Download - Constipation and Enuresis
Constipation and Enuresis
Katie Mallam
Paediatric Update for Primary care9th October 2012
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
• Standardise approach• Early treatment
– Reduce consequences and cost
• No need to remember history and examination: http://guidance.nice.org.uk/CG99/Questionnaire
Constipation – NICE
Constipation?
2 of ……..
Breast fed babies can go up to a week without opening
bowels
*
*
Constipation?
http://www.childhoodconstipation.com/Extra/Documents.aspx
Constipation?
2 of ……..
Breast fed babies can go up to a week without opening
bowels
*
*
• 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)
Constipation – Causes
Constipation – History 1
Constipation – History 2
Faltering growth = treat and do coeliac and
TFT (refer)
Constipation – Examination
No PR in primary care
NB perianal strep
Perianal streptococcal infection
Swab
Treat infection and constipation
Constipation – Examination
No PR in primary care
NB perianal strep
• No need to remember history and examination: http://guidance.nice.org.uk/CG99/Questionnaire
Constipation – It’s NICE
Microsoft Word Document
Microsoft Word Document
< 1 year ≥ 1 year
• Red (or amber) flagsRefer paeds
• No red flagsReassureExplain constipation and treatment (could just do briefly and
give patient information using resources in ‘Explain 2’ slide)Treat
Constipation – Actions
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
• 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’
Constipation – Explain 2
• 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
Constipation – Treat
• 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
Constipation – Get empty
• 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
Constipation – Stay empty 1
• 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
Constipation – Stay empty 2
Constipation – Stay empty 3
• Fluids
Page 15, NICE Quick Reference Guide http://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf
• Diet– High Fibre = fruit, veg, high fibre bread, wholegrain
breakfast cereals, baked beans
• Activity
Constipation – Stay empty 4
• 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
Constipation – Failed treatment
• RED FLAGS, refer paeds– History and examination questionnaires
http://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 NICE
http://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
Constipation Toolkit
• 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
Enuresis - definitions
• Secondary (especially recent):
– UTI– Diabetes (drinking overnight)
– Constipation– Neurological: spine and lower limb exam
– Emotional/behavioural difficulties: consider psychology
Urinary Incontinence – History 1
Urine dipstick
NB same day referral if suspect diabetes
• 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
Urinary Incontinence – History 2
Diary
• Effect on child/YP/family– Social (sleep-over), self-esteem
• PMHx:– UTI– Developmental, attention or learning difficulties: consider specific
management
Urinary Incontinence – History 3
• Primary Nocturnal: not required according to NICE
• Secondary Nocturnal or Daytime Symptoms:– Genitalia– Abdomen– Spine– Lower limb neuro
Urinary Incontinence – Examination
• 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
Urinary Incontinence – Referral
• 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
Enuresis – NICE
Enuresis
• Prevalence
Age < 2 per week ≥ 2 per week
4.5y 21% 8%
9.5y 8% 1.5%
• 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
Enuresis – NICE
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)
• 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/
Enuresis – Information
• 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
Enuresis – Alarm
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/
• 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/
Enuresis – Other treatments
• 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