Constipation Flashcards
What can constipation in children be defined as?
The infrequent passage of dry, hardened faeces, often accompanied by straining or pain and bleeding associated with hard stools
What is the problem with defining ‘normal’ frequency of defecation?
Highly variable, and varies with age
What is the average frequency of defecation in the 1st week of life?
4 stools per day
What happens to the frequency of defecation by 1 year?
It falls to an average of 2/day
How long may it take for breastfed infants to pass stool?
Several days
What are the causes of constipation in children?
- Underlying conditions
- Lack of high-fibre foods
- Difficulties with potty training
- Anxiety
- Anal fissure
Are primary causes for constipation common?
No, rare
What underlying conditions should be considered in a child with constipation?
- Hirschsprung’s disease
- Lower spinal cord problems
- Anorectal abnormalities
- Hypothyroidism
- Coeliac disease
- Hypercalcaemia
Give an example of when anxiety may lead to constipation
Anxiety about opening bowels in school or in unfamiliar toilets
What are the risk factors for constipation?
- Sedentary lifestyle
- Certain medications
- Medical conditions affecting anus or rectum
- Family history of constipation
What are the symptoms of constipation in children?
- Infrequent defecation
- Large stool that is difficult to pass
- ‘Rabbit dropping’ stools
- Abdominal pain, which waxes and wanes with passage of stool
- Overflow soiling
What is found on examination in constipation?
Normally reveals a well child, with normal growth, soft abdomen, and normal examination of back and perineal area
Should you do a DRE in children with constipation?
No, refer to specialist if required
What are the amber flag signs in constipation?
- Faltering growth
- Signs of possible maltreatment
- Perianal streptococcal infection
What should be done when faltering growth is present with constipation?
Test for coeliac disease and hypothyroidism
Give two examples of signs of maltreatment in constipation
- Perianal bruising
- Multiple fissures
What should be done when there is perianal streptococci infection in constipation
Treat for constipation and infection
What should be done if there are any red flag symptoms in constipation?
Do not treat constipation, and refer urgently to relevant HCP
What are the red flag symptoms of constipation?
- 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
What is the concern when there is failure to pass meconium in the first 24 hours of life?
Hirschsprungs
What is the concern when there is gross abdominal distention with constipation?
Hirschsprungs, or another GI dysmotility
Give two examples of abnormal lower limb neurology or deformity that would be a red flag sign in constipation
- Talipes
- Secondary urinary incontinence
What is the concern when there is abnormal lower limb neurology or deformity with constipation?
Lumbosacral pathology
What is the concern when there is a sacral dimple over the natal cleft/spine in constipation?
Spina bifida occulta
What is the concern when there is abnormal appearance or patency of anus in constipation?
Anorectal anomaly
What is the concern when there is a perianal fistulae, abscess, or fissures in constipation?
Crohn’s
Are investigations required in constipation?
They are not normally required to diagnose constipation, but can be carried out as indicated by history or clinical findings
What should be done in all children with idiopathic constipation?
Assessment of faecal impaction
How is a child assessed for faecal impaction?
Using a combination of history and physical examination, including looking for overflow soiling and/or palpable faecal mass
What is the first line management for constipation with faecal impaction?
Polyethylene glycol 3350 and electrolytes, using escalating dose regime
What should be done if first line treatment does not lead to disimpaction after 2 weeks in constipation with faecal impaction?
Add stimulant laxative
What should parents be advised of regarding faecal disimpaction regimes?
That they can initially increase symptoms of soiling and abdominal pain
What should be done if all oral medications fail in faecal disimpaction?
Use rectal medications or sodium citrate enemas
What should be done once disimpaction is achieved in constipation?
Continue maintenance therapy
What is the first line management for constipation when faecal impaction is not present?
Maintenance therapy with polyethylene glycol and electrolytes, adjusting dose to symptoms and response
As a guide, what should the starting maintenance dose for constipation be?
Half the disimpaction dose
i know this isn’t helpful lol
What should be done if first line management of constipation is ineffective?
Add stimulant laxative
Why is it important to reassess frequently in constipation?
- Ensure not becoming impacted
- Ensure no issues in maintaining treatment
How long should maintenance treatment for constipation be continued for?
Several weeks after regular bowel habit has been established
How long might it take to establish regular bowel habit on maintenance treatment for constipation?
Several months
How should medication be stopped in constipation?
It should be done gradually over a period of months, in response to stool consistency and frequency
How long can laxative therapies go on for in some children?
Some children can be on laxative therapy for several years, and a minority need ongoing laxative therapy
How is faecal retention managed when it is very severe?
Evacuation using enemas, or manual evacuation under anaesthetic
What is the role of dietary interventions in constipation?
They should not be used alone as a first-line treatment, however you should ensure the patient is receiving adequate fluid and fibre
Is the addition of extra fibre to the diet helpful in constipation?
No
Why is the addition of extra fibre to the diet not helpful in constipation?
Because it may make stools larger and more difficult to pass
How can the medical management of constipation be supplemented?
Negotiated and non-punitive behavioural interventions suited to the child’s age of development
What behavioural interventions may be useful in constipation?
- 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
What is the advantage of encouraging the child to sit on the toilet after mealtimes?
To utilise the psychological gastrocolic reflex, and improve likelihood of success
When is the outcome of constipation management more likely to be successful?
If the child is engaged in the treatment process
What does ensuring that the child is engaged in the treatment process involve?
Ensuring the child’s concerns and motivation to change
Why is encouragement by family and HCPs essential in constipation?
As relapse is common, and psychological support is sometimes required
What do you need to emphasise regarding laxatives when managing constipation?
That they are safe, even long-term, and underuse is the most common reason for treatment failure
What are the complications of constipation?
- Anal fissures
- Rectal prolapse
- Stool withholding
- Encopresis (overflow soiling)
What can encopresis result in?
Secondary behavioural problems
Why can encopresis result in secondary behavioural problems?
As children of school age are frequently teased as a result
