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Constipation and Enuresis

Constipation and Enuresis. Katie Mallam Paediatric Update for Primary care 9 th October 2012. Constipation – Why?. Common Prevalence 5-30% 1/3 become chronic (>8 weeks) = soiling Debilitating Social, psychological and educational consequences Cost

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Constipation and Enuresis

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  1. Constipation and Enuresis Katie Mallam Paediatric Update for Primary care 9th October 2012

  2. Constipation – Why? • Common • Prevalence 5-30% • 1/3 become chronic (>8 weeks) = soiling • Debilitating • Social, psychological and educational consequences • Cost • Longer duration = longer, more intensive treatment • Varying advice = angry parents

  3. Constipation – NICE • Standardise approach • Early treatment • Reduce consequences and cost • No need to remember history and examination: http://guidance.nice.org.uk/CG99/Questionnaire

  4. Constipation? 2 of …….. * Breast fed babies can go up to a week without opening bowels *

  5. Constipation? http://www.childhoodconstipation.com/Extra/Documents.aspx

  6. Constipation? 2 of …….. * Breast fed babies can go up to a week without opening bowels *

  7. Constipation – Causes • Mostly idiopathic • Rarely • Hirschsprung’s • Neurological NB lumbosacral abnormalities • Anorectal malformations • Hypothyroid • Coeliac • Cystic fibrosis (but normally diarrhoea due to fat malabsorption) • Cow’s milk protein intolerance • Associations • Cerebral palsy • Autism • Down’s syndrome (NB beware hypothyroidism and Hirschsprung’s)

  8. Constipation – History 1

  9. Constipation – History 2 Faltering growth = treat and do coeliac and TFT (refer)

  10. Constipation – Examination No PR in primary care NB perianal strep

  11. Perianal streptococcal infection Swab Treat infection and constipation

  12. Constipation – Examination No PR in primary care NB perianal strep

  13. Constipation – It’s NICE • No need to remember history and examination: http://guidance.nice.org.uk/CG99/Questionnaire < 1 year ≥ 1 year

  14. Constipation – Actions • Red (or amber) flags • Refer paeds • No red flags • Reassure • Explain constipation and treatment (could just do briefly and give patient information using resources in ‘Explain 2’ slide) • Treat

  15. Constipation – Explain 1 • Rectum gets used to being full: normal reflexes and power are reduced = ‘baggy’. • Reduced sensation and overflow: soiling is not intentional • Need to ‘get empty and stay empty’ for rectum to shrink back and recover reflexes and sensation: takes time

  16. Constipation – Explain 2 • Tameside = comprehensive leaflet • Patient.co.uk = very good, can print pdf leaflet • ERIC = lots of info for professionals and parents/patients (age banded) http://www.eric.org.uk/ • NICE ‘template letter’

  17. Constipation – Treat • Get empty, stay empty! • Faecal impaction? • Soiling • Abdominal mass • Movicol, movicol, movicol! • NB different strengths e.g. Paed Plain = no taste • ‘Softeners’ • Movicol, Lactulose, Docusate (also squeezes) • ‘Squeezers’ • Senna, sodium picosulphate, bisacodyl • Doses as per BNFc or NICE

  18. Constipation – Get empty • Disimpaction • Aiming for liquid and no more lumps = messy • Review after 1 week • Movicol • If not tolerated = stimulant laxative +/- lactulose • If not worked after 2 weeks = add stimulant laxative and urgently refer to Paeds • Enemas and manual evacuation only if all else failed

  19. Constipation – Stay empty 1 • Maintenance • Until rectum no longer stretched and reflexes return • Laxatives do not make bowel lazy: may need for several years and should be gradually reduced • Movicol • If not tolerated = stimulant +/- lactulose, or docusate alone • If not effective = add stimulant

  20. Constipation – Stay empty 2 • Behavioural • Non-punitive (I say ‘training the subconscious’) • Regular toileting after meals • Foot support, sit forward (rock and pop!), bubbles, books • Diary and rewards (things under their control) • NB school (NB ERIC info) • Use school nurses and HV

  21. Constipation – Stay empty 3 • Fluids Page 15, NICE Quick Reference Guide http://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf

  22. Constipation – Stay empty 4 • Diet • High Fibre = fruit, veg, high fibre bread, wholegrain breakfast cereals, baked beans • Activity

  23. Constipation – Failed treatment • Disimpaction has failed if not responded to Movicol after 2 weeks: • Urgent referral to Paeds (or Bladder and Bowel Specialist Nurse) • Maintenance has failed: • In those aged <1 year, if not responded after 4 weeks • Refer paeds • In those aged ≥ 1 year, if not responded after 3 months • Check no red flags • If red flags = refer paeds • No red flags = refer to the Bladder and Bowel Specialist Nurse Service

  24. Constipation Toolkit • RED FLAGS, refer paeds • History and examination questionnaireshttp://guidance.nice.org.uk/CG99/Questionnaire • Bristol Stool Chart • EXPLAIN: Tameside leaflet • IMPACTED? GET EMPTY, STAY EMPTY! • Medical: usually Movicol Paed Plain as per BNFc • Non Medical: see Tameside leaflet and fluid rqmts on page 15 of NICEhttp://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf • If fails, add stimulant • Disimpaction failure, refer paeds • Maintenance failure, refer Bladder and Bowel Specialist Nurse

  25. Enuresis - definitions • Incontinence • uncontrollable leakage of urine • Enuresis • Incontinence of urine when sleeping: usually say Nocturnal • Bedwetting: ‘involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology’ (NICE) • Primary • Secondary = previously dry for ≥ 6 months

  26. Urinary Incontinence – History 1 • Secondary (especially recent): • UTI • Diabetes (drinking overnight) • Constipation • Neurological: spine and lower limb exam • Emotional/behavioural difficulties: consider psychology Urine dipstick NB same day referral if suspect diabetes

  27. Urinary Incontinence – History 2 • Pattern of bedwetting • Variable volume, >1 per night: could be Overactive Bladder • Daytime symptoms • Urgency, Frequency >7/day, Infrequent <4/day, straining, pain • Consider UTI, Overactive Bladder, Neuro/Uro cause • Urine dipstick • If significant, refer to consider investigation/treatment of those symptoms first • Toileting patterns • NB School • Fluid intake • Check not restricting Diary

  28. Urinary Incontinence – History 3 • Effect on child/YP/family • Social (sleep-over), self-esteem • PMHx: • UTI • Developmental, attention or learning difficulties: consider specific management

  29. Urinary Incontinence – Examination • Primary Nocturnal: not required according to NICE • Secondary Nocturnal or Daytime Symptoms: • Genitalia • Abdomen • Spine • Lower limb neuro

  30. Urinary Incontinence – Referral • RED FLAGS = recurrent UTI, Diabetes, examination abnormalities: • refer paeds • No red flags • Nocturnal only: • refer HV or school nurse • Day only, or Nocturnal with daytime symptoms: • refer to Bladder and Bowel Specialist Nurse

  31. Enuresis – NICE • Principles of Care • Not their fault: non-punitive management • Tailor management to child/YP and parent/carer • Consider parental support • Do not exclude <7y • Reassure

  32. Enuresis • Prevalence

  33. Enuresis – NICE • Principles of Care • Not their fault: non-punitive management • Tailor management to child/YP and parent/carer • Consider parental support • Do not exclude <7y • Reassure • Trial of BASICS • <5y: encourage toilet training if not done already and trial out of nappies at night

  34. Enuresis – Management BASICS! • Fluids: avoid caffeinated (and ?fizzy and blackcurrant) • Regular toileting 4-7/day • NB double voiding if Overactive Bladder symptoms • Trial out of nappies/pull-ups: offer alternatives • Reward system: for agreed behaviour (not dryness)

  35. Enuresis – Information • NHS choices: concise, for parents http://www.nhs.uk/Conditions/Bedwetting/Pages/Introduction.aspx • Patient.co.uk: concise, for parents http://www.patient.co.uk/health/Bedwetting.htm • ERIC: all ages, parents, professionals http://www.eric.org.uk/

  36. Enuresis – Alarm • High long-term success rate (weeks) • But need commitment and can disrupt sleep • Contraindications: • < 1-2 wet nights/week • Parental distress or negativity (consider parental support) • Need training • Hence referral to HV/school nurse • http://www.patient.co.uk/health/Bedwetting-Alarms.htm • Encourage to combine with reward system • Get up and go to toilet, help change sheets

  37. Enuresis – Desmopressin • Rapid, short-term results (sleep-over) • Alarm is inappropriate or undesirable • Inform them: • many relapse when treatment is withdrawn • how desmopressin works • fluid restriction from 1 hour before until 8 hours after taking desmopressin • that it should be taken at bedtime • how to increase the dose if the response to the starting dose is not adequate • that treatment should be continued for 3 months • that repeated courses can be used • Stop during sickle cell crises or D&V http://www.medicinesforchildren.org.uk/search-for-a-leaflet/desmopressin-for-bedwetting/

  38. Enuresis – Other treatments • Only on advice of specialist • Anticholinergic with desmopressin • Oxybutinin • If: • Not responded to desmo+/-alarm • Daytime symptoms • Imipramine • Gradual increase and withdrawal • Warn re dangers of OD • http://www.medicinesforchildren.org.uk/search-for-a-leaflet/

  39. Secondary: think other causes esp Diabetes Examine if Secondary or Daytime Refer all? Red flags = paeds Others = HV/school nurse/BBSN Basics Give/direct to information Urinary Incontinence – Top tips

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