20100623-g052 - guideline in the management of childhood constipation - issue 1

8/8/2019 20100623-G052 - Guideline in the Management of Childhood Constipation - Issue 1

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Folder Section: 2 Child and FamilyApproval Date: March 2010Review Date: March 2012

April 2009 -Final draft 1

Guideline in the Management of Childhood Constipation

Policy Reference: G052

Version: 1Ratified by: Patient Safety and Quality Group

Name of Originator/Author: Sue WalkerName of responsible committee or

individual:Patient Safety and Quality Group

Date Issued: March 2010Review Date: March 2012

Target Audience: Childrens Services


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Guideline in the management of Childhood Constipation

Contents Page 1

Aim Page 2Target Population Page 2Intended users of Guideline Page 2Background Page 2Definitions Page 2-3

Prevention Page 3Short history (less than one month) /mild Constipation in a child who is otherwise well Page 4Severe Constipation Page 5Dietary Advice Page 6Toileting Program Page 6Laxatives Page 7Follow up Page 7What is progress? Page 7Further Support Page 8

Management of Childhood Constipation & Faecal Soiling Flow chart Page 9

Appendix 1 - Fibre Content of Everyday Foods Page 10-12Appendix 2 - Healthy Bowels in Children - parent leaflet Page 13-14Appendix 3 - What Causes Constipation? Page 15Appendix 4 - Laxative prescription guide Page 16Appendix 5 - Assessment Form Page 17-19Appendix 6 - Constipation and Soiling -A guide for parents/ carers Page 20-29

References Page 30


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Aim

To reduce the incidence and prevalence of childhood constipation

For health professionals to give consistent advice and management ofchildhood constipation

Reduce the number of children needing to be referred to a secondary service

e.g. paediatricians - acute & community, and continence service.

Target population

All children and young people under the school leaving age.

Intended Users of the Guideline

GP Practices, School Nurses, Health Visitors, Community Staff Nurses,Specialist Nurses in the Community, Nursery Nurses in Child and Familyteams, Paediatric Continence Nurse Advisor and Community Paediatricians

within Derby City & Southern area of Derbyshire County PCTs .

Background

Childhood constipation is estimated to occur in about 10% of the population(Leung, Chan & Cho 1996). It accounts for approximately 10% of referrals toPaediatricians at Derby Foundation Trust and 6% of referrals to theCommunity Paediatricians in Derby City & Southern area of DerbyshireCounty PCTs. This figures are similar those reported nationally (ref)

Definitions

Normal Bowel pattern

Age Bowel Movements perweek

Average bowelmovements per day

0-3 months breast fed 5 to 40 2.90-3 months formula fed 5 to 28 2.06-12 months 5 to 28 1.81-3 years 4 to 21 1.4> 3 years old 3 to 14 1.0

(Fontana et al 1987)


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The chart above shows that as the child gets older the number of stoolsgradually reduces. Meconium should be passed within 48 hours of birth. Byday 7 babies should produce 2 soft yellow poos per day until 4-6 weeks(McNally et al 2008). After 6 weeks exclusively breast fed babies can goseveral days without having their bowels opened. Providing the stoolsproduced are soft and the baby is growing well this is normal (McNally et al2008). By the time he/she is 4 years old the number of bowel movementsshould range from alternate days to up to 3 per day. Outside this rangeconstipation should be considered.

The Bristol Stool chart should be used to record the type of stool passed

NICE guideline definitionIdiopathic (functional) constipation is defined as the subjective complaint ofpassing abnormally delayed or infrequent dry, hardened faeces (stools) oftenaccompanied by straining and/or pain. It may also be associated with soiling,defined as involuntary passage of fluid or semi-solid stool into clothing,usually as a result of overflow from a faecally loaded bowel. Constipation is

termed idiopathic if it cannot be explained by a known cause (anatomical,physiological, radiological or histological abnormalities). The exact aetiology isnot fully understood, but it is generally accepted that a combination of factorsmay contribute to the condition

Constipation is considered to be chronic if it continues for more than a month(Impact Pathway 2005).

Prevention

All the intended users of this policy have a role in prevention. The aim is toensure that consistent advice is given wherever the family access help.


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Babies should not be weaned before the age of 6 months. Constipation inexclusively breastfed babies is uncommon and a pathological cause shouldbe considered.

Advice around ensuring all carers are making formula feeds up in line with themanufacturer's guidelines may reduce risk of constipation. Babies who areformula fed and are under 6 months, who are passing hard stools (type 1-2Bristol stool form) may be offered cooled boiled water after their milk feed.

Current weaning advice of offering vegetables and fruits should be

encouraged. Children, with poor dietary intake should be encouraged toslowly increase the amount of fibre in their diet by eating wholegrain cereals,breads and aiming for 5 portions of fruit and vegetables per day. For childrenunder the age of 5 years the guide to portion size is the amount that fits in thepalm of a child's hand. See Appendix 1 for fibre chart

Children should have 6-8 drinks per day, milk product intake should be limitedto the equivalent to 1 pint (568 ml) per day in infants over one year old.

Encouraging children to increase the amount they exercise. The role ofabdominal massage in the older child is currently being studied and may be ofbenefit. Infant massage may also be of benefit (touchlearn website)

Advice should be given to help parents to achieve toilet training in a relaxedmanner, as many toddlers can start to withhold if coercive toilet trainingmethods are used.

Patient leaflet (Appendix 2) Healthy Bowels in Children. Department of Health5 a day guideline /leaflets.

Short history (less than one month) / mild Constipation in a child who isotherwise well

The diagnosing G.P. or Nurse Practitioner, is responsible for the care, with orwithout the support of the Health Visitor/ School Nurse or Community Nursewho has completed the Trust's constipation and soiling training. CommunityPharmacist can offer advise but should refer to G.P. for long termmanagement.

A full history should be taken (appendix 5 assessment form may be used) andexamination undertaken if appropriate. See Appendix 3 for rare causes ofconstipation


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Advice as in prevention section should be given.

Parents should be advised to encourage children to sit on the toilet 20minutes after a meal for 5 -10 minutes and try to have their bowels opened.The child should be encouraged to do a limited number of pushes e.g.10, toreduce the child straining and potentially causing bowel prolapse. Rewards forsitting and passing wind should be given, not just a bowel movement.

Advice around the sitting position on the toilet should be given i.e. the child

should sit in a relaxed position with legs supported at greater than 90degrees.

Laxatives should be prescribed if assessment indicates see Appendix 4.

Patients should be reviewed and laxatives titrated 1-2 weekly until the child ishaving 1-2 soft bowel movements per day (Prodigy May 2007).

If the child is being supported by more than one person and receivinglaxatives, the prescriber is responsible to ensure that those involved in thecare are aware of the medication prescribed. If there is a therapeutic dose

range the indication for changing dose must be clearly documented e.g.Movicol 1-4 sachets to be titrated to maintain a daily stool of 3-4 Bristol stoolform. A date for review should also be clearly documented.

"Titration of medication which has been prescribed within a range of dosage isacceptable, by nurses and specialist community public health nurses who areregistered on the Nursing and Midwifery Council Register, according to thepatient's response and symptoms. The Registered Nurse / Public HealthNurse must competent to interpret test results and be aware of any sideeffects of the medication" (NMC 2007).

If the Registered Nurse / Public Health Nurse changes the dose this must beclearly documented and the prescriber informed, as soon as possible, ideallywithin 24 hours.

Refer to flow chart on page 9.

Severe Constipation

Constipation, which has not responded to initial treatment or has regularfaecal (overflow) soiling.

Management should be by a team which should include as a minimum aRegistered Nurse in the Child & family team who has completed the Trusts


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constipation and soiling training and GP/ Paediatrician. A PaediatricContinence Nurse Advisor will provide support and advice to the RegisteredNurse / GP / Paediatrician via telephone or joint visit at any point during themanagement. The Paediatric Continence Nurse Advisor will accept referralsfor children who have not responded to support by school nurse, unlessanother professional/agency is more appropriate.

A full medical history and examination should take place with a differentialdiagnosis being made. If there is a suspected pathology appropriateinvestigations should be undertaken, or referrals should be made. A

diagnosis of functional constipation needs laxatives prescribed to ensuredisimpaction see Appendix 4.

To ensure a full history is taken Nurses should complete assessment form inAppendix 5. If assessment form is not used by other professionals the fullhistory must be clearly documented. During this assessment the child andfamily/ carers should be educated in the role of the bowel and why thingssometimes go wrong. The Parent/Carer Guide to Constipation and Soiling,included as Appendix 6, should be provided to parents

The social situation of the family should be included in this assessment. The

Victoria Climbie Inquiry (Laming 2003) found that her continence was initiallywell within normal limits for her age, this significantly deteriorated as theabuse escalated, but no professional assessed this change.

Maintenance Therapy has four components (taken from Impact pathway)

1. Dietary intervention2. Toileting programmes3. Laxatives4. Follow-up

Dietary Advice

Children with chronic constipation have been found on average to consumeonly 25% of the recommended amount of dietary fibre. A whole familyapproach should be taken to encourage an increase in dietary fibre. It isimportant to explain to parents that if they would like their child to eat morefibre containing foods such as fruit and vegetables, then they will need tohave these available in the house. The child will need to see other familymembers eating the same sort of food or they will, understandably, view the


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enforcement of this type of diet as a punishment with predictably negativeresults.

Increased fluid intake has been shown to increase water content of stools,making them softer, thus reducing constipation. A child should aim to have 6-8 glasses of fluid (water, squash and fruit juice). Milk intake should be limitedto 1 pint (568 ml) plus 1 pint (568 ml) of fluids.

Families should be encouraged to have regular meals, reducing snacking onlow fibre, high sugar/ fat snacks. This will also help toileting programme, due

to the gastro-colic reflex. Healthy snacks, such as chopped and dried fruit(prunes and rhubarb act as bowel stimulants) , toast and rice cakes (withoutsalt) can be used to increase a child's fibre intake.

Toileting Program

Ideally the child should spend 5 10 minutes after each meal on the toilet.This time should be unhurried and part of the childs normal routine. Thistakes advantage of the gastro-colic reflex. Give positive direction, for examplesaying: It is time to sit on the toilet. Use of a step to allow the child to resttheir feet on whilst pooing may be of help. Correct toilet position is shown in

appendix 4.

Toileting should be relaxed, giving the child praise for each sitting whether astool is produced or not. Use a chart to record each sitting time and considerusing stars to celebrate each one. Younger children may prefer instantrewards i.e. stars or raisins. An older child/ young person may want to saveup their rewards for a bigger treat. Encourage the child to create and designtheir own chart and their own stickers. It is also important to have consistencybetween carers.

The emphasis should be on poo in toilet not dirty pants. A diary should be

kept recording all stool passed, time, amount and where passed.

Watch out for the warning signs. A stool frequency of less than one stoolevery three days, or an excessively large stool, or increasing frequency ofsoiling suggest that the child is starting to reimpact. Parents need to beadvised how to recognise the warning signs of relapse and how to alter theprescribed medication maintenance regime to avoid reimpaction.

The long term aim is for the child/ young person to respond to their own bodysignals instead of pooing "to order".

Laxatives


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Prescription of laxatives should be as described in the mild constipationsection.

Carers need to be aware that their child may need maintenance medicationfor several years and that they may suffer from a number of relapses.

One should aim to very gradually wean medication when the child has beenregularly passing soft formed stools for between 3 and 6 months. Theminimum acceptable is three or more stools per week with no pain or soiling.

The most common reason for treatment failure in the maintenancephase is stopping the medication too soon or using doses that are toosmall. The prognosis is that 25% of children will be off laxatives after 6months of treatment, 50% by one year and 75% by two years. Therefore 1 in4 children will need to continue on laxatives for more than 2 years.

Follow-up

Support for the child and family/ carer should be made through regular contactwhich could be in the form of face to face, multi-agency working or telephonecontact.

Initial contacts should be 1-2 weekly, until routines have been established.Then reduced to monthly, then 3 monthly.

What is progress?

The establishment of good toileting routines and improvement in dietaryintake, which initially may not reduce the number of soiling episodes.

Compliance with medication.

Increase in number of soft formed stools on the toilet.

Child and or family feel there has be an improvement.Progress can be slow, therefore it is important to set small and realistic goals.

Further Support

www.eric.org.ukwww.promocon.co.ukwww.cks.library.nhs.uk/constipationwww.5aday.nhs.uk


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Managing Bowel & Bladder Problems in Schools & Early Years Settings -Guideline - Guidelines for good practice (2006)(downloadable from promoconwebsite)

Including me (2005) Council for disabled Children & Department for Educationand Skills

Telephone advice / consultation is available from the Paediatric ContinenceNurse Advisor on 01332 888080 ext 8332.

Referrals to the Paediatric Continence Advisor should be in writing and senttoWilderslowe121 Osmaston RoadDerbyDE1 2GA


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IMPACT/04/0436

NoEffective?

No

Review 1-2 weekly

Reassess in 1 month

Effective?

NoYes yes

Continue

until no

problem

No

Child Mental HealthServices & Community

Paediatrician

History. Obtain details of: Examination (doctor or suitable qualified nurse only)

Present constipation/soiling problem Abdomen distension, palpable faecal mass

Associated wetting (enuresis) Perianal inspection fissures, inflammation

Delay in passage of meconium Spine Hairy patch, dimple

Developmental history (forced training) Knee / ankle reflexes

Details of dietary and fluid intake Overall development

Toilet fears / withholding behaviour Height / weight

Pain on defecation

Blood in stools

Other health problems (family attitude to poo)

Dietary adviceIncrease fluid intake.Increase vegetable &fruit intake gradually

Increase fibre intake

Yes

Adapted from IMPACT Paediatric Bowel Care Pathway. www.childhoodconstipation.com. February 2005

Demystification:Discuss causes

Explain symptomsDiscuss management

Explain prognosis

Mild constipation (short history/no soiling) Severe constipation/Overflow soiling Suspected pathology Emotional/behavioural problems

(deliberate) encopresis, smearing

Management by GP /Paediatrician and School Nurse

Demystification / Dietary advice / Regular Toileting

Evaluation of retained faeces (disimpaction) (see drug chart)

Telephone advice from Continence Nurse Advisor available

Management by School Nurse / HealthVisitor / GP:

Demystification

Diet increased fibre/fluid intake

Regular toileting (5-10 minutes once of

twice daily particularly after main meal)

Reward system e.g. star chart

Laxatives if appropriate

Continue until no

problem

Refer to GP, or GPtelephone advise from

Paediatric Continence

Effective?

Prevent re-accumulation of faeces:

Oral laxatives (Movicol Paediatric Plain or combination of a bulkand stimulant usually for several months. See drug chart)

Dietary management

Regular toileting (5-10 minutes once of twice daily particularly after

main meal)

Use patients diary to monitor progress

Regular follow up

Continue until no problem.Try to stop laxativesgradually after 6 months Effective?

PaediatricContinence

Advisor

Hospital

Specialist

No

Refer

Yes

ReferRefer

Yes

Effective?

Management of Childhood Constipation & Faecal Soiling


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Appendix 1

Fibre Content of Everyday Foods

A high fibre and fluid diet is a healthy diet and is suitable for all the family. You shouldencourage a regular meal pattern and increase the whole family's fibre and fluid intake atevery meal. By doing this you will increase the water content of stools making them softerand easier to pass.

How to calculate how much fibre your child should be eating: Age + 5 grams per day inchildren older than 2 years. eg If your child is 7 years old, the calculation would be 7 +5 = 13grams per day.

Food Portion Size Fibre Content(grams)

BREAD

Brown 1 small slice 0.9High Fibre White 1 small slice 0.8

Hovis 1 small slice 0.8Wholemeal 1 small slice 0.8

Wholemeal pitta bread 1 mini 1.8

BREAKFAST CEREALS

All-bran Average small bowl 7.2Bran Buds Average small bowl 6.6

Bran Flakes Average small bowl 2.6

Corn Flakes Average small bowl 0.2Country Store Average small bowl 1.2Fruit 'n Fibre Average small bowl 1.4

Mini Shredded Wheat Average small bowl 3.4Muesli Average small bowl 2

Raisin Splitz Average small bowl 2.3Sultana Bran Average small bowl 2.0

Weetabix 1 biscuit 1.9

BISCUITS & PASTRY

Cereal Bar 1 1.0Cracker - wholemeal 1 0.4Digestive (plain) 1 0.3

Ginger nuts 1 0.2Oat based biscuit 1 0.5

Oatcakes 1 0.7

Shortbread 1 0.2Wholemeal fruit cake Average slice 1.7

Wholemeal scone Average size (1) 2.6


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FRUIT (Raw)Eating apples 1 small 1.3Avocado pear pear 2.6

Banana 1 medium 1.1

Blackberries 10 1.55Dates - dried 5 3.0

Fruit cocktail (canned in juice) Small bowl 1.2Grapefruit 1.0

Grapes 10 0.6

Kiwi fruit 1 medium 1.1Mango 1 slice 1.0

Melon (cantaloupe) 1 slice 1.5

Orange 1 small 2.0Peach 1 small 1.1Pear 1 medium 3.3

Pineapple 1 large slice 1.0Plum 1 small 0.5

Prunes (dried) 5 2.3Raisins 1 tablespoon 0.6

Raspberries 10 1.0Tangerine 1 small 0.6

Strawberries 5 0.7

Sultanas 24 0.5

NUTS - should not be given tochildren under 5 years due to

the risk of choking

Almonds 6 whole 1.0Brazils 3 whole 0.6

Peanuts 10 whole 0.8Peanut Butter Thickly spread on 1 slice

bread1.4

RICE AND PASTABrown boiled rice 2 heaped tablespoons 0.6

Wholemeal spaghetti 3 tablespoons 3.1

VEGETABLESBaked beans 2 tablespoons 3.0

Beetroot 4 slices 0.8Broad beans 2 tablespoons 7.8

Broccoli tops (raw) 2 spears 2.4Butter beans 2 tablespoons 3.7

Cabbage 2 tablespoons 1.1Carrots 2 tablespoons 2Cauliflower 3 florets 0.5


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Celery - raw 1 stick 0.3Chickpeas 2 tablespoons 2.9

Corn-on-the-cob 1 whole 2.7Green peppers 1 tablespoon 0.8

Leeks Stem, white portion only 1.1

Lentils - split (boiled) 2 tablespoons 1.5Oven chips Small portion 1.2

Peas 2 tablespoons 3.0Potatoes - baked with skin Small 2.7

Potatoes - new 2 average size 1.2

Red kidney beans 2 tablespoons 4.3Spinach 2 tablespoons 1.7Sweetcorn - can 2 tablespoons 2Tomatoes - raw 4 slices 0.8

Turnip 1 tablespoon 0.8

(impact guideline 2005)


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Appendix 2

What is normal? When is it a problem?

Most children will have their bowels open between 3 times Your child may be suffering from constipation if there is aa day to 3 times per week. delay in passing stool (poo) from their normal pattern which

leads to pain, poor appetite, tiredness or is soiling (havingThe type of stool (poo) will vary from child to child, but most accidents after being fully toilet trained)of the time be should be between type 3 -5.

Another sign of constipation is having a regular type 7 stool,

which is not associated with being ill in any other way. This issometime called overflow (see chart).

What can you do to help?

Increase the amount of drinks and fruit & vegetables.

Encourage more active play / infant massage.

Encourage your child to sit on the toilet for 5 minutes after ameal & do 10 pushes.If your child struggles to "push" get them to blow bubbles

Reward your child for sitting and pushing e.g. star charts.

Keep a record of your child's bowel movements.


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April 2009-Final draft 16

Appendix2

WhendoI needtoget help? HealthyBowelsinChildren

If theproblemdoesnot get better within7days.

If it iscausingyour childtobedistressed.

If theyarepassingblood.

WherecanI canget help?Youcanget helpfromyour healthvisitor/ school nurse,GPpractice.

Tohelpkeepyour bowel healthyyouneedto:Local phonenumbers

Aimfor 5portionsof fruit &vegetablesper day.NHSDirect 08454647

Drink6-8water baseddrinksper day.Healthclinic............................................ Limitedmilkintaketoapint adayif childisover 1

yearsold

Eat fibrerichfoods, suchaswholegraincereals&breads

GP.....................................................Exerciseincludingwalkingtoschool &playingoutside


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Appendix 3

What Causes Constipation?

The most common cause of constipation is functional. Other causes of constipation are

uncommon but need to be excluded

Differential diagnosis Salient features

Hirschsprung's disease delay in passage of meconium

abdominal distension, vomiting,

faltering growth, temporary

improvement following PR,

occasionally positive family history

(3.5% recurrence in siblings)

Anorectal malformation Abnormally positioned anal opening.

absence of anal wink

Hypothyroidism Faltering growth

dry skin

delayed development

Streptococcal infection Perianal cellulitus

Neurological -spina bifida Appearance of lumbosacaral area


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Appendix 4 - Laxative prescription guideDefinitions

Osmotic Laxatives- increase the amount of water in the large bowel, either by drawing fluid from thebody into the bowel or by retaining the fluid they were administrated with.

Stimulant Laxatives increase intestinal motility and often caused stomach cramps. Stools shouldbe softened by increasing dietary fibre and liquid or with an osmotic laxative.

Infants under 2 years who are presenting with dry hard stools which are difficult topass

Presentation Plan Medication

Consider severity:Delay in passage inmeconiumConstipation in 1st month oflifeVomitingFailure to thriveAbdominal distension

If present - excludeHirschprung disease oranorectal abnormality

refer for surgical opinion.

No symptoms - Assessfeeding

Exclusively breastfed-gaining weight

Reassure Nil

Poor feeding/ weight gain Boost intake Review growthFormula feed/ weaned andgaining weight

Offer additional water If stool is dry:Add lactulose as BNF.Promote oral hygeine

Consider that activewithholding has developed(not normally before 18months) Consider degree ofwithholding:

StrainingUpright or stiff postureAvoiding contact whenstrainingHiding

Discourage toilet training Continue lactulose with orwithout sodium picosulphateas BNF.


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Appendix 4 - Laxative prescription guide

Children aged greater than 2 years old who are presenting with dry hard stools which aredifficult to pass

Short history (less than one month)

Presentation Advice Medication ReviewDry hard stool If toilet training, delay

for a month.Diet & fluid review

Lactulose as BNF 1 -2 weekly aimingfor a daily stool oftype 4-5 Bristol stoolform

Consider degree ofwithholding:StrainingUpright or stiffposture

Avoiding contactwhen strainingHiding

If toilet training, delayfor a month.Diet & fluid review

Use Osmotic laxative(Lactulose) ormacrogols(paediatric movicol).If not having bowels

opened regularlyenough addstimulant laxative(e.g. Senna orsodium picosulphate)as BNF.

1 -2 weekly aimingfor a daily stool oftype 4-5 Bristol stoolform

Medication should be slowly weaned approximately one month after symptoms cease or after toilettraining completed.

Severe Constipation chronic constipation with or without soiling

Evaluation of retained faeces (disimpaction) -Paediatric Movicol as BNF (not licensed for under 5years old for disimpactment, but from 2 years for maintenance of chronic constipation)

Outcome Medication

Clear abdominal examination. Bowelsopened daily.

Titrate movicol dose to maintain a daily stoolof type 4 Bristol Stool form. Initial review 1-2weekly. Once maintenance dose establishedreview monthly reducing to 3 monthly.Continue medication for a minimum of 12months or a long as the history ofconstipation, which ever is the longer.

Clear abdominal examination. Bowelsopened less than alternate days. Titrate movicol dose to maintain a stool oftype 4 Bristol Stool form. Add a stimulantlaxative (e.g. Senna, sodium picosulphate).Titrate doses to maintain a daily type 4Bristol Stool form. Once maintain doseestablished review monthly reducing to 3monthly. Continue medication for a minimumof 12 months or a long as the history ofconstipation, which ever is the longer.

Stool palpable per abdominal examination.Bowel pattern not between 3 time per dayand alternate days.

Consider if disimpactment needs repeating.Discuss compliance with medication.Consider Klean- Prep via nasogastric tube

(would require hospital admission) or manualevacuation under general anaesthetic.

Compliance issues


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Child does not like taste of movicol paediatric plain (has electrolytes in which taste salty) can beadded to any water based flavoured drink.

Child does not like liquid medication - Senna available in tablets-Sodium picosulphate available in capsules (Perles)- Bisacodyl Tablets (from aged 4)


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Appendix 5 Constipation Assessment FormName Known as Assessor

Address Base

Date of assessment:

Postcode PCT GP

DOB age M/F

Phone number Religion

Ethnic group Interpreter required?

School

other workers, e.g, nurses, therapists, social

worker, consultant, school nurse, health visitor

Favourite activities: Consent to share information & discussed data

protection

Referred by Reason for referral

Family structure

Parental responsibility held

by..

Early history

pregnancy birth early milestones

Current development

Special needs

Behavioural/school problems

Understanding level

Vision Hearing

previous health problems

current health problems

history of urinary tract infections

bowel pattern/any constipation

medication include over the counter allergies

typical diet

appetite

typical fluid intake

continence history

current problem

family history of similar problem

refer to continence service/GP/paediatrician: failed treatments for primary enuresis, secondary nocturnal enuresis/daytime enuresis

not responding to initial advice, constipation/ soiling not responding to initial advice

medical check urinalysis other tests

height centile weight centile

discharged outcome referred to date


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when did problem start?

triggers (eg. weaning, nursery, illness, toilettraining)

any constipation

-witholding

-blood in stools-pain

-soiling

-smearing

-associated wetting

-hiding clothing

usual stool pattern

usual size

consistency (Bristol Stool scale)

where is stool passed?

sensation of needing to evacuate? Where?awareness of problem (eg soiling)

impact on child/motivation

impact on carer

is problem associated with:

-time of day

-event/activity

-fears/anxiety/emotional link

previous investigations/treatments

compliance with any laxative medication

how are soiling episodes managed at

school/home?

MANAGEMENT PLAN2-4 week baseline record

bowel explanation (visual aids/stories)

medication explanation

is medical follow up planned?

no blame approach

appropriate rewards/achievable goals

address fears/emotional links

plan toileting routine

(longer term goal: child to respond independently tobody signals)

positioning on toilet

diet

fluids

exercises

continence products if needed

managing clothing home/school

www.eric.org.uk01179603060

keep recording

explain realistic timescales / Signs of progress


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DAY TYPE OFSTOOL

1-7

SIZE (SMALL,

MEDIUM,

LARGE)

USED TOILET

TIME

SOILED PAD /

PANTS

TIME

MEDICATION HOW MANY

DRINKS ?

FIBRE RICH FOOD

EATEN ?

MON

TUES

WED

THURS

FRI

SAT

SUN

NAME: .

DATE: ..


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Appendix 6


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Constipation and Soiling

A parents guide

The aim of this guide is to support what your doctor has told you today about your

childs constipation and soiling.

It aims to answer some of the questions you might have:

How does the body work?

What happens when my child is constipated?

How do the laxatives (medicine) work?

How can I help my child?

How can I get them to sit on the toilet?


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How does the body work?

Here are the important parts of the digestive system:

These diagrams show what the bowel does:

Mouth

Stomach

Small bowel

This is where the body

absorbs the water out

of the food, before

squashing it into poo and

storing the poo until it

is passed in the toilet

Large bowel

Mouth

Stomach

Small bowel

Large

bowel

Stomach (tummy)

Mouth

Largebowel

Small

bowel

Here the body

absorbs all of the

nutrients out of the

food


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Once the bowel is full of poo, it stretches the special muscles in the bowel wall a little,

and this sends a message to the brain saying go to the toilet to have a poo.

Normally this is first felt in the tummy area in front but if this signal is ignored or

suppressed too many times, for example because it is not a convenient time or place to

have a poo, the next feeling that a poo is needed will come from the bottom area when

very little time is left to get to the toilet on time!

What happens when my child is constipated?

When your child gets constipated, the poo in the large bowel becomes harder andbigger, and is difficult to push out on the toilet.

It gets bigger and stretches the special muscles in the bowel wall so much that they

stop sending the message to the brain telling them to go to the toilet. This blockage by

the hard poo still allows runnier poo from further back in the bowel to leak past.

Because the brain does not know they need a poo, the child may not realise that the poo

is going to leak out until it does so.

Big lumps of

hard poo

that have

got stuck

Very

stretched

bowel wall

The orange

arrows show

the runny poo

leaking past


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How do the laxatives work?

The laxatives (medicine) that the doctor or specialist nurse gives you are very

important, because they help to clear the big lumps of hard poo that have formed. Ifthese big lumps are out of the way, no poo can leak past, so then their pants will be

clean. The bowel need to gets back to its normal unstretched state so that it can send

messages to the brain again.

Even when your child stops soiling, it is important to continue the medicine. It is

likely that they may have to continue taking it for a year or more, but it does not do

your child any harm and stopping it too early will result in your child becoming

constipated again, and the soiling restarting. Stopping the medicine too early, even

after several months, is the most frequent cause of relapse. The bowel will take many

months or a few years to return to its unstretched state.

Fibre, which is found in fruit and veg, helps thelaxatives by helping to make poo softer

and helping stop hard poo building up again. Try to make sure your child has five

portions (one portion = around the size of a fist) of different fruit and veg a day.


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How can I help my child?As well as giving your child their medication, there are other things you can do to help

them stop soiling:

1. Sit your child on the toilet four or five times a day.

2. Many children spend too little time sitting on the toilet, so it might

help to set an alarm on a clock/oven/watch for five minutes, and let

them get off the toilet once it beeps. Reward staying on the toilet

for the full 5 minutes with a star on their star chart.

3. 5-15 minutes after they have eaten a meal or had a snack is a good time to sit them

on the toilet, as the bodys natural reflexes often allow them to have a poo at thistime.

4. Give a copy of the toilet-sitting times to other caregivers the child sees throughout

the day, such as childminders, grandparents and nursery staff, to make sure

everyone is keeping to the times you have chosen.

5. Watch for behaviour/grimaces/poses (such as crossing their legs) that might

indicate they need the toilet, and ask them to sit on the toilet at those times as well.

6. Give praise if they ask to go to the toilet or go to the toilet un-reminded but if

accidents occur, help them to clean themselves up, and try not to shout or tell them

off.

7. Milk can make constipation worse, so try and make sure your child doesnt have more

than one pint of milk (including milk products) a day.

8. Make sure they are active and not sitting on the sofa the whole day long.

9. It is also important to make sure your child is drinking plenty of water, or very dilute

squash if they dont like water, as this will help soften the poo too. You should aim

for at least 2-3 pints of fluid a day. This also helps their concentration!


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How can I get them to sit properly on the toilet?

Once your child is sitting on the toilet, you could:

1. Have a special toy that they are only allowed to play with whilst they are on the

toilet.

2. Read them a story or sing songs along with a radio/tape/c.d.

3. Encourage them to push some poo out if they can. If they do some in the first

couple of minutes, praise them and ask them to sit there for the rest of the 5

minutes, because they may do some more.

4. Ask them to blow bubbles, blow up a balloon or blow a party trumpet this

tightens the same tummy muscles that they use to have a poo, and may help themsqueeze it out. (Always make sure you are sitting with them when they do this

though as balloons can be dangerous and easily swallowed by young children)

5. Have a special box/step/stool to help them climb on and off the toilet that they

can rest their feet on whilst they sit there. It is much easier for them to do a

big push to have a poo if their feet are

supported and not dangling in the air.

6. Once the five minutes have finished, help them wipe their bottom, flush the

toilet and wash their hands so that they learn and practice good hygiene habits.

7. If your child is scared when flushing the toilet, add some food colouring (that you

use just for this purpose) to the water in the cistern just before they flush.


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You may not realise how common constipation and soiling is, but research has shown that

3% of children aged 5 yrs (3 children in every 100 children) suffer from it. So,

although you may not be aware of it (children do not discuss this problem with their

friends) there will be at least one other child in your childs school that is going through

the same thing.

It is very important to remember that your child wants to stop soiling as much as you

want them to stop, and although it is very frustrating when your child soils, they are not

doing it on purpose. Some children may hide behind a sofa or in the corner when they

are soiling; this is because they are embarrassed that they do not have enough warning

to get to the toilet, not because they are soiling on purpose. They may also hide their

dirty underwear from you, as they may be embarrassed by this too, but it is very

important not to get angry by this behaviour. Work out a strategy with your child about

where they can put their dirty underwear such as a special wash basket in theirbedroom so that they do not hide them somewhere else.

Try preparing a pack that your child can keep in their school bag, that contains clean

underwear and some baby wipes for example, so that they can clean themselves up at

school.

Bristol Stool Chart

Type 1

Separate hard lumps,

like nuts (hard to

pass)

Type 2Sausage shaped but

lumpy

Type 3

Like a sausage but

with cracks on its

surface

Type 4

Like a sausage or

snake, smooth and

soft

Type 5

Soft blobs with clear

cut edges (passed

easily)

Type 6

Fluffy pieces with

ragged edges, a

mushy stool

Type 7

Watery, no solid

pieces. Entirely

liquid


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Hopefully, once the medication is working, your childs poo should look like type 3 or

type 4.

Bowel Recording ChartOn the next page is a bowel recording chart - it may help to fill out this chart before

you next go to see your doctor/specialist nurse so that they have some idea how the

medication is working.

You can also use the blank space at the bottom of this page to write down any other

questions you want to ask at your next appointment.

Questions I want to ask

1.

2.

3.

4.

5.


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References

1. BNF for Children (2008)

2. Clayden, G. Management of chronic constipation. Archives of disease in childhood, 1992;

67:340-344

3. Clayden G.S, Keshtgar, A.S. Carcani_Rathwell, I. Abhyankar, A. The Management of

Chronic Constipation and Related Faecal Incontinence in Childhood, Arch Dis Child Educ

Pract Ed 2005;90:ep58-ep67

4. Fontana M, Bianch C, Cataldo F et al. Bowel frequency in healthy children. Acta

Paediatric Scand, 1987; 78:682-684

5. Leung AK, Chan PY, Cho HY, Constipation in children, Am Fam Physician, 1996 Aug;

54(2):611-8, 627

6. McClung HJ, Boyne L & Heitlinger L. Constipation and Dietary Fibre intake in children.

Paediatrics, 1995; 96:999-1001

7. McNally, S. Napier, K. Welford, H. (2008) What's in a nappy? NCT/Simpson Centre for

Reproductive Health

8. National Institute for Health and Clinical Excellence (NICE), Scope - Constipation: the

diagnosis and management of idiopathic childhood constipation in primary and secondary

care, (June 2008)

9. Norgine ,RCN, IMPACT Paediatric Bowel Care Pathway, (January 2005)

10. Nursing & Midwifery Council (August 2007) Standards for medicines management

11. Prodigy Quick reference Guide Version 2 (May 2007)

12. www.cks.library.nhs.uk/constipation

13. www.touchlearn.co.uk

20100623-g052 - guideline in the management of childhood constipation - issue 1

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