‘Doctor, my 5 year old is constipated’

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 10-20 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