‘Doctor, my 5 year old is constipated’

Dr. Sadananda

Constipation

Difficulty or delay in passage of stool

< 3 per week/less often than normal

may be associated with pain / discomfort

stools not necessarily hard

rectum usually full

‘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

Encopresis

Term first used in 1926 to suggest similarity with ‘enuresis’ for wetting

Inappropriate passage of normal stoolStool passed in pants or deposited

‘elsewhere’ (where it can be found!)Normal bowel sensationOften associated with other behavioural

problems

Causes of constipation in childhood

‘Holding on’ - often initiated by passage of large / painful stool

delay in passage of normal stoolanal fissuregroup ‘A’ hemolytic streptococcal anal

infectiontoilet phobias / fearsChild sexual abuse

Causes of constipation (continued)

Functional faecal retention -usually associated with soiling

follows from ‘holding on’ unless managed appropriately

symptoms of increasing faecal loading - soiling/irritability/abdo pain/anorexia

symptoms resolve on passage of stool May require long term treatment and follow up

Causes of constipation (contd)

HypothyroidismPolyuria causing dehydration in DM,

Diab insipidusLead poisoningCows milk intolerance

Constipation – environmental issues

School toilets!Toilet cold/darkToilets dirtyUncomfortableLack of privacyLack of toilet paperinaccessible

Constipation – psychological factors

Fear / anxietyPrecipitating family stressLearned behaviour? Coercive potty training‘Cry’ for help

Assessing constipation

‘Red flag’ symptoms include:> 48 hours before passing meconium as a

neonateAbdominal distension esp if failing to thrive Infrequent small or ribbon stoolsConstant leaking especially if linked with

urinary leaking tooFailed management with appropriate standard

intervention (with compliance)

General health profile

Check for:daytime urinary problemsnocturnal enuresisappetite / fibre intakefluid intake - how much milk?any medical problemsany current medication

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

Toilet training profile

Age toilet training commencedage acquired bladder controlage acquired bowel control

(if appropriate )any significant changes / problems / events

occurring at this time

Constipation and soiling – Management Overview

Education

Evacuation

Maintenance

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

Treatment of constipation

consistent scheduled toiletingpositive reinforcementdiet / fluid adjustmentoral laxativesSuppositories/enemas only as very last

resort and if tolerated by child

How much fluid?

‘ensure adequate fluid intake’

e.g. 4 year old weighing 16 kg -

needs 85ml/kg = 1360 mlaim for 6-8 cups throughout the dayencourage water based drinks

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

Evacuation

Traditionally softened stools first using osmotic laxative e.g. lactulose/docusate

Then introduced stimulant e.g. sennaAdded Sodium picosulphate or similar if poor

resultEnema or EUA if above failedPoor compliance and protracted treatment time

Evacuation - Single step Approach

Movicol Paediatric Plain -majority of children can undergo single line treatment with appropriate dose titration.

Children find enemas very distressing and should only be given to children as a very last resort

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.

Movicol: Adult dose 8 sachets per day for 3 days

Laxative Dosage

Lactulose: <1 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

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

Finishing treatment

Gradual reduction

Reduce bowel stimulant (if using) first

Treat early if relapse

Managing soiling and encopresis

Assessing the soiling problem

Is the child soiling because of:

Delayed bowel control

Overflow soiling with underlying constipation

Encopresis

Soiling profile

Age at onset of soilingduration of soilingfrequency of soilingdescription of soiling

- consistency

- volume

Behaviour / school profile

general behaviour at home and schoolany reported problems associated with the

toiletsany reported bullying

Child’s feelings

What are child’s feelings about using the toilet - at home and school?

does child willfully ‘hold on’ to stool?what are child’s feelings about the soiling?what does the child think is the cause of the

soiling?

Family feelings

How do parents view soiling?How do they manage when it happens?What do they do when it doesn’t happen?

Treatment -’whole child’ approach

Families often perceive the main problem is the ‘soiling’

constipation secondary issueemphasis needs to be made on poos in the

toilet NOT clean pantsengaging the child to sit on the toilet and

perform often most difficult part of treatment

Medication

Need to treat any underlying constipation first

Fine tune treatment to avoid constipation, but prevent diarrhoea

Maintain for at least 6 monthsThen consider cautious dose reductionAdvice family appropriately if relapse occursShort term goals, positive reinforcements

Summary

History- fluid/ fibre intake, environmental issues, r/o red flags, any soiling/ encopresis

ExaminationManagement – education, evacuation,

maintenance