Guidance in brief

NICE provides a consistent and coordinated approach to managing childhood constipation

22 June 2010

Childhood idiopathic constipation can cause anxiety, despair and frustration for children and parents. New guidance offers best practice recommendations

Keywords Childhood continence, idiopathic constipation, faecal soiling, NICE guideline

This article outlines the recommendations from National Institute for Health and Clinical Excellence guidance on idiopathic constipation and its implications for nurses.

Background

Idiopathic constipation affects 5-30% of children and, without early diagnosis and treatment, can become a long term condition that is difficult to resolve (NICE, 2010). The term refers to constipation in children presenting with no known anatomical or physiological cause (Benninga et al, 2005), a third of whom may need referral to acute care for the management of chronic constipation (NICE, 2010). Associated symptoms include:

Faecal soiling;
Irregular bowel activity;
Abdominal pain;
Poor appetite.

These symptoms can have adverse effects on the child and family and lead to considerable costs for healthcare services.

Children and parents often experience confusion, frustration and despair when confronted with this condition and may delay seeking help through embarrassment. It has also been suggested that some healthcare professionals underestimated the impact of constipation on children and families (Farrell et al, 2003).

The new NICE guideline is based on best available evidence and offers strategies to support early diagnosis and timely and effective management.

The aim is to provide a consistent and more coordinated approach and improve outcomes for children, young people and their families.

The guidance includes useful tools and detailed information to enable healthcare professionals to implement the recommendations (see Box 1 for main points). This guidance is invaluable to healthcare professionals and continence organisations that talk to parents and are aware of the distress that long term constipation and soiling can cause.

Implications for nurses

Developed by expert healthcare professionals and patient representatives who consulted with children and families, the guideline will help the multiprofessional team work in a coordinated way to reduce the incidence of long term constipation and the problems associated with the condition, such as faecal soiling. This should also improve continuity of care and ensure families have a better understanding of the principles of treatment. The evidence based information can be shared with parents and children to increase their understanding of the condition; this can play a role in any treatment’s success.

The guideline also gives clear advice on the value of clinical investigations such as digital rectal examination (this must be performed by a healthcare professional competent to carry out and interpret findings), radiography and endoscopy in diagnosing idiopathic constipation. Tests should not be carried out unless there is clinical need.

Box 1. Overview of the main recommendations

Take a history to establish whether the child is constipated.
If constipation is present, exclude any underlying cause and establish a diagnosis of idiopathic constipation. If findings and diagnostic clues indicate the possibility of an underlying condition/disorder (“red flag” symptoms), refer the child urgently.
Carry out a physical examination and urgently refer children with red flag symptoms.
Inform the child and family if idiopathic constipation is diagnosed. Reassure them that there is a suitable treatment, but it may take time to work.
Assess for faecal impaction and treat with an oral medication regimen. Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain. Children undergoing disimpaction should be reviewed within one week.
If the bowel is not impacted, or when disimpaction is complete, start maintenance therapy and continue ongoing treatment. Children should be reassessed regularly, preferably by the same person or team, to ensure impaction does not recur.
Advise about diet and lifestyle (not as first line treatment but in conjunction with an appropriate medication regimen).
Give information and support. Provide verbal information, backed up by written or website information, and offer a point of contact with a healthcare professional, be it face to face or by telephone. School nurses are a source of support who can help raise awareness of the child’s needs with school staff.
Maintain accurate records.

Useful organisations

Education and Resources for Improving Childhood Continence (ERIC, www.eric.org.uk) is a national charity that helps children, young people and their families with wetting and soiling problems.
Promocon (www.promocon.co.uk), working as part of Disabled Living in Manchester, provides a national service to improve life for all people with bladder or bowel problems by offering product information and advice.

ANNE WEAVER is retired RGN school nurse and former clinical adviser at Education and Resources for Improving Childhood Continence (ERIC)

References:

Benninga M et al (2005) The Paris Consensus on Childhood Constipation Terminology (PACCT) Group. Journal of Paediatric Gastroenterology and Nutrition; 40: 3, 273-275.

Farrell M et al (2003) Management of childhood constipation: parents’ experiences. Journal of Advanced Nursing; 44: 5, 479-489.

National Institute for Health and Clinical Excellence (2010) Constipation in Children and Young People. Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care. London: NICE.