Presentation is loading. Please wait.

Presentation is loading. Please wait.

Constipation and Enuresis Katie Mallam Paediatric Update for Primary care 9 th October 2012.

Similar presentations


Presentation on theme: "Constipation and Enuresis Katie Mallam Paediatric Update for Primary care 9 th October 2012."— Presentation transcript:

1 Constipation and Enuresis Katie Mallam Paediatric Update for Primary care 9 th October 2012

2 Constipation – Why? Common –Prevalence 5-30% –1/3 become chronic (>8 weeks) = soiling Debilitating –Social, psychological and educational consequences Cost –Longer duration = longer, more intensive treatment Varying advice = angry parents

3 Standardise approach Early treatment –Reduce consequences and cost No need to remember history and examination: Constipation – NICE

4 Constipation? 2 of …….. Breast fed babies can go up to a week without opening bowels * *

5 Constipation?

6 Constipation? 2 of …….. Breast fed babies can go up to a week without opening bowels * *

7 Mostly idiopathic Rarely –Hirschsprung’s –Neurological NB lumbosacral abnormalities –Anorectal malformations –Hypothyroid –Coeliac –Cystic fibrosis (but normally diarrhoea due to fat malabsorption) –Cow’s milk protein intolerance Associations –Cerebral palsy –Autism –Down’s syndrome (NB beware hypothyroidism and Hirschsprung’s) Constipation – Causes

8 Constipation – History 1

9 Constipation – History 2 Faltering growth = treat and do coeliac and TFT (refer)

10 Constipation – Examination No PR in primary care NB perianal strep

11 Perianal streptococcal infection Swab Treat infection and constipation

12 Constipation – Examination No PR in primary care NB perianal strep

13 No need to remember history and examination: Constipation – It’s NICE < 1 year ≥ 1 year

14 Red (or amber) flags  Refer paeds No red flags  Reassure  Explain constipation and treatment (could just do briefly and give patient information using resources in ‘Explain 2’ slide)  Treat Constipation – Actions

15 Constipation – Explain 1 -Rectum gets used to being full: normal reflexes and power are reduced = ‘baggy’. -Reduced sensation and overflow: soiling is not intentional -Need to ‘get empty and stay empty’ for rectum to shrink back and recover reflexes and sensation: takes time

16 Tameside = comprehensive leaflet Patient.co.uk = very good, can print pdf leafletpdf leaflet ERIC = lots of info for professionals and parents/patients (age banded) NICE ‘template letter’‘template letter’ Constipation – Explain 2

17 Get empty, stay empty! Faecal impaction? –Soiling –Abdominal mass Movicol, movicol, movicol! –NB different strengths e.g. Paed Plain = no taste ‘Softeners’ –Movicol, Lactulose, Docusate (also squeezes) ‘Squeezers’ –Senna, sodium picosulphate, bisacodyl Doses as per BNFc or NICE Constipation – Treat

18 Disimpaction –Aiming for liquid and no more lumps = messy –Review after 1 week  Movicol  If not tolerated = stimulant laxative +/- lactulose  If not worked after 2 weeks = add stimulant laxative and urgently refer to Paeds Enemas and manual evacuation only if all else failed Constipation – Get empty

19 Maintenance –Until rectum no longer stretched and reflexes return –Laxatives do not make bowel lazy: may need for several years and should be gradually reduced  Movicol  If not tolerated = stimulant +/- lactulose, or docusate alone  If not effective = add stimulant Constipation – Stay empty 1

20 Behavioural –Non-punitive (I say ‘training the subconscious’) –Regular toileting after meals –Foot support, sit forward (rock and pop!), bubbles, books –Diary and rewards (things under their control) –NB school (NB ERIC info) –Use school nurses and HV Constipation – Stay empty 2

21 Constipation – Stay empty 3 Fluids Page 15, NICE Quick Reference Guide

22 Diet –High Fibre = fruit, veg, high fibre bread, wholegrain breakfast cereals, baked beans Activity Constipation – Stay empty 4

23 Disimpaction has failed if not responded to Movicol after 2 weeks:  Urgent referral to Paeds (or Bladder and Bowel Specialist Nurse) Maintenance has failed: –In those aged <1 year, if not responded after 4 weeks  Refer paeds –In those aged ≥ 1 year, if not responded after 3 months  Check no red flags  If red flags = refer paeds  No red flags = refer to the Bladder and Bowel Specialist Nurse Service Constipation – Failed treatment

24 RED FLAGS, refer paeds –History and examination questionnaires –Bristol Stool ChartBristol Stool Chart EXPLAIN: Tameside leafletTameside leaflet IMPACTED? GET EMPTY, STAY EMPTY! –Medical: usually Movicol Paed Plain as per BNFc –Non Medical: see Tameside leaflet and fluid rqmts on page 15 of NICE If fails, add stimulant –Disimpaction failure, refer paeds –Maintenance failure, refer Bladder and Bowel Specialist Nurse Constipation Toolkit

25 Incontinence –uncontrollable leakage of urine Enuresis –Incontinence of urine when sleeping: usually say Nocturnal –Bedwetting: ‘involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology’ (NICE) Primary Secondary = previously dry for ≥ 6 months Enuresis - definitions

26 Secondary (especially recent): –UTI –Diabetes (drinking overnight) –Constipation –Neurological: spine and lower limb exam –Emotional/behavioural difficulties: consider psychology Urinary Incontinence – History 1 Urine dipstick NB same day referral if suspect diabetes

27 Pattern of bedwetting –Variable volume, >1 per night: could be Overactive Bladder Daytime symptoms –Urgency, Frequency >7/day, Infrequent <4/day, straining, pain –Consider UTI, Overactive Bladder, Neuro/Uro cause –Urine dipstick –If significant, refer to consider investigation/treatment of those symptoms first Toileting patterns –NB School Fluid intake –Check not restricting Urinary Incontinence – History 2 Diary

28 Effect on child/YP/family –Social (sleep-over), self-esteem PMHx: –UTI –Developmental, attention or learning difficulties: consider specific management Urinary Incontinence – History 3

29 Primary Nocturnal: not required according to NICE Secondary Nocturnal or Daytime Symptoms: –Genitalia –Abdomen –Spine –Lower limb neuro Urinary Incontinence – Examination

30 RED FLAGS = recurrent UTI, Diabetes, examination abnormalities:  refer paeds No red flags –Nocturnal only:  refer HV or school nurse –Day only, or Nocturnal with daytime symptoms:  refer to Bladder and Bowel Specialist Nurse Urinary Incontinence – Referral

31 Principles of Care –Not their fault: non-punitive management –Tailor management to child/YP and parent/carer –Consider parental support –Do not exclude <7y Reassure Enuresis – NICE

32 Enuresis Prevalence Age< 2 per week≥ 2 per week 4.5y21%8% 9.5y8%1.5%

33 Principles of Care –Not their fault: non-punitive management –Tailor management to child/YP and parent/carer –Consider parental support –Do not exclude <7y Reassure Trial of BASICS <5y: encourage toilet training if not done already and trial out of nappies at night Enuresis – NICE

34 Enuresis – Management BASICS! Fluids: avoid caffeinated (and ?fizzy and blackcurrant) Regular toileting 4-7/day NB double voiding if Overactive Bladder symptoms Trial out of nappies/pull-ups: offer alternatives Reward system: for agreed behaviour (not dryness)

35 NHS choices: concise, for parents tion.aspx tion.aspx Patient.co.uk: concise, for parents ERIC: all ages, parents, professionals Enuresis – Information

36 High long-term success rate (weeks) But need commitment and can disrupt sleep Contraindications: –< 1-2 wet nights/week –Parental distress or negativity (consider parental support) Need training –Hence referral to HV/school nurse –http://www.patient.co.uk/health/Bedwetting-Alarms.htmhttp://www.patient.co.uk/health/Bedwetting-Alarms.htm Encourage to combine with reward system –Get up and go to toilet, help change sheets Enuresis – Alarm

37

38 Enuresis – Desmopressin Rapid, short-term results (sleep-over) Alarm is inappropriate or undesirable Inform them: –many relapse when treatment is withdrawn –how desmopressin works –fluid restriction from 1 hour before until 8 hours after taking desmopressin –that it should be taken at bedtime –how to increase the dose if the response to the starting dose is not adequate –that treatment should be continued for 3 months –that repeated courses can be used –Stop during sickle cell crises or D&V bedwetting/

39

40 Only on advice of specialist Anticholinergic with desmopressin –Oxybutinin –If: Not responded to desmo+/-alarm Daytime symptoms Imipramine –Gradual increase and withdrawal –Warn re dangers of OD leaflet/http://www.medicinesforchildren.org.uk/search-for-a- leaflet/ Enuresis – Other treatments

41 Secondary: think other causes esp Diabetes Examine if Secondary or Daytime Refer all? –Red flags = paeds –Others = HV/school nurse/BBSN Basics Give/direct to information Urinary Incontinence – Top tips


Download ppt "Constipation and Enuresis Katie Mallam Paediatric Update for Primary care 9 th October 2012."

Similar presentations


Ads by Google