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Guidance in brief

NICE’s first guideline on idiopathic childhood constipation and its implications for nurses

Idiopathic constipation can affect all aspects of a child’s life. A member of NICE’s guideline development group outlines their first ever guideline on this condition

Keywords Idiopathic constipation, Assessment, Laxatives, Disimpaction

Introduction

Idiopathic constipation in children is relatively common, with a prevalence in the UK of 5-30%, depending on the criteria used for diagnosis. It is the second most referred condition in paediatric gastroenterology, accounting for at least 25% of visits.

Those suffering from constipation can experience social, psychological and educational problems, often requiring prolonged support. However, its signs and symptoms are rarely recognised, yet early identification and effective treatment can greatly improve outcomes for children, saving time and healthcare resources.

NICE commissioned the National Collaborating Centre for Women’s and Children’s Health to develop a guideline on the diagnosis and management of idiopathic childhood constipation in primary and secondary care. Stakeholders were given an opportunity to comment on the draft guideline before the final version was published in May 2010. This is the first guideline of its kind to make evidence based recommendations for the diagnosis and treatment of children with constipation.

Implications for nursing practice

The guideline provides an overview of this debilitating condition, and an opportunity for nurses working with children and their families to gain a better understanding of it. It aims to reduce the myths and inaccuracies that often surround idiopathic constipation, and to encourage a more empathetic and professional attitude towards its management.

Idiopathic constipation can affect all aspects of a child’s life, and the guideline offers a wide range of approaches for healthcare professionals working with children who have the condition to consider. It indicates “red flag” conditions or symptoms, and recommends that children who have these should be referred urgently to a specialist in the appropriate area.

In most cases care should be provided in the community, although the guideline recognises that a minority of children will need support and intervention in acute settings. This has implications for nurses working in primary care environments, whether domiciliary or clinic based.

A number of the recommendations about the management of idiopathic constipation in children have significant implications. For nurses in particular, these include:

  • Pharmacological interventions that can be used by non medical and community nurse prescribers;
  • Behavioural advice and support for families;
  • The appropriate time to refer children for specialist advice and support.

In terms of pharmacological interventions, the guideline states that, for most children, treatment should start with the appropriate dose of oral laxatives for both disimpaction and maintenance therapy. It also gives clear guidance and time frames for weaning off the medication which, for many nurses, may involve training and support.

The recommendations encourage an increase in direct support for the family, particularly at times when a child may need disimpaction and ongoing involvement, such as laxative maintenance treatment and behavioural interventions.

Paediatric continence nurses and community children’s nursing teams are well placed to support children with idiopathic constipation as they can provide both domiciliary and clinic based services, and can reach into the acute setting, including A&E. They can also support children attending schools or day nurseries, and are skilled in holistic assessment of those with long term conditions.

Creative ways of implementing the guideline’s recommendations could be explored locally. An example of this might be collaboration with the school nursing team, ensuring additional support and raising awareness and improving school staff’s understanding. This could help give children confidence that their condition is taken seriously.

The clinical and cost-effectiveness of developing nurse-led clinics would have to be considered to assess if such options would be appropriate. Further research is needed before these can be adopted as evidence based practice.

Conclusion

This guideline gives a comprehensive overview of idiopathic constipation in childhood, and provides evidence based recommendations for its management. Implementing the recommendations will enable nurses to effectively assess their patients, provide appropriate treatment and give tailored information to ensure optimum patient care.

Implementation of this guidance will also ensure consistent best practice across the NHS, giving nurses the opportunity to influence local procedures in managing this condition. This will result in children, parents and carers being given correct, evidence based information and management plans, to improve outcomes for this often debilitating condition.

The full guideline, Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care, and implementation resources are available at www.nice.org.uk/CG99

AUTHOR Sian Hooban, BSc, PGCE, RSCN, RGN, is service manager for community children’s nursing services, Cambridgeshire Community Services Trust, and a member of the NICE guideline development group

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