1. Constipation and Faecal Soiling
Continence Advisory Service :
Bobbie Jones
Gill Prior
Jane Dickson

2. Bowel Function

3. Normal Bowel control First year – reflex activity
• Second year – gradual awareness of need to empty bowel
• Third year – ability to defer bowel opening
• Fourth year – ability to delay bowel opening, and to defecate voluntarily

4. Normal Bowel Function 16 weeks – average of 2 stools / day
99% of babies pass meconium within the first 48hrs of birth
16 weeks – average of 2 stools / day
Weaning results in a firmer stool
Range of 1-3 / day to 2-3 / week
Soft and easy to pass

5. Faeces moves into the sigmoid colon and previously empty rectum
Defecation occurs
Holding on

6. Common Bowel Problems Constipation: Slow Transit Constipation:
Defined as the infrequent passage of hard stools
that is difficult to pass. The passing of stools may
be painful and less frequent than is normal for
that child
Slow Transit Constipation:
Slower than average movement of stool throughout the large bowel. 
Faecal Soiling
The repeated passage of stools, whether involuntary or intentional in a socially unacceptable place in a child over 4 years of age (or equivalent developmental age).

7. Contributing factors of constipation
Reduced fluid intake
Reduced fibre intake
Reduced exercise
Holding on/ ignoring the urge – often initiated by passing of large/painful stool

8. Contributing factors of constipation
Missed training opportunity
Delay in passage of normal stool
Anal Fissure
Toileting phobias or fear
Child abuse

9. Functional faecal retention
usually associated with soiling
follows from ‘holding on’ unless managed appropriately
child ‘forgets’ mechanics of normal defecation
May require long term treatment and follow up

11. Constipation – Signs and Symptoms
Symptoms of increasing faecal loading
Abdominal distention and pain
Irritability
Anorexia
Faecal Soiling

12. Slow transit constipation - Signs and Symptoms
Large soft stools
Frequency 3 per week to 1 per 3 weeks
Abdominal distention
High incidence of faecal incontinence
Symptoms of  severe constipation within a year

13. Assessment Check for: daytime urinary problems nocturnal enuresis
appetite / fibre intake
fluid intake - how much milk?
any medical problems
any current medication

14. Red Flags ‘Red flag’ symptoms include:
More than 48 hours before passing meconium as a neonate
Abdominal distension especially 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)

15. Communication
able to indicate what is happening – (not necessarily verbal)
language used for toileting can be unique to each family

16. Mobility Get to the toilet Remove clothing Get up onto the toilet
Wipe bottom
Replace clothing
Wash hands

17. Social Be able to follow instructions Have the ability to communicate
Wish to please parents/carers
Want to be like their peers

18. Environmental issues School toilets Toilet accessibility Peer pressure
Clothing
Lack of privacy
Attitudes of others

19. Treatment Goals To establish regular bowel habits
To reduce stool retention
To restore normal control over bowel function
To reduce concerns within the family
To help reduce conflict within the family

20. Treatment – Constipation
Education
Proposed course of treatment
Normal variation in bowel habits
Symptoms may get worse initially
Evacuation (if required)
Disimpaction with oral laxatives and enemas

22. Movicol Maintenance Regime
Increase
Movicol Dose
Maintain
Decrease
Stop taking Movicol for a day or two

23. Impaction Regime Children (2 – 11 years):
A course of MOVICOL-Half (OR half adult MOVICOL dose) is for up to 7 days as follows:
Number of MOVICOL-Half Sachets
Age (years)
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
2 – 4
2 (1)
4 (2)
6 (3)
8 (4)
5 - 11
10 (5)
12 (6)

24. Treatment – Constipation
Maintenance
Medication may be required
for 6-12 months, even longer.
Increase fibre and fluid intake
Increase activity in the child

25. Treatment – Slow Transit Constipation
Remove obstruction
Fibre supplement – initially
Laxatives
Antegrade Colonic Enema
Colectomy

26. Treatment Plan Overview
Ensure adequate fluid intake
Ensure balanced diet with adequate amounts of fibre
Encourage regular toileting – minute sits
Encourage correct toileting position
Consider environmental factors e.g. access to school toilets
Management strategies
Refer to health care professional