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Recognising and managing constipation in children

 

Constipation is a common but often hidden condition that affects between 5-30% of children. The term constipation refers to the infrequent or abnormally delayed passage of dry, hardened faeces, often accompanied by straining or pain. Constipation becomes chronic when it lasts for more than eight weeks.1 Early diagnosis and intervention for constipation can lead to better outcomes, however acute constipation in children can easily become chronic when parents delay seeking help and advice. This can be for a number of reasons; they may not recognise the symptoms,2,3 but equally they may fear a negative response from healthcare professionals or be embarrassed.1

Loening-Baucke described a vicious cycle of constipation in children; a large stool leads to painful defecation, which in turn leads to withholding, leading to larger and harder stools.4 This vicious cycle can also be a major contributory factor in acute episodes of constipation in children becoming chronic.

In the majority of cases, constipation in children is idiopathic, that is to say there are no underlying anatomical or physiologic causes for the constipation. There may be several contributing factors, which include pain, dehydration, medicines, intentional withholding, toilet phobia, toilet training, diet and lifestyle. While the exact cause of the constipation is not always clear, there are times in a child's life when constipation is more likely to occur, such as during weaning or toilet training and when starting school.5

Parents are often not aware that their child is constipated. This is more apparent the older the child is, and may be linked to a lack of knowledge of normal defecation patterns. As children become more independent, parents are more likely to be unaware of their toilet habits.6

Children may present to primary care nurses with other problems such as nocturnal enuresis, recurrent urine infections, daytime wetting or even with behavioural problems. Nurses working in universal services are well placed to offer advice, support and signposting to the right place to get constipation diagnosed and treated, and are more likely to use a holistic approach when treating constipation.7

Children can spend years being treated ineffectively and being subject to inappropriate investigations. The aim of the National Institute for Health and Clinical Excellent (NICE) guidance on Constipation in Children and Young People 2010 is to provide an evidence-based framework that standardises treatments and gives guidance the use of invasive procedures and investigations.1

Signs and symptoms

Constipation can be a debilitating illness with a range of signs and symptoms that are often not recognised by parents, carers and health staff. Symptoms may include: 

  • Straining.
  • Withholding.
  • Poor appetite that improves after defecation.
  • Lack of energy.
  • Unhappy, angry or irritable mood.
  • Soiling.
  • Infrequent defecation - less than three times per week.
  • Regular and foul smelling wind.
  • Foul smelling stools.
  • Abdominal pains that wax and wane with defecation.
  • Distended stomach.
  • Hard stools.
  • Large stools that may block the toilet.
  • Painful defecation.
  • Soiling.
  • Small tears or fissures around the anus. 

Not all children will display all of these symptoms, however primary care nurses should be aware that the presence of the above symptoms may be indicative of constipation. To establish a positive diagnosis a full history should be taken and external physical examination carried out. For full details of history taking, examination and red flag symptoms that may indicate an underlying disorder, see the NICE guidelines on Constipation in Children and Young People, published in 2010.1

Soiling

The terms soiling and encopresis are often used interchangeably to mean the same or different things, however it is now generally accepted that the term 'soiling' refers to the passage of fluid or semi-solid stool into clothing resulting from faecal loading, and 'encopresis' refers to deliberate defecation in inappropriate places.1 This distinction is important as children who have overflow soiling have no control over their bowel movements due to the process of the condition; it occurs when liquid faecal matter leaks around the solid lump. When there has been a long-standing problem of constipation, the lower bowel and rectum become overstretched, damaging nerve endings and reducing the signals to the brain that the rectum is full.

Soiling affects one in 30 children between the ages of four and five and one in 100 children aged ten or older,1 yet it is regularly mistaken for diarrhoea or laziness on the part of the child. It is very widely reported that children with soiling problems also suffer from emotional and behavioural problems including low self-esteem, social isolation and bullying as both victim and perpetrator.8 Problems with social isolation can be made worse when children are excluded from school following episodes of soling that are mistaken for diarrhoea. Large chunks of schooling may be missed, and when the child is in school they may find it difficult to concentrate because of the signs and symptoms discussed above. School nurses can play an important role in educating school staff about constipation and soiling. Children with encopresis may require specialist input from child and adolescent mental health services (CAMHS) or other psychological services.

Treatment

The treatment regime for idiopathic constipation recommended by NICE is disimpaction for any faecal impaction with an escalating dose of oral laxatives, followed by maintenance therapy of oral laxatives and a combination of behavioural interventions appropriate to the child's age, which should include establishing regular bowel habits.1

Children should be encouraged to sit on the toilet for 5-10 minutes after meals; they should be comfortable on the toilet and adopt good toilet posture. If necessary a step should be used to support the child's feet so that their hips are slightly higher than their knees. The toilet area should be a non-threating, warm and the child should have unhurried and uninterrupted access to the toilet. Rewards can be used to encourage the child to comply with medication regimes and for good toilet routines. Parents should be encouraged to be relaxed and calm, to keep toilet times fun and not blame or ridicule the child. Disimpaction can be an unpleasant experience for the child and family, and warning them of this can ensure that they continue with the regime.

It is also important to demystify the condition by explaining to the child, with the aid of age-appropriate materials, what is happening in their body and to explain to parents that soiling is beyond the child's control. This simple measure in itself can go a long way to alleviating feelings of guilt, fear and anxiety associated with constipation, especially concerns that parents may have that constipation is a sign of a more serious illness or condition. It is also important to stress to the child and the family that they are not alone by giving them information about the prevalence of the problem. This holistic approach fits in with the National Service Framework core standards which state that services should be family centred and treat the whole child.9 Education is one of the most important components to successful treatment and improving outcomes. Messages may need to be repeated several times whilst the child is being treated.

NICE recommend that polyethylene glycol 3350 should be the first choice oral laxative. If this is not effective after two weeks, or polyethylene glycol is not tolerated by the child, then a stimulant laxative should be added or substituted. Rectal medications are not recommended in the guidance unless oral medication has failed; the use of rectal medications including enemas is not well tolerated amongst children and may contribute to withholding behaviours. Similarly, manual evacuation under anaesthetic is not recommended unless oral and rectal medications have failed.1

Borowitz et al found that children prescribed regular laxatives were significantly more likely to have been treated successfully after two months than children treated more conservatively with advice about dietary changes.10

For acute episodes of constipation, the previous first-line treatment was to give advice related to diet and lifestyle changes. NICE recognises the importance of early identification and treatment of constipation, and while diet and lifestyle changes are an important factor in the long-term management of constipation, providing advice on this alone as a first line treatment can lead to an acute episode of constipation becoming chronic. Families can feel embarrassed and to blame, leading to delays in seeking treatment.3 If they are then told when they do seek help that it can be resolved simply by dietary and lifestyle changes, their guilt feelings may be compounded. By taking the emphasis away from dietary advice, the blame and guilt felt by parents may be alleviated, making it more likely that they will present earlier with symptoms of constipation.

Follow-up should be tailored to the needs of the child and family, with some families requiring more intensive support than others.

Conclusion

Constipation in children is common but many parents, carers and healthcare staff are not always aware of the signs and symptoms. Early recognition and treatment are important factors in improving outcomes for children with constipation. Primary care nurses are well-placed to provide advice, support and treatment, as well as education on recognising constipation.

Resources

ERIC (education & resources for improving Childhood Continence)

ERIC are running a national awareness campaign to increase early recognition of the signs and symptoms of constipation in children. As part of the campaign, posters will be put up in 6,000 GP surgeries across the country to alert parents to the link between a child soiling their pants and underlying constipation. The campaign posters are supported by resources that parents and children can use together with their healthcare professional, including a wall chart and a questionnaire. The resources can be downloaded from the ERIC website.

References

1. National Institute for Health and Clinical Evidence. Clinical Guidance No 99. Constipation in children and young people. Diagnosis and management of Idiopathic childhood constipation in primary and secondary care. London: NICE; 2010.

2. McGrath K, Caldwell P, Jones M. The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting. Journal of Paediatrics and Child Health 2008;44:19-27.

3. Dobson P, Blannin J. Treatment of idiopathic constipation in children and young people. Primary Health Care 2010;20(7)16-9.

4. Loening-Baucke V. Chronic constipation in children. Gastroenterology 1993;105:1557-64.

5. Rogers J. Assessment, prevention and treatment of constipation in children. Nursing Standard 2012;26(29):46-52.

6. Akyol I, Adayener C, Senkul T, Baykal K, Iseri C. An Important Issue in the Management of Elimination Dysfunction in Children: Parental Awareness of constipation. Clinical Paediatrics 2007;46:601-4.

7. Prynn P. Managing idiopathic constipation in children. Nursing Times 2011:107.

8. Joinson C, Heron J, Butler U, Von Gontard A. Psychological differences between children with and without soiling problems. Paediatrics 2006;117(5):1575-84.

9. DOH. National service framework for children, young people and Maternity core standards. London: The Stationary Office: 2004.

10. Borowitz S, Cox C, Kovatchev B, Ritterband L, Sheen J, Sutphen J. Treatment of childhood constipation by primary care physicians - ef- ficacy and predictors of outcomes. Paediatrics 2005;115(4):873-7.