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
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5-hydroxytryptamine (5-HT) <-gut distension
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Substance P excitatory
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CF constipation. Channel activators for treatment.
Increased mast cells
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?XS NO inhibits colonic motility in STC?
Chloride drives fluid secretion into colon
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Lower substance P nerve fibre density in children
with IND
Nitric Oxide NO inhibitory
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->local Ach -> muscle contraction upstream
->NO muscle relaxation downstream
? Primary or secondary to injury
Progesterone reduces excittory Ach and 5HT
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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
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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