Nurses are well-placed to offer advice and support to those involved with the care of children with constipation
In this article..
- Causes of idiopathic constipation
- Diagnosing the condition
- Different therapies to manage idiopathic constipation
- The importance of follow-up
Phil Prynn is continence services manager, Berkshire West PCT, Wokingham Community Hospital.
Prynn P (2011) Managing idiopathic constipation in children. Nursing Times; 107: early on-line publication.
Key words: Idiopathic constipation, Children, Impaction
- This article has been double-blind peer reviewed
5 key points
- Constipation affects up to one in three children in the UK
- The term idiopathic describes constipation where there is no anatomical or physiological abnormality
- Idiopathic constipation in early childhood is often a result of stool retention
- The condition can involve infrequent, painful passage of large hard stools, flatulence, faecal incontinence and abdominal discomfort
- Treating constipation early can prevent it having long-term physical and psychological consequences
Constipation is a common condition affecting up to one in three children in the UK (National Institute for Health and Clinical Excellence, 2010). It usually causes the child to strain to defecate, to pass hard stools and to do so less frequently than normal. Associated faecal leakage, which is often mistaken for diarrhoea, suggests faecal impaction. A third of children with chronic constipation continue to have problems beyond puberty.
When the condition is not caused by anatomical or physiological abnormalities it is known as idiopathic constipation; it is important to exclude abnormalities requiring medical or surgical intervention before treating constipation. NICE (2010) identifies red-flag symptoms, which indicate an underlying disorder requiring urgent referral to a specialist, and amber-flag symptoms, which suggest idiopathic constipation is possible. It also offers best-practice advice on the care of children with idiopathic constipation. Prompt diagnosis and treatment is vital to avoid complications such as anal fissure or faecal impaction related to chronic constipation.
Idiopathic constipation in early childhood is often due to stool retention. This is usually an acquired behaviour that follows a specific identifiable trigger, such as a distressing bowel movement (Biggs and Dery, 2006). If a child frequently avoids defecating, the rectum eventually stretches to accommodate the retained faecal mass, sensation is blunted and the propulsive power of the rectum is diminished.
Factors contributing to idiopathic constipation include: fever, dehydration, insufficient dietary fibre, psychological concerns, toilet training problems, constipating medication and a family history of constipation. Some children and young people with a physical disability, such as cerebral palsy or those with a learning disability are more prone than the general population to idiopathic constipation.
It is important to recognise and treat constipation early to avoid debilitating long-term physical and psychological consequences, as well as educational disadvantages to the child. Nurses are well-placed to offer advice and support, to liaise with teachers and other relevant healthcare professionals, and to make decisions appropriate to individual circumstances in consultation with children and their parents or guardians.
No aetiological factors can be found in most children with idiopathic constipation. However, Hirschsprung’s disease, cystic fibrosis, ano-ectal abnormalities and metabolic conditions such as hypothyroidism are rare causes (NICE, 2010; Abhyankar et al, 2008).
Diagnostic criteria for idiopathic constipation vary but involve: infrequent, painful passage of large hard stools, flatulence, retentive posturing or withholding, faecal incontinence, abdominal discomfort, poor appetite, irritability and general malaise (Rasquin et al, 2006).
A diagnosis of idiopathic constipation is established by excluding underlying causes. Children presenting with red flag symptoms must be referred urgently to a healthcare professional experienced in the specific aspect of health causing concern (NICE, 2010).
A general history should be taken followed by specific questions about the constipation including the frequency of defecation, stool consistency using the Bristol Stool Form Scale, episodes of faecal incontinence, stool volume, pain and behavioural issues. Examination should include palpation of the abdomen for faecal mass and if indicated, inspection for overflow soiling and faecal impaction. Digital rectal examination is not routinely necessary or required and routine radiography is not recommended.
The aim is to clear faecal impaction, establish a regular bowel pattern and to prevent recurrence. The diagnosis identifies the most appropriate management strategy.
It is important to establish a rapport with the child and his or her parents or carers, take a non-judgemental approach and reassure them that underlying causes have been excluded by the history and/or physical examination. It is essential to spend time at the initial consultation to explain that constipation is common and likely to improve with age and simple therapies such as behavioural modification and laxatives, and that while treatment is usually successful it may take several months with prolonged courses of laxatives.
As defecation becomes regular the laxatives may be carefully titrated down and, where possible, contributing factors should be resolved, such as reviewing constipating medication and addressing psychosocial issues. The management plan should include the elements below.
Impacted faeces must first be cleared so that management can begin with a clean bowel (Weeks et al, 2000). Rectal medication should not be used for disimpaction unless all oral medications have failed. The NICE guideline suggests polyethylene glycol 3350, using an escalating-dose regimen as the first-line treatment; if this does not lead to disimpaction after two weeks a stimulant laxative should be added. If polyethylene glycol 3350 is not tolerated a stimulant or a combined stimulant and osmotic laxative may be prescribed (NICE, 2010)
Include dietary advice, maintain a bowel chart, persevere with laxatives and avoid stopping and starting treatment, which can result in sporadic impaction. Continue medication at maintenance dose for several weeks after a regular bowel habit has been established. Titrate the laxatives down gradually over a period of months according to stool consistency and frequency. Some children may need to maintain laxative therapy for several years (NICE, 2010).
There is no clear evidence to suggest that increased fluid and fibre intake will relieve constipation. Recommended levels of fluid intake should be maintained to avoid dehydration, which tends to be a side-effect of osmotic laxatives. A balanced diet containing some fibre should be promoted, but a high-fibre diet could exacerbate symptoms.
Empirical evidence suggests that lack of exercise may contribute to constipation, so physical activity tailored to the child’s stage of development and ability should be promoted. The Department of Health (2004) recommends that children should do at least 60 minutes of moderate intensity physical activity a day.
Explain the reason for overflow faecal incontinence and encourage a regular pattern for using the lavatory, taking advantage of the post-prandial colorectal reflex, particularly after breakfast and especially if laxatives are taken at bedtime.
Support the child in establishing a regular bowel habit by scheduling an unhurried toileting regime about 15 minutes after meals. It may be helpful to have a small rewards system in place for successful use of the lavatory.
Offer regular follow-up and a point of contact with specialist healthcare professionals. Bear in mind that relapses are common, so continued use of positive reinforcement contributes to long-term bowel success.
Key indicators for the treatment of constipation are pain on defecation, severe straining and overflow incontinence. If symptoms are mild, reassurance and dietary advice may be all that is required. If symptoms are persistent and psychosocial problems present additional input and continued support will be necessary.
The NICE guidance will help the multiprofessional team to take a coordinated approach to early intervention that may reduce the incidence of constipation in children and young people. School nurses, health visitors, children’s nurses, nurses specialising in the care of children with learning disabilities and GPs have key roles in detecting and treating early symptoms of constipation. School nurses can also encourage schools to improve standards of comfort, privacy and cleanliness in their lavatories and to adopt a humane approach to pupils’ opportunities for toilet visits (Perez, 2010).
Care of young people in transition between paediatric and adult services should be planned and managed according to best practice guidance. Successful transition planning depends on co-operation between children’s and adult services, and these teams should work together to provide services for young people with idiopathic constipation. Management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care. Where the process of transition is well planned, the clinical, educational and social outcomes for young people are greatly enhanced (DH, 2006).
Constipation is too common a problem to leave to the experts. Everyone involved in child care should be aware of the risks associated with allowing simple constipation to go unacknowledged, undiagnosed and untreated.
Abhyankar A et al (2008) Constipation in children. BMJ Clinical Evidence; 10: 303.
Biggs WS, Dery WH (2006) Evaluation and treatment of constipation in infants and children (Disease/Disorder overview). American Family Physician; 73: 469-477.
Department of Health (2004) At Least Five a Week: Evidence on the Impact of Physical Activity and itsRelationship to Health. London: DH.
Department of Health Child Health and Maternity Services Branch (2006) Transition: Getting it Right forYoung People. London: DH.
National Institute for Health and Clinical Excellence (NICE) 2010.Constipation in Children and YoungPeople. Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care.NICE CG99. London: NICE.
Perez J (2010) Minimum standards for school toilets are needed to improve child health. Nursing Times; 106: 24, 30.
Rasquin A et al (2006) Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology; 130: 5, 1527-1537.
Weeks SK et al (2000) Key to bowel success. Rehabilitation Nursing; 25: 2, 66-99.