constipation and faecal soiling continence advisory service : bobbie jones gill prior jane dickson

Constipation and Faecal Soiling

Continence Advisory Service :Bobbie Jones

Gill PriorJane Dickson

Bowel Function

Normal Bowel control

First year – reflex activity

• Second year – gradual awareness of need to empty bowel

• Third year – ability to defer bowel opening

• Fourth year – ability to delay bowel opening, and to defecate voluntarily

Normal Bowel Function

• 99% of babies pass meconium within the first 48hrs of birth

• 16 weeks – average of 2 stools / day

• Weaning results in a firmer stool

• Range of 1-3 / day to 2-3 / week

• Soft and easy to pass

Faeces moves into the sigmoid colon and previously empty rectum

Defecation occurs

Holding on

Common Bowel Problems• Constipation:

Defined as the infrequent passage of hard stools that is difficult to pass. The passing of stools may be painful and less frequent than is normal for that child

• Slow Transit Constipation: Slower than average movement of stool throughout the large bowel.

• Faecal Soiling The repeated passage of stools, whether involuntary or intentional in a socially unacceptable place in a child over 4 years of age (or equivalent developmental age).

Contributing factors of constipation

• Reduced fluid intake

• Reduced fibre intake

• Reduced exercise

• Holding on/ ignoring the urge – often initiated by passing of large/painful stool

Contributing factors of constipation

• Missed training opportunity

• Delay in passage of normal stool

• Anal Fissure

• Toileting phobias or fear

• Child abuse

Functional faecal retention

• usually associated with soiling

• follows from ‘holding on’ unless managed

appropriately

• child ‘forgets’ mechanics of normal defecation

• May require long term treatment and follow up

Constipation – Signs and Symptoms

Symptoms of increasing faecal loading

• Abdominal distention and pain

• Irritability

• Anorexia

• Faecal Soiling

Slow transit constipation - Signs and Symptoms

• Large soft stools

• Frequency 3 per week to 1 per 3 weeks

• Abdominal distention

• High incidence of faecal incontinence

• Symptoms of severe constipation within a year

Assessment

• Check for:– daytime urinary problems

– nocturnal enuresis

– appetite / fibre intake

– fluid intake - how much milk?

– any medical problems

– any current medication

Red Flags 

• ‘Red flag’ symptoms include: – More than 48 hours before passing meconium as a

neonate – Abdominal distension especially if failing to thrive – Infrequent small or ribbon stools – Constant leaking especially if linked with urinary

leaking too – Failed management with appropriate standard

intervention (with compliance)

Communication

• able to indicate what is happening – (not necessarily verbal)

• language used for toileting can be unique to each family

Mobility

• Get to the toilet

• Remove clothing

• Get up onto the toilet

• Wipe bottom

• Replace clothing

• Wash hands

Social

• Be able to follow instructions

• Have the ability to communicate

• Wish to please parents/carers

• Want to be like their peers

Environmental issues

• School toilets

• Toilet accessibility

• Peer pressure

• Clothing

• Lack of privacy

• Attitudes of others

Treatment Goals

• To establish regular bowel habits

• To reduce stool retention

• To restore normal control over bowel function

• To reduce concerns within the family

• To help reduce conflict within the family

Treatment – Constipation

Education

• Proposed course of treatment

• Normal variation in bowel habits

• Symptoms may get worse initially

Evacuation (if required)

• Disimpaction with oral laxatives and enemas

Increase Movicol Dose

Increase Movicol Dose

Maintain Movicol Dose

Maintain Movicol Dose

Decrease Movicol Dose

Decrease Movicol Dose

Stop taking Movicol for a day or two

Movicol Maintenance Regime

Impaction RegimeChildren (2 – 11 years):

Number of MOVICOL-Half Sachets

Age (years) Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

2 – 4 2 (1) 4 (2) 4 (2) 6 (3) 6 (3) 8 (4) 8 (4)

5 - 11 4 (2) 6 (3) 8 (4) 10 (5) 12 (6) 12 (6) 12 (6)

A course of MOVICOL-Half (OR half adult MOVICOL dose) is for up to 7 days as follows:

Treatment – Constipation

Maintenance

• Medication may be required

for 6-12 months, even longer.

• Increase fibre and fluid intake

• Increase activity in the child

Treatment – Slow Transit Constipation

• Remove obstruction

• Fibre supplement – initially

• Laxatives

• Antegrade Colonic Enema

• Colectomy

Treatment Plan Overview

• Ensure adequate fluid intake

• Ensure balanced diet with adequate amounts of fibre

• Encourage regular toileting – minute sits

• Encourage correct toileting position

• Consider environmental factors e.g. access to school toilets

• Management strategies

• Refer to health care professional