Constipation in children GP REFRESHER NOVEMBER 2015 Phil Wylie

WHY??!! Common 5-30% (depending on definition) – 1/3 become chronic (ie last > 8 weeks) Causes lot of suffering Prognosis altered by speed at which access effective advice/treatment

Based on Academy Paediatric Gastroenterology study day 30/9/14 ESPGHAN/NASPGHAN evidence based recommendations 2014 NICE guideline 99 – Constipation in children and young people

What is constipation? Rome III criteria > 2 features 1/12 (2/12 > 4 yrs) < 2 per week Painful/hard Faecal mass rectum Large diameter stools Stool retention Soiling (>1 episodes per week) Bristol stool chart

Infant dyschezia <6 months Crying, straining/anal sphincter (? Related allergy) Soft stool Failure to coordinate intra-abdominal pressure with relaxation pelvic floor Incidence 1 month 21%, 3 months 7% Self resolving Not related to future constipation

Functional (95%) or organic (5%)? Constipation is a symptom not a diagnosis RED FLAGS Onset < 1/12 (at least daily) NB Breastfed babies > 6 weeks can have infrequent bowel actions Delay passing meconium > 48 hours Ribbon stools Abdominal distension with vomiting Neurological problems with lower limbs/urinary problems

Other features in history AMBER FLAGS Psychosocial concerns - ? Safeguarding Faltering growth OTHERS Allergy (CMPA allergic first year more likely to have constipation) FH – assoc conditions – coeliac, constipation (functional – 30% vs 7% in control), HD – 7% FH

Examination Growth Dysmorphism Abdo examination – distension (vomit), mass Dysmorphism/hypermobility Anus – position, tags, ?stenosis (ribbon stools), perianal redness (?strep) PR? (? Impaction, red flags, ? Stenosis) NICE suggests rectal if not responding optimal treatment within 4 weeks in < 1 year old Lumbosacral Gait and lower limb neurology (reflexes lower limb) Cremasteric reflex/anal reflex?

What is usual position of anus? Anal position index Ratio anus-fourschette (girls) or anus-scrotum boys to the distance between coccyx and fourscette/scrotum API girls 0.45 (95%CI: 0.44-0.46) API boys 0.54 (95%CI:0.53-0.55)

Investigations AXR – not to diagnose constipation Transit time – not routine Coeliac – 0.2% coeliac – constipation as only presenting feature – not recommended Hypothyroid – 0.08% - not recommended (still in NICE) Calcium/Pb no different to general population – not recommended (still in NICE) Rectal biopsy gold standard for HD (suction usually sufficient)

Treatment Fibre – “normal” – may make worse in short term NICE – don’t use first line without other treatment and don’t recommend unprocessed bran Chocolate/banana no association stool frequency/consistency Fluid – “normal” (NICE gives recommended volumes) Physical activity – “normal” Behavioural advice important (schedule, diary, reward system etc) Written information (www.eric.co.uk)

Disimpaction Oral vs enema – equally effective but NICE recommends oral route first Use PEG usual recommended regime Warn soiling will get worse before it gets better

Maintenance PEG first line (Movicol Paed Plain) Maintenance – PEG superior to lactulose Stimulants 2nd line Can chronic use stimulants cause any long term issues?? No evidence. Can see melanosis coli At least 2 months in maintenance phase with at least 1 month of normal bowel habit before gradual reduction of treatment

Prognosis Duration symptoms key < 3/12 duration at presentation – 80% not using laxatives at 6 months compared to 32% if symptoms >3/12 at presentation Overall 50% off laxatives by 12 months (relapse common and parents need to be aware of this) Intractable 80% off laxatives 10 years (need to be confident and “aggressive”

Summary Diagnose accurately and know “red flags” Start treatment early and be bold Don’t just advise increased fibre Use PEG first line (lactulose by itself often ineffective) Don’t be put off by licensing restrictions – refer to NICE guideline (informed consent) Patient information key Follow up/availability to support

Licensing in the UK Lactulose – licensed 1 month onwards PEG – not licensed faecal impaction < 5 years or maintenance treatment < 2 years but NICE quotes recommended dosages down to < 1 year Senokot – syrup not licensed < 2 years but NICE quotes recommended doses > 1/12 age Picosulphate – age range not specified by manufacturer but NICE quotes recommended dosages from >1/12 age Dosages in NICE often not BNFC recommended Use but informed consent documented