Sandra Hanson and Helen Ripper made a video that helps parents and GPs to treat childhood constipation in the community. Their initiative won the Continence Promotion and Care category in the 2017 Nursing Times Awards
Childhood constipation is easily treated, as long as parents and carers receive the right information and support at first diagnosis. Left untreated, it can become chronic and have disastrous consequences on the lives of children and their families. In 2016, a specialist nurse and a support worker running a childhood constipation service in Kent filmed a video with one goal: to explain how parents can manage their child’s constipation effectively at home. The authors’ aim is to prevent children from developing chronic constipation in the first place, both to spare children and families distress and anxiety, and the NHS costly hospital referrals and admissions.
Citation: Hanson S, Ripper H (2018) A video to help parents and GPs manage childhood constipation. Nursing Times [online]; 114: 5, 24-25.
Authors: Sandra Hanson, specialist nurse; Helen Ripper, support worker; both at the childhood constipation service, Dartford and Gravesham Trust.
Childhood constipation can have disastrous consequences, but is not perceived as a major problem and often mismanaged. Many children we see in our childhood constipation service at Darent Valley Hospital in Kent have had severe constipation for years. We believe this common condition can be nipped in the bud through correct and early treatment in the community.
Idiopathic constipation in children is common in the UK, its prevalence being estimated at 5-30% of the childhood population (National Institute for Health and Care Excellence, 2010). If acute childhood constipation is unresolved, it can become chronic and cause abdominal pain and distension, poor appetite and lack of energy; affected children are likely to become unhappy, angry or moody.
Children may develop physical issues such as mega rectum, faecal impaction, soiling, loss of sensation and withholding. These are usually accompanied by psychological and emotional issues, such as poor self-esteem, irritability, distress, shame and guilt, and can have severe long-term consequences. According to NICE (2010): “many children and young people experience social, psychological and educational consequences that require prolonged support”.
Chronic childhood constipation has a huge negative impact, not only on children and families (parents often tell us their lives revolve around their child passing a stool), but also on the NHS and its scarce resources.
Our childhood constipation service receives 350-400 referrals per year, with numbers increasing as it becomes more widely known. The children and parents call us the ‘poo nurses’. We offer a group education clinic for parents, carers and professionals, which emphasises self-management. It gives parents greater understanding of their child’s condition and the information they need to treat it at home. It also gives them a chance to talk openly and meet others experiencing the same difficulties. After attending the clinic, parents are supported via telephone consultations. To help us improve, we ask them to fill in a questionnaire; so far, we have over 400.
Lack of information
As stated by NICE (2014), the first-line treatment for constipation in children and young people is an oral macrogol (Box 1). Macrogols, which are osmotic laxatives, work by drawing water into the bowel to soften stools and make them easier to pass.
Box 1. NICE’s six quality statements
- Children and young people with constipation receive a full assessment before a diagnosis of idiopathic constipation (IC) is made
- Children and young people with IC receive oral macrogols as a first-line treatment
- Children and young people with IC starting disimpaction therapy have their treatment reviewed by a health professional within one week
- Children and young people with IC starting maintenance therapy have their first treatment review by a health professional within six weeks
- Children and young people with IC starting laxative treatment, or their parents or carers, receive written information about laxatives
- Children and young people with IC that does not respond to initial treatment within three months are referred to a health professional with expertise in the problem
Source: National Institute for Health and Care Excellence (2014)
Time and again, parents told us:
- If we had known how to use a macrogol and had the information at the start, our child would not have suffered for so long
- We did not know how the macrogol worked, when to give it or for how long to use it;
- It caused diarrhoea, so we stopped it;
- We were told to give one sachet a day, but this did not work;
- We were told to stop it as soon as our child had had a bowel movement or was no longer constipated.
Parents were also worried about giving their child laxatives for long periods, and many found their child refused to take the macrogol as they did not like the taste.
We looked at a random sample of 50 parent questionnaires and found that, on average, children had attended 5.7 GP appointments for their constipation. Many had presented in accident and emergency, had seen paediatric consultants or gastroenterologists, and had been hospitalised for enemas, suppositories, nasogastric tubes and manual evacuation of faeces under anaesthetic.
This told us that children and families were suffering for long periods and the NHS was bearing a heavy financial burden. It also raised our suspicion that health professionals in the community were not following national guidance on childhood constipation (NICE, 2014; NICE, 2010).
In 2014, we audited the compliance of ourselves and our referrers against the six NICE quality statements on constipation in children and young people (Box 1). Using a random sample of 50 patients from our caseload, we found GPs were not fully compliant and, for some quality statements, 100% were non-compliant.
Developing useful resources
How could we help GPs and parents treat children with constipation effectively and early, to reduce referrals to paediatric consultants, A&E visits and hospital admissions? After unsuccessful attempts at connecting with local clinical commissioning groups and GPs, we explored the idea of recording a video, which would allow us to:
- Spread the message locally and UK wide;
- Reach many more parents than our clinics ever could;
- Provide a resource that parents could learn from in their own time;
- Provide easily accessible information to anyone who needed it.
A conversation with our director for strategic development and performance led us to NHS Elect and, in 2015, it agreed to fund a 15-minute video and microsite (which can be viewed on a smartphone).
We decided to focus the video on how to use macrogols and wrote a script explaining how constipation develops in children, how it can be resolved using a macrogol, and what regimens to follow for disimpaction and maintenance. We tried to answer parents’ most common questions and concerns. In March 2016, the video was filmed, animated and post-produced.
The video and microsite were launched in September 2016 and the video posted on YouTube in December 2016. We were unable to promote it as much as we wanted but it has been picked up by parents and shared on social media.
The video has had over 2,000 views on YouTube and between 1 February 2017 and 31 January 2018, our microsite has had 10,366 visits and 18,876 page views. Recent statistics show it has been visited by people in more than 10 countries.
“We were truly impressed by this initiative, which allows patients to feel empowered and is based on impressive qualitative data” (Judges’ feedback)
The message is reaching health professionals: paediatric consultants and the Autistic Society have thanked us for making the video, while our consultants have shared it with counterparts in India, Australia and other countries. The video is watched by children and shared in schools and nurseries; adult services are using it and parents have shared it with relatives who have been prescribed a macrogol.
A member of Dartford, Gravesham and Swanley CCG saw the video and was keen to ensure that childhood constipation is managed correctly in the community. Together, we designed a referral pathway for GPs that:
- Signposts GPs to the NICE quality statements;
- Reminds them to prescribe a macrogol as the first-line treatment;
- Prompts them to give parents the URL for our microsite and tell them to watch our video.
Childhood constipation can be effectively treated if it is caught early, and if parents are supported by their GPs and given the right advice from the start. Parents also need to be patient, encouraging and supportive. Our video is helping many professionals, children and families, so we would like to make other videos on related issues such as toileting, rewards, fear and withholding behaviour, children who will only pass stools in nappies, and personal care in school. We are currently trying to source funding for this.
- Childhood constipation can have devastating consequences for children and families
- Early and correct treatment can prevent acute constipation from becoming chronic
- The first-line treatment for constipation in children and adolescents is an oral macrogol
- Parents need to know how to use macrogols effectively
- An online video is helping parents and GPs to treat childhood constipation more effectively
National Institute for Health and Care Excellence (2014) Constipation in Children and Young People.
National Institute for Health and Care Excellence (2010) Constipation in Children and Young People: Diagnosis and Management.