1. ‘Doctor, my 5 year old is constipated’
Dr. Sadananda

2. 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

3. ‘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

4. Encopresis
Term first used in 1926 to suggest similarity with ‘enuresis’ for wetting
Inappropriate passage of normal stool
Stool passed in pants or deposited ‘elsewhere’ (where it can be found!)
Normal bowel sensation
Often associated with other behavioural problems

5. Causes of constipation in childhood
‘Holding on’ - often initiated by passage of large / painful stool
delay in passage of normal stool
anal fissure
group ‘A’ hemolytic streptococcal anal infection
toilet phobias / fears
Child sexual abuse

6. 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

7. Causes of constipation (contd)
Hypothyroidism
Polyuria causing dehydration in DM, Diab insipidus
Lead poisoning
Cows milk intolerance

8. Constipation – environmental issues
School toilets!
Toilet cold/dark
Toilets dirty
Uncomfortable
Lack of privacy
Lack of toilet paper
inaccessible

9. Constipation – psychological factors
Fear / anxiety
Precipitating family stress
Learned behaviour
? Coercive potty training
‘Cry’ for help

10. Assessing constipation
‘Red flag’ symptoms include:
> 48 hours before passing meconium as a neonate
Abdominal distension esp if failing to thrive
Infrequent small or ribbon stools
Constant leaking especially if linked with urinary leaking too
Failed management with appropriate standard intervention (with compliance)

11. General health profile
Check for:
daytime urinary problems
nocturnal enuresis
appetite / fibre intake
fluid intake - how much milk?
any medical problems
any current medication

12. 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

14. Toilet training profile
Age toilet training commenced
age acquired bladder control
age acquired bowel control
(if appropriate )
any significant changes / problems / events occurring at this time

15. Constipation and soiling – Management Overview
Education
Evacuation
Maintenance

16. 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

17. Treatment of constipation
consistent scheduled toileting
positive reinforcement
diet / fluid adjustment
oral laxatives
Suppositories/enemas only as very last resort and if tolerated by child

18. How much fluid? ‘ensure adequate fluid intake’
e.g. 4 year old weighing 16 kg -
needs 85ml/kg = 1360 ml
aim for 6-8 cups throughout the day
encourage water based drinks

19. 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

20. Evacuation
Traditionally softened stools first using osmotic laxative e.g. lactulose/docusate
Then introduced stimulant e.g. senna
Added Sodium picosulphate or similar if poor result
Enema or EUA if above failed
Poor compliance and protracted treatment time

21. 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

22. 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

23. 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 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

24. 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

25. Finishing treatment Gradual reduction
Reduce bowel stimulant (if using) first
Treat early if relapse

26. Managing soiling and encopresis

27. Assessing the soiling problem
Is the child soiling because of:
Delayed bowel control
Overflow soiling with underlying constipation
Encopresis

28. Soiling profile Age at onset of soiling duration of soiling
frequency of soiling
description of soiling
- consistency
- volume

29. Behaviour / school profile
general behaviour at home and school
any reported problems associated with the toilets
any reported bullying

30. 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?

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

32. Treatment -’whole child’ approach
Families often perceive the main problem is the ‘soiling’
constipation secondary issue
emphasis needs to be made on poos in the toilet NOT clean pants
engaging the child to sit on the toilet and perform often most difficult part of treatment

33. Medication Need to treat any underlying constipation first
Fine tune treatment to avoid constipation, but prevent diarrhoea
Maintain for at least 6 months
Then consider cautious dose reduction
Advice family appropriately if relapse occurs
Short term goals, positive reinforcements

34. Summary
History- fluid/ fibre intake, environmental issues, r/o red flags, any soiling/ encopresis
Examination
Management – education, evacuation, maintenance