The following is an extract of Prof Candy and Dr Paul's review of the best practice methods and treatments for childhood constipation from the September/October edition of Journal of Family Health Care - to read the article in full subscribe here.
Constipation is one of the commonest childhood conditions and can be defined as difficulty, delay or pain during defecation. It is also one of the commonest reasons for consultation with a health professional and referral to the secondary care during childhood.
Available statistics shows that constipation can account for three to five per cent of general paediatric outpatient visits and up to 25 per cent of paediatric gastroenterology consultations. It has a prevalence of around five to 30 per cent in children, although this depends on the criteria used for the diagnosis. The symptoms can become chronic in more than a third of patients, and a third of these may have problems persisting beyond puberty.
Similar prevalence rates are found in both sexes. Health professionals may be dealing with the "tip of the iceberg", as true morbidity may go under-reported as some parents or older children do not seek advice as they feel embarrassed. Families may also not seek help as they fear a negative response from healthcare professionals. However, it is vital that when health visitors and community practitioners are consulted by parents a detailed history of symptoms is taken before any treatment starts. It is also worth noting that some children may also present with symptoms, such as urinary incontinence, which are subsequently shown to be due to constipation.
According to the Rome III Childhood/Adolescent Committee Diagnostic Criteria for Functional Constipation for a correct diagnosis of constipation two or more of the following should be present in a child with a developmental age of at least four years at least once a week for two months:
1. ≤ 2 defecations in the toilet per week
2. At least one episode of faecal incontinence per week
3. History of retentive posturing or excessive volitional stool retention
4. History of painful or hard bowel movements
5. Presence of a large faecal mass in the rectum
6. History of large diameter stools that may obstruct the toilet (often
described as "loo blockers")
Treatment is primarily aimed at disimpaction of faeces and restoration of regular bowel habits, which consist of passage of soft, normal stools without discomfort at least once every three days and in appropriate places.
Maintenance therapy can be started in children who do not have faecal impaction. There are three main oral therapies used in the outpatient management of children with constipation:
i) Macrogols: polyethylene glycol 3350 + electrolytes (Movicol)
ii) Osmotic laxatives: lactulose
iii) Stimulant laxatives: sodium picosulfate, bisacodyl, senna, docusate sodium.
The majority of the children with idiopathic constipation do not suffer any long-term morbidity. The prevalence of chronic constipation in childhood is estimated between one to five per cent in the UK and USA. In most cases no obvious etiological factors are found. In 30 per cent of cases it can persist to continue beyond puberty. Children aged two to four years were found to have a higher rate of recurrence, and therefore may need a prolonged course of medication.
A follow-up study has noted increased risk of persistent constipation in children who developed constipation early in infancy and who have a family history of constipation. Another follow-up study, which assessed the clinical course of severe functional constipation in early childhood, found that after initial successful treatment, a relapse occurred in 15 per cent of children within three years.
A long term follow-up study from the Netherlands involving 401 children between the ages of five to 18 years with idiopathic constipation found the following factors were associated with poor clinical outcomes in adulthood: older age at onset, longer delay between onset of symptoms and first presentation to the outpatient clinic, and lower frequency of defecation at study entry. It is suggested that a symptom duration of ≤ 3 months at referral is associated with a better outcome.
Role of community practitioners
Health visitors and other primary care workers can play a vital role in detecting and managing children with constipation. A holistic approach is necessary in managing these children and supporting the families, as the medical aspects may just be only one aspect and unless the other issues are addressed the treatment may remain unsuccessful. Health visitors can provide support and help by ensuring that:
●● There is an early detection of children with constipation (especially those with a strong family history)
●● Children with red flag symptoms are identified and referred to paediatric services at the earliest opportunity
●● Parents understand how to administer the medications and are given explanatory written information to accompany this.
●● The parents take the child for consultations and have access to a regular supply of medication
●● Guidance is given on a healthy balanced diet and regular exercise
●● Other issues, such as the child's behaviour, family disputes, child neglect, etc, are appropriately addressed
●● Children who soil are not inappropriately sent home from nursery or school, thus hampering their education
●● In recurrent failed treatment scenarios, it may be necessary to take monitory steps to ensure that the child is actually given the medicines on a regular basis.
Health visitors can play a significant role in the overall management of this chronic and often debilitating condition. Families may need lot of support and
explanation about how the laxative therapy works on the bowel to prevent inappropriate and early discontinuation of the therapy. The NICE guidelines, published in 2010, are a valuable resource for the health professionals, by providing guidance in dealing with different nonmedical aspects of idiopathic constipation.
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