Constipation & soiling Flashcards
How is constipation defined in children?
Constipation is defined as less than 3 times per week or significantly difficulty passing stool.
=> chronic constipation in children is assoc. with hard pellet, large hard stool, distress/straining/bleeding with the passage of stool
The frequency at which children open their bowel decreases with age from ~3 times per day for infants under 6 months old to once a day after 3 years old
What are the symptoms of constipation?
- Abdominal pain
- Abdominal masses
- Overflow soiling ± lavatory blocking enormous stool (megarectum)
- Anorexia
What are the causes of constipation in children?
Most are idiopathic.
- Poor fluid intake / dehydration
- Low fibre diet
- Fear e.g. as a result of anal fissure
- Hirshprung’s disease - rare
- Hypothyroidism
- Hypercalcaemia
- Learning disability
- Medications i.e. opiates
- Over-enthusiastic potty training
- Pain on passing stool
- Not recognising the sensation of passing stool
What are the red flags to note in children presenting with constipation?
- Constipation from birth or first few weeks
- Failure to pass meconium within 48h
- Faltering growth (consider coeliac’s/hypothyroidism)
- New weakness / abnormal reflexes in legs, delayed locomotion
5. Abnormal appearance of anus / skin in sacral/gluteal region. Look for: => sacral dimples, => hairy patches, => flattening of gluteal muscles, => multiple fissures
- Gross abdominal distension with vomiting
- Ribbon stools
- Abdominal distension
A diagnosis of constipation can be made by 2 or more of the following:
- Stool pattern:
i) Child <1 year:
=> <3 complete stool/week (type 3 or 4 on Bristol Stool Form scale)
=> Hard large stool
=> Rabbit droppings (type 1)
ii) Child >1 year
=> <3 complete stool/week (type 3 or 4)
=> Overflowing soiling - commonly very loose, very smelly, stool passed without sensation
=> Rabbit droppings (type 1)
=> Large infrequent stools that can block the toilet
- Symptoms associated with defecation:
i) Child <1 year
=> Distress on passing stool
=> Bleeding assoc. with hard stool
=> Straining
ii) Child >1 year
=> Poor appetite that improves with passage of large stool
=> Waxing and waning of abdominal pain with passage of stool
=> evidence of retentive posture i.e. straight legged, tiptoed, back arching posture
=> Straining
=> Anal pain
- History:
i) Child <1 year
=> Previous episodes of constipation
=> Previous or current anal fissure
ii) Child >1 year old => Previous episode of constipation => Previous or current anal fissure => Painful bowel movement => Bleeding assoc. with hard stools
After making the diagnosis of constipation, NICE suggests excluding secondary causes. If no red flags present then diagnosis of idiopathic constipation can be made.
Prior to starting treatment, child needs to be assessed for faecal impaction. Factors suggesting this:
=> Symptoms of severe constipation
=> Overflow soiling / diarrhoea (from fluid moving past the hard stool in the rectum)
=> Faecal mass palpable in abdomen
What is the treatment for if faecal impaction is present?
- Polyethylene glycol 3350 + electrolytes (MOVICOL Paediatric Plain) using an escalating dose regimen => First Line
i) Child <1yr : 0.5-1 sachet daily
ii) Child 1-5yrs : 2 sachets on 1st day, then 4 sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily
iii) Child 5-12yrs : 4 sachets on 1st day, then increased in steps of 2 sachets daily to a maximum of 12 sachets daily - Add a stimulant laxative if Movicol does not lead to disimpaction
=> substitute stimulant laxative singly or in combination with osmotic laxative i.e. Lactulose if Movicol not tolerated
=> Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
- Ensure adequate fluid and fibre intake
- Regular toileting and non-punitive behavioural interventions - reward system
- Sitting exercise
What is the maintenance therapy for constipation in children?
Very similar to earlier treatment
- First line: Movicol Paediatric Plain
- Add a stimulant laxative if no response
- Substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative i.e. Lactulose or Docusate if stools are hard
- Continue meds at maintenance dose for several weeks after regular bowel habits established then reduce gradually.
What is soiling?
What is encopresis?
Soiling is the escape of stool into the underclothing.
Encopresis: repeated passage of solid faeces in the wrong place in those >4yrs
Boys > Girls [5:1]
What is faecal incontinence?
Faecal soiling in the context of a physical/anatominal lesion i.e. Hirschsprung’s disease, anal malformation, anal trauma, meningomyelocele, muscle disease
What are the causes of soiling?
Common:
=> Constipation with overflow
=> Emotional & behavioural
Important:
=> Abuse
Rare: => Neurological / anal sphincter => Malabsorption => Hirschsprung's => Tumour
How is retentive encopresis treated?
- Enemas
- Extra dietary fiibre
- Stool softner
- Mandatory daily toilet sitting 15-30mins after eating
- Behaviour therapy and referral to a child and adolescent psychiatrist for non-retentive soiling => part of an emotional disorder
Sitting exercise:
1-3 times per day
20 mins after meal
Push for 2-3 minutes
Stars for pushing and stars for results!
Regular review and encouragement
INFO CARD
Types of laxatives:
How do osmotic laxatives work and what some the examples of this?
Osmotic - increases osmotic pressure attracts water in colon and soften stool
E.g.
- Movicol or Laxido paediatric sachets
=> Macrogol (polyethylene glycol)
=> sachets of powder mixed with water
=> Maintenance 1-4 sachets daily - Lactulose
=> sami-synthetic disaccharide
=> 5-10mls twice a day, increasing as necessary e.g. to 30mls bd
Types of laxatives:
How do stimulant laxatives work and what some the examples of this?
Stimulants - stimulates wall of intestine, smooth muscle contraction and peristalsis
- Senokot:
=> Age 6-12 : 2.5-5ml
=> Age >12 : 5-10mls - Sodium pico sulphate:
=> Age 4-10 : 2.5-5mg
