1. Constipation and Soiling
Emma Potter
Children’s Community Nurse
April 2012
Hi I’m Emma Potter.
I’m a Children’s community Nurse based at Epsom Hospital

2. Constipation in Childhood
A Hidden Problem
Taboo subject.
Adversely affects the child's school life, social life and family life
Emotional and financial cost
Lack of understanding and help
Constipation effects 5-30% of the child population
Constipation is thought to effect between 5-30% of the child population.
Despite the large numbers of children having problems with Constipation is not a topic discussed at the school gate.
But the impact of constipation on the child and family can be enormous, with the child's school, social and family life all being effected.
I mean How do you tackle a school swimming session when you know your pants are full of poo?
{Children and parents often experience confusion, frustration and despair when they are confronted with this condition and may delay seeking help through embarrassment or fear of blame.}
{Constipation with no anatomical or physiological cause is termed 'idiopathic'. }

3. History-taking NICE Clinical Guideline 99 Issued 2010
Two or more symptoms:
Stool patterns
Fewer than 3 stools per week
Rabbit droppings or Infrequent large stools
Overflow soiling
Symptoms associated with defecation
<1yr Distress, Bleeding associated with hard stool, Straining
> 1 yr Poor appetite that improves with passage of stool, abdominal pain, retentive posturing, Straining, anal pain
History
Previous episode(s) of constipation,
Previous or current anal fissure
Painful bowel movements and bleeding associated with hard stools
Nice Clinical Guideline published in 2010 have a table listing the key components of history taking to diagnose constipation.
Fewer than 3 stools per week [this does not apply to exclusively breastfed babies after 6 wks of age]
Rabbit droppings [type 1 Bristol Stool chart]
Infrequent Hard large stools. I remember one mother of a child who had been soiling for nearly 2 years telling me their child could not possibly be constipated because only last week she had to use a stick from the garden to unblock the toilet.
Overflow soiling usually a loose, smelly, stool passed without sensation. The consistency of overflow soiling can vary. Frequently parents describe it as normal stool
Symptoms associated with doing a poo
For Children under 1yr these can include Distress on passing a stool, excessive Straining &/or Bleeding associated with hard stool,
Children over a 1 yr may have a Poor appetite that improves with passage of large stool, Waxing and waning of abdominal pain with the passage of stool Evidence of retentive posturing:
Withholding behaviour in the younger child is often misinterpreted by parents as straining to pass a stool. Typically the child will be walking around on tip toes, legs stiff, buttocks clenched. Defecation dance
The child may have a history of Previous episodes of constipation, bleeding associated with hard stools &/or anal fissure
So 2 or more symptoms indicate constipation

4. refer urgently to specialist services
Red Flags
Constipation present from birth or first weeks of life
Delayed passage of meconium Ribbon stools
Abnormal appearance/position/patency of anus.
Abdominal distension with vomiting
Abnormal spine/lumbosacral region/gluteal examination.
Previously unknown or undiagnosed weakness or deformity in legs, locomotor delay or history of falls. Abnormal reflexes.
Red flag found
refer urgently to specialist services
Need to confirm a positive diagnosis of idiopathic constipation by excluding underlying causes.
If a child has any red flag symptoms do not treat then for constipation but refer urgently to specialist services
Possible red flags can be summarised as
Constipation that is present from birth or the first weeks of life
Delayed passage of meconium (that is more than 48 hours after birth)
Ribbon stools
Abnormal appearance/position/patency of anus.
Abdominal distension with vomiting
Abnormal spine/lumbosacral region/gluteal examination
Previously unknown or undiagnosed weakness or deformity in legs, locomotor delay, history of falls.
Abnormal reflexes.
Organic causes are Responsible for constipation in fewer than 5 % of children and are most likely to be seen in the neonatal period.
A digital rectal examination should not be routinely performed and only performed by healthcare professionals competent in diagnosing anatomical abnormalities. These children are already sensitive enough about their bottoms.
{Amber flag‟, possible idiopathic constipation
Growth and general wellbeing:
Faltering growth (see recommendation on faltering growth, below)
Personal/familial/social factors:
Disclosure or evidence that raises concerns over possibility of child maltreatment}

5. Management 1. Education 2. Disimpaction 3. Maintenance 4. Weaning
Management requires
Education of the child and family to enlist their co operation and alleviate blame
Disimpaction with oral medication being the route of choice for disimpaction
Maintenance phase with ongoing contact with the family to offer support with toileting, exercise and dietary interventions, laxatives
And
A period of weaning off medication

6. 1. Education Demystification of constipation and faecal impaction
Managing soiling episodes at home and school.
Encourage carers to be positive and supportive
Emphasise the need for long term treatment / laxatives and that relapses are common.
Education involves
Demystification of constipation and faecal impaction
Discussion around managing soiling episodes at home and school.
Encouraging carers to be positive and supportive
And Emphasising that children who have been soiling are likely to need long term treatment / laxatives
and that relapses are common.

7. PRESS RETURN
We show the family and the child if appropriate these drawings by Professor Graham Clayden Kings College London school of medicine
They show a simplified version of the anatomy of the rectum and anal sphincter
We explain that normally the rectum is nearly always empty.
That Peristalsis of the bowel moves poo into rectum and that this often happens following meals due to the Gastro colic reflex.
The person becomes aware of poo in the rectum and contracts the Anal sphincter to holds the poo in until a toilet can be found. Then we Sit on the toilet and the poo released leaving the rectum empty
We point out the Kink and explain how this helps to keep the rectum empty
We then show the rectum of a constipated child. The bowel is full. There is No kink. Even after passing a stool the rectum quickly becomes filled again.
Rectum thick, stretched and baggy. Child desensitised to the messages

8. 2. Disimpaction Oral disimpaction
Polyethylene glycol 3350+electrolytes
(Movicol® Paediatric Plain)
Add stimulent laxative if required
( Senna, Sodium picosulfate / Dulco-lax Perles ®)
Review within 1 week
The choice of medication is not as
important as the parents’ and child’s concordance with the regime.
Oral route for disimpaction. This is better tolerated by everyone particularly by the child
Rectal medication or manual disimpaction should only be used when oral medication has failed
It is Important to get Child and family are on board with treatment choice. I can’t tell you how many times I have visited a family post Dr’s app. who had have started and immediately stopped or not even started the laxatives that were prescribed.
Time needs to be taken to discuss the various medications available and try to help the child and parents chose a method of disimpaction that they feel will work best for them
Movicol is the NICE and our treatment of choice. It can however be difficult to convince a child to drink. We suggest mixing it with flavoured drinks but still have parents finding full cups of Movicol hidden behind the curtains.
If Movicol has not worked after 2 weeks consider adding stimulant laxative.
Sodium Picosulfate is easy to administer, well tolerated easy to manipulate dose. The Perles are particularly good for young teenagers. We find that Senna does not seem to be as effective in younger children and currently there appears to be a supply problem
Docusate Sodium 3 times a day does not make it easy for families .

9. 3. Maintenance therapy The goal is to achieve one soft stool per day
Help the muscles and nerves of the rectum to recover sensitivity and strength by promoting regular toileting and preventing further stool impaction.
Need to overcome child's fear of passing a stool
Treatment focuses on the prevention of a recurrence of impaction.
The goal is to achieve
one soft stool per day
Help the muscles and nerves of the rectum to recover sensitivity and strength by promoting regular toileting and preventing further stool impaction. Need to overcome child's fear of passing a stool and prevent the recurrence of impaction
The goal is to achieve one soft stool per day

10. Maintenance Laxatives Maybe required for several weeks to years
Dietary interventions
Not to be used alone or as a first line treatment for idiopathic constipation
Scheduled Toileting
Negotiated and non-punitive behavioural interventions
Exercise
Four components of maintenance:
Laxatives:
maybe required for several weeks to years
Titrating laxative dose can be difficult and support is essential in the early weeks. Initially we try to maintain weekly phone calls until medication dose is appropriate & concordance achieved then 3-6 monthly until discharged. It can be 2 to 3yrs from initial referral to complete resolution of the problem.
Dietary interventions:
Takes time to change children’s diets. Whole family involved. High fibre food available in the house and offered at each meal. Regular meal pattern stop grazing. Drink 6-8 glasses of fluid each day. Assess milk intake may need to advise reduction in Milk intake 1 pint / 500mls per day as some children use it as meal replacement.
Cows milk exclusion diet only on advice of a paediatrician with support of a dietician. reduced Milk intake 1 pint / 500mls per day
Scheduled toileting:
important in preventing reimpaction and laxative reduction
Need to get ‘buy in’ to the programme from child and carers 
The emphasis should be initially on sitting on the toilet and then on passing stools in toilet, not on keeping pants clean
Sit child on toilet about 15 minutes after every meal to take advantage of the gastro colic reflex
The child's feet should be supported with knees higher than bottom. Toilet insert. Books or bubble pots star charts!
Encourage parents to keep a record of progress
Exercise
Daily physical activity incorporated into daily life where possible. For example walking to school.

11. Re impaction Relapse is common.
The child and parents need to be aware of the warning signs of re impaction
The most common reason for treatment failure in the maintenance phase is stopping the medication too soon or using doses that are too small
Relapse is common.
Child and parents need to be aware of the warning signs of re impaction
It is important to respond quickly to any difficulties voiced by the family or child. The parents and child must have a rescue plan to ensure early response to relapse. We ask parents to phone immediately they recognise a problem
The type of laxative may need to be changed if child unhappy to take or parents finding it difficult to find the time to administer
It may be necessary to up or down dosage due to holidays or antibiotics
The most common reason for treatment failure in the maintenance phase is stopping the medication too soon or using doses that are too small

12. Stopping Laxative treatment
Wean medication when the child has been passing regular soft formed stools for 3 months.
Do not stop medication abruptly.
Step up contact during the weaning period.
25% of children will be off laxatives after 6 months of treatment, 50% by one year, 75% by two years
Difficulty establishing regular bowel habit or weaning off laxatives - Referral to Paediatrician
Wean medication when the child has been regularly passing regular soft formed stools for 3 months.
Children who are on toilet training should remain on laxatives until toilet training is well established.
Do not stop medication abruptly. Laxatives weaned very slowly, each child will be different.
Estimated that 25% of children will be off laxatives after 6 months of treatment, 50% by one year, 75% by two years
Difficulty establishing regular bowel habit or weaning off laxatives - Referral to Paediatrician

13. Further Information
Epsom Children’s Community Nursing Team based at Epsom Hospital
Referrals by letter or Fax
NICE clinical guideline 99Constipation in Children and Young People
ERIC Education and Resources for Improving Childhood Continence
Movicol Norgine Limited
Medical Information/ leaflets [Julia Deeley ]