Constipation and Faecal Soiling Continence Advisory Service : Bobbie Jones Gill Prior Jane Dickson

Bowel Function

Normal Bowel control First year – reflex activity • Second year – gradual awareness of need to empty bowel • Third year – ability to defer bowel opening • Fourth year – ability to delay bowel opening, and to defecate voluntarily

Normal Bowel Function 16 weeks – average of 2 stools / day 99% of babies pass meconium within the first 48hrs of birth 16 weeks – average of 2 stools / day Weaning results in a firmer stool Range of 1-3 / day to 2-3 / week Soft and easy to pass

Faeces moves into the sigmoid colon and previously empty rectum Defecation occurs Holding on

Common Bowel Problems Constipation: Slow Transit Constipation: Defined as the infrequent passage of hard stools that is difficult to pass. The passing of stools may be painful and less frequent than is normal for that child Slow Transit Constipation: Slower than average movement of stool throughout the large bowel.  Faecal Soiling The repeated passage of stools, whether involuntary or intentional in a socially unacceptable place in a child over 4 years of age (or equivalent developmental age).

Contributing factors of constipation Reduced fluid intake Reduced fibre intake Reduced exercise Holding on/ ignoring the urge – often initiated by passing of large/painful stool

Contributing factors of constipation Missed training opportunity Delay in passage of normal stool Anal Fissure Toileting phobias or fear Child abuse

Functional faecal retention usually associated with soiling follows from ‘holding on’ unless managed appropriately child ‘forgets’ mechanics of normal defecation May require long term treatment and follow up

Constipation – Signs and Symptoms Symptoms of increasing faecal loading Abdominal distention and pain Irritability Anorexia Faecal Soiling

Slow transit constipation - Signs and Symptoms Large soft stools Frequency 3 per week to 1 per 3 weeks Abdominal distention High incidence of faecal incontinence Symptoms of  severe constipation within a year

Assessment Check for: daytime urinary problems nocturnal enuresis appetite / fibre intake fluid intake - how much milk? any medical problems any current medication

Red Flags ‘Red flag’ symptoms include: More than 48 hours before passing meconium as a neonate Abdominal distension especially if failing to thrive Infrequent small or ribbon stools Constant leaking especially if linked with urinary leaking too Failed management with appropriate standard intervention (with compliance)

Communication able to indicate what is happening – (not necessarily verbal) language used for toileting can be unique to each family

Mobility Get to the toilet Remove clothing Get up onto the toilet Wipe bottom Replace clothing Wash hands

Social Be able to follow instructions Have the ability to communicate Wish to please parents/carers Want to be like their peers

Environmental issues School toilets Toilet accessibility Peer pressure Clothing Lack of privacy Attitudes of others

Treatment Goals To establish regular bowel habits To reduce stool retention To restore normal control over bowel function To reduce concerns within the family To help reduce conflict within the family

Treatment – Constipation Education Proposed course of treatment Normal variation in bowel habits Symptoms may get worse initially Evacuation (if required) Disimpaction with oral laxatives and enemas

Movicol Maintenance Regime Increase Movicol Dose Maintain Decrease Stop taking Movicol for a day or two

Impaction Regime Children (2 – 11 years): A course of MOVICOL-Half (OR half adult MOVICOL dose) is for up to 7 days as follows:   Number of MOVICOL-Half Sachets Age (years) Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 2 – 4 2 (1) 4 (2) 6 (3) 8 (4) 5 - 11 10 (5) 12 (6)

Treatment – Constipation Maintenance Medication may be required for 6-12 months, even longer. Increase fibre and fluid intake Increase activity in the child

Treatment – Slow Transit Constipation Remove obstruction Fibre supplement – initially Laxatives Antegrade Colonic Enema Colectomy

Treatment Plan Overview Ensure adequate fluid intake Ensure balanced diet with adequate amounts of fibre Encourage regular toileting – minute sits Encourage correct toileting position Consider environmental factors e.g. access to school toilets Management strategies Refer to health care professional