Let’s Get Going Managing Childhood Constipation

Dr Bobby Tsang, Specialist Paediatrician North Shore Hospital

Childhood constipation

Common 10-30%

Associated incontinence

Essential aim - prevent pain with defecation

Invasive investigations not routinely needed

Refer if organic disease or review treatment

Behavioural and social consequences

Long term managment

Epidemiology

“Normal” relates to culture and diet

Majority pass 1 motion per day

1% < 3 per week or > 3 per day

3-5% Paediatric outpatients

Bimodal

Infancy (soon after birth) and around 2yrs

M:F 2:1

65-70% better after 2y

Persists post puberty >30%

Rome III criteria >2 for >2m

Developmental age > 4 y

<3 stools pw 75%

Fecal incontinence >1 pw 75-90%

Retentive posturing or XS volitional stool

retention 35-45%

Painful or hard bowel movements 70%

Large fecal mass in the rectum 30-50%

Large-diameter stools that obstruct toilet 75%

Other symptoms

Lack of energy, “not well”

Poor appetite 25%; Vomit 10%

Abdominal distension 20-40%

Fissures or haemorrhoids 5-25%

Rectal bleeding 7% Anal prolapse 3%

Enuresis or UTI 30%

Excessive foul flatus and stool

Scybalous stool

Psychological / Social 20%

Poorly organised family environments

Less expressive

Poor social competence

Poor scholastic performance, learning

disabilities, ADHD

Anxiety / depression

Unhappy, angry, irritable, moody

Disobedient, disruptive behaviour

Incontinence

Barrier to independence

Education, work, financial, social, relationships

Emotional

Low self-esteem, worry, embarrassment, guilt, fear,

isolation, sadness, frustration

Psych probs - Joinson 2006

Adult OR=2

OAB, LUT dysfn, UTI, obesity, sexual dysfn, mood

disorders

Fitzgerald 2006, Minassian 2006

Colon

Highly efficient complex organ

Absorbs

400ml/day (up to 3 litres)

Homeostasis of electrolytes

Stores faeces

Tone

Rhythmic segmentation 5-40 mmHg 60/day

Discharges faeces

Secretes mucus

Peristalsis

Mass movements 100 mmHg, on waking and PC

HAPC High amplitude propogating contractions

Paraplegia

Hyperactive irregular segmentation

Refinement of concept first proposed by Cajal and later Daniel and Posey-Daniel Neurotransmitter released from enteric motor neurones binds primarily to receptors expressed by (ICCs). Ward S M Gut 2000;47:iv40-iv43

Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved.

interstitial cells of Cajal

Molecular level

5-hydroxytryptamine (5-HT) <-gut distension ->local Ach -> muscle contraction upstream ->NO muscle relaxation downstream

Substance P excitatory Lower substance P nerve fibre density in children

with IND

Nitric Oxide NO inhibitory ?XS NO inhibits colonic motility in STC?

Chloride drives fluid secretion into colon CF constipation. Channel activators for treatment.

Increased mast cells ? Primary or secondary to injury

Progesterone reduces excittory Ach and 5HT Receptors overexpressed in women with STC

Symptoms vary with menstrual cycle

Ano-Rectum

Stores faeces temporarily

Continence maintained by

Valves of Houston – rectum

Freq of contraction distally

Levator floor tone

Rectopubalis sling – lifts weight of faeces

Anus

Internal sphincter relax w rectal distension

External sphincter reflex contraction and voluntary

relaxation

Sensation touch, pin prick, temperature

Defaecation

Pressure threshold in sigmoid/descending colon

Haustrations disappear

Rectal filling and anal sampling

Reduced angulation of ano-rectal canal (squat)

Bolus moves lubricated by rectal mucus

Reflex relaxation Internal anal sphincter

Voluntary relaxation of ext anal sphincter

Valsalva increases intra-abdominal intrarectal pressure

Peristaltic cleaning wave follows bolus

Dys-synergia

Factors affecting activity

Posture - CP Physical exercise – hypotonia Eating Psychological stimulus Osmotic material in duodenum Gastrocolic response – mass movt

Emotion pain/stress – inconsistent handling/caregivers? Drugs Codeine, antacids, anticholinergics (oxybutinin) antipsychotics/antidepressants

Bristol stool form chart

Red flags

Symptoms @birth - few weeks

Meconium > 48 h after birth

'Ribbon' stool (usly <1 y)

Abdominal distension with vomiting

Weak legs or locomotor delay (falls > 1 y)

Lower limb deformity or neurology vDTR

Anus Fistula; bruising; fissures; tight or patulous;

anteriorly placed; absent wink)

Lumbosacral Asymmetric glutei, sacral agenesis, scoliosis,

skin abnormality, sinus, central pit)

Amber flags

Faltering growth and well-being

Possible maltreatment

Causes - infants and toddlers

History

Genetic predisposition

Breast feeding to cows’ milk formula

Cows’ milk protein allergy

Lack of fibre

Stool withholding

Retentive posturing

Coeliac disease

Examination Anal fissure

Spina bifida

Anorectal malformations

Hirschsprung disease

Causes – School and adolescent

History

Poor intake

Toilet training coerced

Attention-deficit disorders

Developmental handicaps

Toilet phobia, school bathroom avoidance

Excessive anal interventions

Examination

Anorexia nervosa

Depression

Slow transit constipation

Psycho-social history

Family attitude and motivation Toilet training High stress environments Socioeconomic level Development Temperament Peer relations Physical environments

School / home

Sexual abuse

Non-functional Hirschsprung Disease Drugs Cow's milk intolerance Celiac disease Intestinal neuronal dysplasia Anorectal malformations Megacystis microcolon intestinal hypoperistalsis syndrome

MMIHS (Berdon syndrome)

Chronic dysmolity / pseudo obstruction

Autoimmune autonomic ganglionopathy

Acetylcholine receptor AChR dysmotility Neuromuscular conditions

Hypertonia CP Hypotonia Hypothyroidism Spinal dysraphism, tethered cord Prune-belly syndrome HypoK hyperCa Neuropathic/ Myopathic / mitochondrial

Hirschprungs History

50% delayed meconium >36 hr

Constipation week 1 of life

Vomiting – bile

Alternating constipation & diarrhoea

Soiling rare

Severe abdominal distension

Failure to thrive

Tight anus

Explosive response to rectal exam

Family history 1:5000 Short segment M5:F1

Long segment M=F

Acute

Infants change in diet

Following bed rest

Anal tears and fissures

Rectal prolapse

Treatment

Increase fluids

Chronic Constipation

Soiling 70%

Faecal loading Indentable masses

Huge motions

Lax anus Anal fissures

Associated wetting

Recurrent abdominal pain

Retentive posturing

Painful defecation

Poor appetite & irritability

Physical Examination

Abdominal faeces

Perineum

location of anus

halfway betw posterior fourchette (base of

the scrotum) and tip of coccyx

fissures, fistulae, or haemorrhoids

anal wink and tone

Lumbar Spine and lower limb

neurology

Rectal examination

Neurogenic Bowel

Spinal dysraphism

Tethered cord

Sacral Agenesis

Vertebral deformities

Spinal cord tumour

Cord or nerve injury

Franco 2008

Investigations

None if thriving, eating and symptoms

confined to anorectum

Abdominal xray

Lumbar spine

Thyroid function

Calcium

Biopsy - rectal / large bowel

Transit study for IND

Running on Empty

Explanation/education

Empty Bowel

Keep bowel empty

Stool softener

Stimulants

Scheduled toileting

Fibre fluids exercise

Support

Maintenance

Develop relationship

Reassure Encourage Support

Empower

Demystify diagnosis and causes

They are not alone

Develop treatment plan with child

Be positive - spontaneous cure 15% pa

Assess motivation

Long term maintenance

General Issues

Toilet Routine

Scheduled

after meals

Comfortable

Footstool

School toilets

Positive

Reinforcements – star chart, praise++, rewards

No fuss/ nag / threat/ scold/ force/ tease/ leave in

soiled pants

Transfer responsibility

Sneaky poo

Regular evacuation

Establish Daily routine < 24 h Avoid and treat constipation

Empty bowel

Praise & reinforcement with assistance

Outreach nursing support

Schedule with meals, baths, physical activities, time

Potty 10-15 minutes, 20-30 minutes after a meal

Knees higher than buttocks - footrest

Cough or grunt for abdominal activity

Digital stimulation, Wipe anus

Levator lift with fingers to each side of anus

Manage stool consistency – fibre H2O + laxatives

Suppository / enema for routine

To soften stool

Chocolate / malt

Kool-aid , fruit juice

Candy

Citrus fruit, tomato,

passionfruit, pineapple

Corn (fresh or tinned)

Baked beans

Pizza

Nuts/dried fruit

Disimpaction

Prescriptions

Bulk forming laxatives

benefibre metamucil konsyl mucilax isogel etc

Stool softeners and lubricants

lactulose paraffin coloxyl

Hyperosmotic cathartics

Picoprep, Golytely, Movicol

Magnesium Hydroxide 8% 1ml/kg (max 60ml)

Stimulants

Senna, Castor, bisacodyl (dulcolax), danthron (codalax)

5HT4 agonist

Tegaserod (J Liem et al J Pediatr Gastro and Nutrition 46:54–58 # 2008 by

European Society for Pediatric Gastroenterology,)

Per Rectum

Suppository

Glycerol

Fleet glycerine (glycerol)

Fleet laxative (bisacodyl)

Coloxyl sup (bisacodyl;docusate)

Enema

Microlax (Na citrate; Na lauryl sulfoacetate; sorbic acid; sorbitol)

Fleet phosphate enema (Na phosphate)

Coloxyl enema conc (docusate Na)

Fleet micro- enema (Na citrate; Na lauryl sulfoacetate; sorbitol)

Fleet phospho-soda buffered saline mixture (Na Phosphate)

Colonic washouts

Clean bowel 2–3 days

Volume and hydrostatic pressure

Saline/water; soap/water; other

Reduce soiling

Latex precautions

Can contribute to dependency

Retrograde

30 ml balloon catheter w large syringe

Shandling catheter

Peristeen anal irrigation kit

Mic Bowel management Kit

Antegrade continent enema (ACE)

High degrees of satisfaction Improves independence esp for

wheelchair dependent

Sterile bowel – no smell

Chait cecostomy button

Malone (MACE) – continent appendicostomy

Monti technique - donut of ileum/colon cecum or splenic flexure

Anal plugs

Prevents rectal leakage up 12 h

Porous foam Lubricated with Vaseline

Expands with moisture 30 sec

Mushroom shape

Removed with attached string

Changed after toilet visit

Increase independence

Additional resources For healthcare professionals

NICE Diagnosis and management of idiopathic childhood constipation in primary and secondary care. 2010. http://publications.nice.org.uk/constipation-in-children-and-young-people-cg99 and www.nice.org.uk/CG99

NHS Evidence. Constipation in children. Management. www.cks.nhs.uk/constipation_in_children/management/scenario_diagnosis_and_assessment_younger_than_1_year/view_full_scenario#467016006

For Families

www.kidshealth.org.nz/constipation

Continence Association NZ http://www.continence.org.nz

ERIC http://www.eric.org.uk/Constipation/constipation_and_soiling

One Step at a time for children with disability http://www.continencevictoria.org.au/sites/default/files/Booklet.pdf

NHS choices www.nhs.uk/Conditions/Constipation/Pages/Treatment.aspx —Advice for families on constipation and treatment, incl lifestyle

NICE http://guidance.nice.org.uk/CG99/PublicInfo/doc/English —Guideline for familiy on NICE guidance CG99

National Digestive Diseases Information Clearinghouse -UShttp://digestive.niddk.nih.gov/ddiseases/pubs/constipationchild/

Childhood constipation

Common 10-30%

Associated incontinence 70%

Essential aim - prevent pain with defecation

Invasive investigations not routinely needed

Refer if organic disease or review treatment

Behavioural and social consequences

Empty bowel and keep empty

Maintain good habits