Dr Bobby Tsang, Specialist Paediatrician North Shore Hospital Let’s Get Going Managing Childhood Constipation Childhood constipation Common 10-30% Associated incontinence Essential aim - prevent pain with defecation Invasive investigations not routinely needed Refer if organic disease or review treatment Behavioural and social consequences Long term managment Epidemiology “Normal” relates to culture and diet Majority pass 1 motion per day 1% < 3 per week or > 3 per day 3-5% Paediatric outpatients Bimodal Infancy (soon after birth) and around 2yrs M:F 2:1 65-70% better after 2y Persists post puberty >30% Rome III criteria >2 for >2m Developmental age > 4 y <3 stools pw 75% Fecal incontinence >1 pw 75-90% Retentive posturing or XS volitional stool retention 35-45% Painful or hard bowel movements 70% Large fecal mass in the rectum 30-50% Large-diameter stools that obstruct toilet 75% Other symptoms Lack of energy, “not well” Poor appetite 25%; Vomit 10% Abdominal distension 20-40% Fissures or haemorrhoids 5-25% Rectal bleeding 7% Anal prolapse 3% Enuresis or UTI 30% Excessive foul flatus and stool Scybalous stool Psychological / Social 20% Poorly organised family environments Less expressive Poor social competence Poor scholastic performance, learning disabilities, ADHD Anxiety / depression Unhappy, angry, irritable, moody Disobedient, disruptive behaviour Incontinence Barrier to independence Education, work, financial, social, relationships Emotional Low self-esteem, worry, embarrassment, guilt, fear, isolation, sadness, frustration Psych probs - Joinson 2006 Adult OR=2 OAB, LUT dysfn, UTI, obesity, sexual dysfn, mood disorders Fitzgerald 2006, Minassian 2006 Colon Highly efficient complex organ Absorbs 400ml/day (up to 3 litres) Homeostasis of electrolytes Stores faeces Tone Rhythmic segmentation 5-40 mmHg 60/day Discharges faeces Secretes mucus Peristalsis Mass movements 100 mmHg, on waking and PC HAPC High amplitude propogating contractions Paraplegia Hyperactive irregular segmentation interstitial cells of Cajal Refinement of concept first proposed by Cajal and later Daniel and Posey-Daniel Neurotransmitter released from enteric motor neurones binds primarily to receptors expressed by (ICCs). Ward S M Gut 2000;47:iv40-iv43 Copyright © BMJ Publishing Group Ltd & British Society of Gastroenterology. All rights reserved. Molecular level 5-hydroxytryptamine (5-HT) <-gut distension Substance P excitatory CF constipation. Channel activators for treatment. Increased mast cells ?XS NO inhibits colonic motility in STC? Chloride drives fluid secretion into colon Lower substance P nerve fibre density in children with IND Nitric Oxide NO inhibitory ->local Ach -> muscle contraction upstream ->NO muscle relaxation downstream ? Primary or secondary to injury Progesterone reduces excittory Ach and 5HT Receptors overexpressed in women with STC Symptoms vary with menstrual cycle Ano-Rectum Stores faeces temporarily Continence maintained by Valves of Houston – rectum Freq of contraction distally Levator floor tone Rectopubalis sling – lifts weight of faeces Anus Internal sphincter relax w rectal distension External sphincter reflex contraction and voluntary relaxation Sensation touch, pin prick, temperature Defaecation Pressure threshold in sigmoid/descending colon Haustrations disappear Rectal filling and anal sampling Reduced angulation of ano-rectal canal (squat) Bolus moves lubricated by rectal mucus Reflex relaxation Internal anal sphincter Voluntary relaxation of ext anal sphincter Valsalva increases intra-abdominal intrarectal pressure Peristaltic cleaning wave follows bolus Dys-synergia Factors affecting activity Posture - CP Physical exercise – hypotonia Eating Psychological stimulus Osmotic material in duodenum Gastrocolic response – mass movt Emotion pain/stress – inconsistent handling/caregivers? Drugs Codeine, antacids, anticholinergics (oxybutinin) antipsychotics/antidepressants Bristol stool form chart Red flags Symptoms @birth - few weeks Meconium > 48 h after birth 'Ribbon' stool (usly <1 y) Abdominal distension with vomiting Weak legs or locomotor delay (falls > 1 y) Lower limb deformity or neurology vDTR Anus Fistula; bruising; fissures; tight or patulous; anteriorly placed; absent wink) Lumbosacral Asymmetric glutei, sacral agenesis, scoliosis, skin abnormality, sinus, central pit) Amber flags Faltering growth and well-being Possible maltreatment Causes - infants and toddlers History Genetic predisposition Breast feeding to cows’ milk formula Cows’ milk protein allergy Lack of fibre Stool withholding Retentive posturing Coeliac disease Examination Anal fissure Spina bifida Anorectal malformations Hirschsprung disease Causes – School and adolescent History Poor intake Toilet training coerced Attention-deficit disorders Developmental handicaps Toilet phobia, school bathroom avoidance Excessive anal interventions Examination Anorexia nervosa Depression Slow transit constipation Psycho-social history Family attitude and motivation Toilet training High stress environments Socioeconomic level Development Temperament Peer relations Physical environments School / home Sexual abuse Non-functional Hirschsprung Disease Drugs Cow's milk intolerance Celiac disease Intestinal neuronal dysplasia Anorectal malformations Megacystis microcolon intestinal hypoperistalsis syndrome MMIHS (Berdon syndrome) Chronic dysmolity / pseudo obstruction Autoimmune autonomic ganglionopathy Acetylcholine receptor AChR dysmotility Neuromuscular conditions Hypertonia CP Hypotonia Hypothyroidism Spinal dysraphism, tethered cord Prune-belly syndrome HypoK hyperCa Neuropathic/ Myopathic / mitochondrial Hirschprungs History 50% delayed meconium >36 hr Constipation week 1 of life Vomiting – bile Alternating constipation & diarrhoea Soiling rare Severe abdominal distension Failure to thrive Tight anus Explosive response to rectal exam Family history 1:5000 Short segment M5:F1 Long segment M=F Acute Infants change in diet Following bed rest Anal tears and fissures Rectal prolapse Treatment Increase fluids Chronic Constipation Soiling 70% Faecal loading Indentable masses Huge motions Lax anus Anal fissures Associated wetting Recurrent abdominal pain Retentive posturing Painful defecation Poor appetite & irritability Physical Examination Abdominal faeces Perineum location of anus halfway betw posterior fourchette (base of the scrotum) and tip of coccyx fissures, fistulae, or haemorrhoids anal wink and tone Lumbar Spine and lower limb neurology Rectal examination Neurogenic Bowel Spinal dysraphism Tethered cord Sacral Agenesis Vertebral deformities Spinal cord tumour Cord or nerve injury Franco 2008 Investigations None if thriving, eating and symptoms confined to anorectum Abdominal xray Lumbar spine Thyroid function Calcium Biopsy - rectal / large bowel Transit study for IND Running on Empty Explanation/education Empty Bowel Keep bowel empty Stool softener Stimulants Scheduled toileting Fibre fluids exercise Support Maintenance General Issues Develop relationship Reassure Encourage Support Empower Demystify diagnosis and causes They are not alone Develop treatment plan with child Be positive - spontaneous cure 15% pa Assess motivation Long term maintenance Toilet Routine Scheduled after meals Comfortable Footstool School toilets Positive Reinforcements – star chart, praise++, rewards No fuss/ nag / threat/ scold/ force/ tease/ leave in soiled pants Transfer responsibility Sneaky poo Regular evacuation Establish Daily routine < 24 h Avoid and treat constipation Empty bowel Praise & reinforcement with assistance Outreach nursing support Schedule with meals, baths, physical activities, time Potty 10-15 minutes, 20-30 minutes after a meal Knees higher than buttocks - footrest Cough or grunt for abdominal activity Digital stimulation, Wipe anus Levator lift with fingers to each side of anus Manage stool consistency – fibre H2O + laxatives Suppository / enema for routine To soften stool Chocolate / malt Kool-aid , fruit juice Candy Citrus fruit, tomato, passionfruit, pineapple Corn (fresh or tinned) Baked beans Pizza Nuts/dried fruit Disimpaction Prescriptions Bulk forming laxatives benefibre metamucil konsyl mucilax isogel etc Stool softeners and lubricants lactulose paraffin coloxyl Hyperosmotic cathartics Picoprep, Golytely, Movicol Magnesium Hydroxide 8% 1ml/kg (max 60ml) Stimulants Senna, Castor, bisacodyl (dulcolax), danthron (codalax) 5HT4 agonist Tegaserod (J Liem et al J Pediatr Gastro and Nutrition 46:54–58 # 2008 by European Society for Pediatric Gastroenterology,) Per Rectum Suppository Glycerol Fleet glycerine (glycerol) Fleet laxative (bisacodyl) Coloxyl sup (bisacodyl;docusate) Enema Microlax (Na citrate; Na lauryl sulfoacetate; sorbic acid; sorbitol) Fleet phosphate enema (Na phosphate) Coloxyl enema conc (docusate Na) Fleet micro- enema (Na citrate; Na lauryl sulfoacetate; sorbitol) Fleet phospho-soda buffered saline mixture (Na Phosphate) Colonic washouts Clean bowel 2–3 days Volume and hydrostatic pressure Saline/water; soap/water; other Reduce soiling Latex precautions Can contribute to dependency Retrograde 30 ml balloon catheter w large syringe Shandling catheter Peristeen anal irrigation kit Mic Bowel management Kit Antegrade continent enema (ACE) High degrees of satisfaction Improves independence esp for wheelchair dependent Sterile bowel – no smell Chait cecostomy button Malone (MACE) – continent appendicostomy Monti technique - donut of ileum/colon cecum or splenic flexure Anal plugs Prevents rectal leakage up 12 h Porous foam Lubricated with Vaseline Expands with moisture 30 sec Mushroom shape Removed with attached string Changed after toilet visit Increase independence Additional resources For healthcare professionals NICE Diagnosis and management of idiopathic childhood constipation in primary and secondary care. 2010. http://publications.nice.org.uk/constipation-in-children-and-young-peoplecg99 and www.nice.org.uk/CG99 NHS Evidence. Constipation in children. Management. www.cks.nhs.uk/constipation_in_children/management/scenario_diagnosis_ and_assessment_younger_than_1_year/view_full_scenario#467016006 For Families www.kidshealth.org.nz/constipation Continence Association NZ http://www.continence.org.nz ERIC http://www.eric.org.uk/Constipation/constipation_and_soiling One Step at a time for children with disability http://www.continencevictoria.org.au/sites/default/files/Booklet.pdf NHS choices www.nhs.uk/Conditions/Constipation/Pages/Treatment.aspx — Advice for families on constipation and treatment, incl lifestyle NICE http://guidance.nice.org.uk/CG99/PublicInfo/doc/English —Guideline for familiy on NICE guidance CG99 National Digestive Diseases Information Clearinghouse UShttp://digestive.niddk.nih.gov/ddiseases/pubs/constipationchild/ Childhood constipation Common 10-30% Associated incontinence 70% Essential aim - prevent pain with defecation Invasive investigations not routinely needed Refer if organic disease or review treatment Behavioural and social consequences Empty bowel and keep empty Maintain good habits