Working towards a multidisciplinary

approach to managing constipation

Managing Chronic Constipationand Soiling in ChildrenInformation booklet for parents/carers

Constipation

• Constipation is a very common condition that affects approximately 10% of children.

• The most common reason for soiling is constipation.

• Of children who soil, 95% also have chronic constipation

Background

• Increasing numbers of children were being admitted and readmitted to the inpatient service with a diagnosis of “constipation”

• The main reasons the bowel becomes faecally loaded again is the constipation is undertreated, inconsistent education and lack of appropriate & timely follow up.

• Different regimens were being used and thus there was no standardised practice.

Background

• It is a massive challenge to the family, especially if associated with soiling (these children may have other complex medical issues)

• If managed from the start, simple constipation may not become chronic, as the chronicity of constipation is mostly preventable .

• Chronic constipation is an issue within the community, and within both paediatric and gastroenterology clinics.

• Mixed messages are given to families and the community

• We felt the care needed to be improved!

• The pathophysiology of functional constipation involves painful bowel movements, leading to faecal withholding and a possible fear of toileting

• Large, withheld stools ultimately cause more pain, leading to more withholding, creating a vicious cycle of disordered defaecation and toilet avoidance.

• If untreated, this problem can progress to rectal dysfunction and incomplete rectal emptying, learnt avoidance of the normal urge to void, and recurring involuntary faecal incontinence.

Background

• The majority of children admitted to the unit with constipation are seen by our Enrolled Nurse (specialist in constipation management) who educates families on constipation and for toileting support

• Constipation management does not get enough time to be addressed in a general paediatric clinic, unless it is the only reason the child is presenting, which is not common.

• Multiple other issues occurring with these families need to be addressed by Paediatricians in the clinic (i.e. often at the end of the consult, the comment from parents/carer is “by the way my child also has trouble pooing”).

• A Clinical Nurse (portfolio of Constipation Management) in the Paediatric Clinic follows up on the children admitted to the ward and those who present to the clinic.

Background

So….How did we begin?

• Our Clinical Nurse and Enrolled Nurse attended a workshop in Melbourne - then the journey started!

• Rebecca Khan workshop: OT in Brisbane – runs her own clinic – “Kids that Go”

• Key messages received from the workshop– Patient and parent education– Consistency in plan – Frequency of visits after clearance – Enemas need to be avoided if possible – Medication routine– Toileting routine– Consequences of chronic constipation on children and

their family

What we did next• We started to look at our own practice and the

practices in different public hospitals

• We found there is:– individual management (dependent on physician)

– no regular follow up

– repeat admissions for clearance

• The message to families seems to be “if there are hard stools, take more laxative”, ? education or addressing challenges and family intervention

• Other hospitals– limited by resources - one nurse consultant is looking forward to having a copy of our book

Creation of the booklet

We had multiple meetings to review the ‘Department of Queensland Health’ booklet which was adapted to our environment.

Authors included –• Paediatric Consultant – Dr Noha Soliman

• Clinical Nurse – Ruth Willis

• 2 x pharmacists – Rosina Gergis and Mark Minervini

• Enrolled Nurse - Maggie Phillips

• Consumer Representative – Sandra Kitchener

• An External Occupational Therapist – Debbie Atkins

• Outpatient Clinic, Clinical Nurse – Sandra Hii

What is in the booklet

The Flinders Medical Centre – Paediatric Unit booklet contains:

– Managing Chronic Constipation and Soiling in Children

– Medical Management

– Medications

– Choose your Poo chart

– Diet and Fluids

– Exercise/Toilet set up/routine/posture

– Diary

– Resources

Management plan

• Other medical issues like asthma, seizures, anaphylaxis have a plan of management, but chronic constipation did not.

This written management plan will assist with:

• Parent information

• GP awareness of management

• Intranet → constipation action plans – the doctor can use the same management plan template.

Constipation – what is in the book!

Medical ManagementThere are three main steps to managing constipation:

STEP 1: CLEAR OUT the blockage of faeces.

• Medicines

• A possible visit to hospital to have a ‘washout’ STEP 2: MAINTENANCE

• of soft stools and regular toilet timeSTEP 3: RESCUE PLAN

• Relapses are common, it is important to teach parents/carers to recognise symptoms and respond

Management plan

• The back page of the plan is the Bristol Stool Chart, for parents to monitor the child’s bowel consistency and size

What we currently do in acute Management

• Assessment by the medical team – looking for possible ‘red flags’

• When referred, our Enrolled Nurse discusses the booklet whilst the child is an in-patient with the family

• She provides education and support with the in-patient and family

• Medical staff discuss the medication and management plan with the family/carers

• Toilet retraining is most effective after bowel clearance

• When and where to start retraining? - This is best achieved in the community and in their own setting.

Our Aim

• Educate other staff – within the department

• Half day workshop in the near future inclusive nurses, medical, allied health, GP

• Outpatient management ??

• Multi D: – Keen people: dietitian – psychology- nurses –

paediatrician – OT – ( Resources and time needed)

• Model of care – Meetings in progress with the above interested discipline

• Outpatient vs community and how to integrate

Our aim

• Chronic functional constipation is a long-term condition that needs ongoing management by the parent and child, with the child increasing in independence as they get older (our hope is to stop constipation becoming a long-term condition)

• Our aim is to recognise constipation early, to give parents/carer’s appropriate, consistent education and management, facilitate ongoing follow up and support , and prevent the condition from becoming chronic

• And for those who suffer from long term constipation –to resume intensive management and address the emotional and behavioural consequences.

Consumer feedback on the booklet

• “Very well written”

• “Easy to understand”

• “Great work to everyone involved”

Questions?