perianal fistulae, abscess, or fissures
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20
Q

What is the concern when there is failure to pass meconium in the first 24 hours of life?

A

Hirschsprungs

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21
Q

What is the concern when there is gross abdominal distention with constipation?

A

Hirschsprungs, or another GI dysmotility

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22
Q

Give two examples of abnormal lower limb neurology or deformity that would be a red flag sign in constipation

A
  • Talipes

- Secondary urinary incontinence

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23
Q

What is the concern when there is abnormal lower limb neurology or deformity with constipation?

A

Lumbosacral pathology

24
Q

What is the concern when there is a sacral dimple over the natal cleft/spine in constipation?

A

Spina bifida occulta

25
Q

What is the concern when there is abnormal appearance or patency of anus in constipation?

A

Anorectal anomaly

26
Q

What is the concern when there is a perianal fistulae, abscess, or fissures in constipation?

A

Crohn’s

27
Q

Are investigations required in constipation?

A

They are not normally required to diagnose constipation, but can be carried out as indicated by history or clinical findings

28
Q

What should be done in all children with idiopathic constipation?

A

Assessment of faecal impaction

29
Q

How is a child assessed for faecal impaction?

A

Using a combination of history and physical examination, including looking for overflow soiling and/or palpable faecal mass

30
Q

What is the first line management for constipation with faecal impaction?

A

Polyethylene glycol 3350 and electrolytes, using escalating dose regime

31
Q

What should be done if first line treatment does not lead to disimpaction after 2 weeks in constipation with faecal impaction?

A

Add stimulant laxative

32
Q

What should parents be advised of regarding faecal disimpaction regimes?

A

That they can initially increase symptoms of soiling and abdominal pain

33
Q

What should be done if all oral medications fail in faecal disimpaction?

A

Use rectal medications or sodium citrate enemas

34
Q

What should be done once disimpaction is achieved in constipation?

A

Continue maintenance therapy

35
Q

What is the first line management for constipation when faecal impaction is not present?

A

Maintenance therapy with polyethylene glycol and electrolytes, adjusting dose to symptoms and response

36
Q

As a guide, what should the starting maintenance dose for constipation be?

A

Half the disimpaction dose

i know this isn’t helpful lol

37
Q

What should be done if first line management of constipation is ineffective?

A

Add stimulant laxative

38
Q

Why is it important to reassess frequently in constipation?

A
  • Ensure not becoming impacted

- Ensure no issues in maintaining treatment

39
Q

How long should maintenance treatment for constipation be continued for?

A

Several weeks after regular bowel habit has been established

40
Q

How long might it take to establish regular bowel habit on maintenance treatment for constipation?

A

Several months

41
Q

How should medication be stopped in constipation?

A

It should be done gradually over a period of months, in response to stool consistency and frequency

42
Q

How long can laxative therapies go on for in some children?

A

Some children can be on laxative therapy for several years, and a minority need ongoing laxative therapy

43
Q

How is faecal retention managed when it is very severe?

A

Evacuation using enemas, or manual evacuation under anaesthetic

44
Q

What is the role of dietary interventions in constipation?

A

They should not be used alone as a first-line treatment, however you should ensure the patient is receiving adequate fluid and fibre

45
Q

Is the addition of extra fibre to the diet helpful in constipation?

A

No

46
Q

Why is the addition of extra fibre to the diet not helpful in constipation?

A

Because it may make stools larger and more difficult to pass

47
Q

How can the medical management of constipation be supplemented?

A

Negotiated and non-punitive behavioural interventions suited to the child’s age of development

48
Q

What behavioural interventions may be useful in constipation?

A
  • Scheduled toileting
  • Maintenance and discussion of bowel diary
  • Information on constipation
  • Use of encouragement and rewards systems
  • Encouraging child to sit on toilet after mealtimes
49
Q

What is the advantage of encouraging the child to sit on the toilet after mealtimes?

A

To utilise the psychological gastrocolic reflex, and improve likelihood of success

50
Q

When is the outcome of constipation management more likely to be successful?

A

If the child is engaged in the treatment process

51
Q

What does ensuring that the child is engaged in the treatment process involve?

A

Ensuring the child’s concerns and motivation to change

52
Q

Why is encouragement by family and HCPs essential in constipation?

A

As relapse is common, and psychological support is sometimes required

53
Q

What do you need to emphasise regarding laxatives when managing constipation?

A

That they are safe, even long-term, and underuse is the most common reason for treatment failure

54
Q

What are the complications of constipation?

A
  • Anal fissures
  • Rectal prolapse
  • Stool withholding
  • Encopresis (overflow soiling)
55
Q

What can encopresis result in?

A

Secondary behavioural problems

56
Q

Why can encopresis result in secondary behavioural problems?

A

As children of school age are frequently teased as a result

A - MSRA Paediatrics [15] (115 decks)

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