Constipation/Faecal Incontinence Flashcards
What is the first bowel action a neonate has?
Meconium passed within first 24h
Outline the number of stools a child has in:
- first weeks
- first months
- ~ 2yo
- First weeks: 4 to 8 stools/day (breastfed more)
- First months: breastfed infants 3 stools/day, vs about 2 stools/day for formula-fed infants
- By 2 yo: < 2/day
At which time points in a child’s life is constipation more common?
- Esp. common during intro of solid foods, toilet training, school entry, illness
What is the most common cause of constipation in childhood? Outline how it occurs.
Functional constipation (95%): Painful defaecation leads to apprehension, retention, passage of hard stool and a cycle of withholding and passage of hard stool. Young children may ignore the urge to defaecate, causing a build-up of large hard bowel actions.
What are some less common, medical causes of constipation?
Cow milk allergy
Coeliac disease
Hypercalcaemia, hypothyroidism
CF
What are some less common, surgical causes of constipation?
Hirschsprung disease
Meconium ileus
Anatomic malformations of anus
Spinal cord abnormalities
In infants <6mo, what is a common ddx for constipation?
Dyschezia:
• Healthy infants (<6mo) can strain and cry before passing soft stools
• This is caused by inability to co-ordinate the increase in intra-abdominal pressure with pelvic floor relaxation
• Unless the stools are also hard, this is not constipation and will self-resolve
What is meconium?
= earliest stool passed my a mammalian infant, composed of things infant ingests in womb e.g. bile, cells, amniotic fluid
What are some behavioural signs of witholding patterns?
- Toilet refusal
- Hiding while defaecating
- Crossing legs
Dx criteria for constipation
Two or more of the following characteristics within the previous 8 weeks:
- < 3 bowel motions/week
- > 1episode of faecal incontinence/week
- Large stools in the rectum or on abdominal examination
- Passing of stools so large that they obstruct the toilet
- Retentive posturing and withholding behaviour
- Painful defecation
What kind of oral laxatives can you trial for children?
○ Children: Stool softener (paraffin oil - Parachoc or Agarol) or osmotic laxative (Movicol or Osmolax)
○ Infants 6-12mo: Coloxyl drops or Lactulose
○ Infants <6months: Coloxyl drops
At what age can you officially diagnose faecal incontinence?
> 4yo
Most common cause of faecal incontinence and how it occurs.
- Constipation most common cause
- Withholding→Increased volume and pressure in rectal ampulla→chronic stretching of rectal ampulla→rectal hyposensitivity
- Intermittent relaxation of external anal sphincter→unexpected faecal leakage
What are some rare causes of faecal incontinence
• Neurological
○ Anismus (incoordination between straining an release of the EAS) and withholding
• Congenital/structural
• Inflammatory
• Psychogenic
• Toilet/defecation phobia with withholding
What posture should one assume to relieve constipation?
• feet supported, knees above hips, legs apart, bulge tummy
- footstool to ensure knees are higher than hips
- Lean forward and put elbows on knees
- A toilet ring should be placed over the toilet seat if needed.
• If baby, tummy rubs and bicycle legs
What kind of toileting changes can you make to improve constipation?
○ 5mins, 3 x D ○ Sit after meals to take advantage of gastro-colic reflex ○ Maximise emptying ○ Timer in bathroom ○ Keep toileting positive experience
• Stool diary • Add rewards ○ Reward for effort (sitting), rather than successful ○ Charts with stars • Regular review and encouragement
Mx plan for constipation
- Disimpact with laxatives if have to
- Then maintenance laxatives with other non-pharmacological Mx options
- Taper laxatives and maintain non-pharma options
