This site is intended for healthcare professionals.

Header Ads

Header Ads

Constipation in children- Management

x

Constipation in children- Management

h

A brief overview of the current management of functional constipation in children.

FAECAL 
IMPACTION TREAT WITH MACROGOL 1ST LINE AND THEN C/O MAINTENANCE THERAPY

Faecal impaction is defined as a hard mass in the lower abdomen identified on physical examination or a dilated rectum filled with a large amount of stool on rectal examination or excessive stool in the distal colon on abdominal radiography NICE recommends to use a combination of history and physical examination to diagnose to diagnose faecal impaction -take note of overflow soiling and / or faecal mass palpable abdominally and / or rectally if indicated 30-75 % of constipated children suffer with impaction More than 90 % of children with faecal incontinence also suffer with impaction Treatment of impaction may initially increase the symptoms of soiling and abdominal pain – forewarn about this and ensure that the child has easy access to a toilet

Maintenance therapy- Start promptly Usual agents used for maintenance dose include osmotic laxatives , lubricants and stimulants NICE recommends a macrogol ( Movicol® Paediatric Plain or Movicol® ) first line
Evidence supports use of PEG – more effective compared with lactulose , milk of magnesia , mineral oil or placebo Dosing
◘ use escalating dose regimen based on response
◘ use effective dose and adjust as required
◘ if disimpaction regimen had to be used – usual maintenance dose is 1/2 of the disimpaction dose
◘ if diarrhoea happens – reduce dose Senna – can be added to regular macrogol treatment if constipation persists despite optimum dose use If macrogol cannot be tolerated use stimulant laxative as Senna For hard stools consider combining with lactulose or a stool softener like docusate Duration of treatment- is not clear
◘ CKS quotes -” continue effective dose of laxative (s) for atleast several weeks after regular bowel movements
 are established “. No duration is mentioned but it goes on to advice that this may take several months
◘ Paper (4) advice’s that maintenance therapy should continue for atleast 2 months , and all constipation symptoms should be resolved for a min of 1 month before changing the medication regimen How to stop – most literature recommends a slow decrease
◘ no ideal guidance on how to taper
◘ CKS mentions – arrange f/u to advice on gradually reducing and stopping laxatives
◘ a safe and accepted approach would be to decrease the treatment gradually


Education
Lifestyle
Behavioral support
& Follow up- NICE recommends
○ balanced diet with sufficient fibre ( children who have been weaned )
○ adequate physical activity
○ fluid intake to normal levels Scheduled toileting Bowel habit diary and using Bristol Stool Form Scale Reward- start chart ESPGHAN and NASPGHAN document states
○ evidence does not support the use of extra fluid intake in treatment of functional constipation
○ no trials to evaluate the effect of ↑ ed physical activity in childhood constipation
○ probiotics- no evidence to support use of pre-or postbiotics
○ no evidence to support use of behavioral therapy or biofeedback

Arrange f/u to check response , compliance and to address any concerns that the parent may have How often and how soon to arrange f/u – no guidance exists use clinical judgement Most parents would be concerned about safety of laxatives in long term use – explain
○ growing evidence to support the efficacy and safety of PEG 3350 in maintenance treatment
○ senna is safe in long term use- advise about rare SE of skin blistering 
( change diaper frequently in children who are not toilet trained -ref 5 ) Re-enforce and advice about duration of treatment and suggest not to stop treatment abruptly

Referral and prognosis

Persistent faecal impaction despite optimal Rx- admit Refer if a serious underlying cause suspected ( see red/ amber flags ) No response to maintenance treatment
○ < 1 yrs- refer after 4 wks to r/o for e.g Hirschsprungs or other serious cause
○ > 1yr and no response after 3 months Constipation – accounts for up to 25 % of referral to tertiary gastroenterology paediatric clinics

Early treatment improves outcome Among children who are referred -
- 50 % will recover and be without laxatives after 6-12 months of treatment
- 10 % are well while taking laxatives
- 40 % will be symptomatic despite taking laxatives Risk of constipation recurrence is 50 % Treatment failure in up to 20 % As many as 25-50 % of children will remain constipated into early adulthood

Links and resources

ERIC is the bladder and bowel charity for children https://www.eric.org.uk/pages/category/bowel-problems

BBUK is another very handy resource and offers a helpline- National Confidential Bladder and Bowel UK Helpline https://www.bbuk.org.uk/children-young-people/children-bowel/

GI Kids is the NAPSGHAN Foundation providing an invaluable resource for parents https://gikids.org/

NICE guidance on constipation in children and young people –https://www.nice.org.uk/Guidance/CG99

The Association of UK Dietitians has written information factsheets https://www.bda.uk.com/foodfacts/home#babies

Mother and baby website has some useful practical tips for parents https://www.motherandbaby.co.uk/baby-and-toddler/toddler/looking-after-your-toddler/toddler-constipation

 

References CKS NHS Constipation in children – revised June 2019 Evaluation and Treatment of Functional Constipation in Infants and Children : Evidence-Based Recommendations from ESPGHAN and NASPGHAN M.M. Tabbers et al JPGN. Volume 58 , Number 2, February 2014 Constipation in children and young people : diagnosis and management NICE CG 99 May 2010 Management of Childhood Functional Constipation Lisa Philichi, MN, CPNP National Association of Paediatric Nurse Practitioners 2017 Are Senna based laxatives safe when used as long term treatment for constipation in children ? Alejandra Vilanova-Sanchez et al Journal of Pediatric Surgery ( Abstract ) Volume 53 , Issue 4 , April 2018 , Pages 722-727 Management of chronic constipation in children Lucy J Howarth et al Paediatrics and Child Health 26:10

 

 

Related Topics

Comments - to make a comment on the above chart please log in.


Register

START TYPING AND PRESS ENTER TO SEARCH