doctor, my 5 year old is constipated dr. sadananda
TRANSCRIPT
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‘Doctor, my 5 year old is constipated’
Dr. Sadananda
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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
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‘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
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Encopresis
Term first used in 1926 to suggest similarity with ‘enuresis’ for wetting
Inappropriate passage of normal stoolStool passed in pants or deposited
‘elsewhere’ (where it can be found!)Normal bowel sensationOften associated with other behavioural
problems
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Causes of constipation in childhood
‘Holding on’ - often initiated by passage of large / painful stool
delay in passage of normal stoolanal fissuregroup ‘A’ hemolytic streptococcal anal
infectiontoilet phobias / fearsChild sexual abuse
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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
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Causes of constipation (contd)
HypothyroidismPolyuria causing dehydration in DM,
Diab insipidusLead poisoningCows milk intolerance
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Constipation – environmental issues
School toilets!Toilet cold/darkToilets dirtyUncomfortableLack of privacyLack of toilet paperinaccessible
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Constipation – psychological factors
Fear / anxietyPrecipitating family stressLearned behaviour? Coercive potty training‘Cry’ for help
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Assessing constipation
‘Red flag’ symptoms include:> 48 hours before passing meconium as a
neonateAbdominal distension esp if failing to thrive Infrequent small or ribbon stoolsConstant leaking especially if linked with
urinary leaking tooFailed management with appropriate standard
intervention (with compliance)
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General health profile
Check for:daytime urinary problemsnocturnal enuresisappetite / fibre intakefluid intake - how much milk?any medical problemsany current medication
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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
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Toilet training profile
Age toilet training commencedage acquired bladder controlage acquired bowel control
(if appropriate )any significant changes / problems / events
occurring at this time
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Constipation and soiling – Management Overview
Education
Evacuation
Maintenance
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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
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Treatment of constipation
consistent scheduled toiletingpositive reinforcementdiet / fluid adjustmentoral laxativesSuppositories/enemas only as very last
resort and if tolerated by child
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How much fluid?
‘ensure adequate fluid intake’
e.g. 4 year old weighing 16 kg -
needs 85ml/kg = 1360 mlaim for 6-8 cups throughout the dayencourage water based drinks
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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
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Evacuation
Traditionally softened stools first using osmotic laxative e.g. lactulose/docusate
Then introduced stimulant e.g. sennaAdded Sodium picosulphate or similar if poor
resultEnema or EUA if above failedPoor compliance and protracted treatment time
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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
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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
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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
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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
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Finishing treatment
Gradual reduction
Reduce bowel stimulant (if using) first
Treat early if relapse
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Managing soiling and encopresis
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Assessing the soiling problem
Is the child soiling because of:
Delayed bowel control
Overflow soiling with underlying constipation
Encopresis
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Soiling profile
Age at onset of soilingduration of soilingfrequency of soilingdescription of soiling
- consistency
- volume
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Behaviour / school profile
general behaviour at home and schoolany reported problems associated with the
toiletsany reported bullying
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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?
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Family feelings
How do parents view soiling?How do they manage when it happens?What do they do when it doesn’t happen?
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Treatment -’whole child’ approach
Families often perceive the main problem is the ‘soiling’
constipation secondary issueemphasis needs to be made on poos in the
toilet NOT clean pantsengaging the child to sit on the toilet and
perform often most difficult part of treatment
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Medication
Need to treat any underlying constipation first
Fine tune treatment to avoid constipation, but prevent diarrhoea
Maintain for at least 6 monthsThen consider cautious dose reductionAdvice family appropriately if relapse occursShort term goals, positive reinforcements
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Summary
History- fluid/ fibre intake, environmental issues, r/o red flags, any soiling/ encopresis
ExaminationManagement – education, evacuation,
maintenance