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Chapter: Paediatrics: Community child health

Paediatrics: Constipation and soiling

This is a common problem in childhood.1 Critical periods occur around the time of infant weaning, toilet training, and starting school. Constipation may follow a period of dehydration leading to hard stools that become painful to pass.

Constipation and soiling

 

This is a common problem in childhood.1 Critical periods occur around the time of infant weaning, toilet training, and starting school. Constipation may follow a period of dehydration leading to hard stools that become painful to pass. The child therefore holds on to stool. Secondary soiling (overflow) is common and leads to anxiety at school that may lead to school refusal. It is important to review the past medical history for pos-sible underlying reasons and causes of constipation.

 

Taking the history

 

Find out when problem first arose. In infants ask about:

   Delay in passage of meconium

 

   Abdominal distension in early infancy

 

   Explosive stools

 

These are possible indicators of underlying HSD or short segment bowel

Also ask about:

   Possible precipitants

 

   Current diet and fluid intake

 

   Psychological factors

 

   coercive or chaotic toilet training

   fear of toilet

   parental neglect/discord /illness

   environmental stressors

 

 

Examination and investigations

 

Examination

 

   Inspect anus for:

   fissures

   infection

   skin disease—excoriation/fistula

   dilatation

   Palpate abdomen

 

·  General examination of child including growth: rarely presentation of hypothyroidism

 

Investigations

 

·  AXR (to demonstrate faecal loading)—not routinely needed for diagnosis

·  Bloods:

 

   FBC

   TFT

Management

 

Throughout this time parents and child will need considerable support from the nursing team (i.e. health visitor/school nurse/specialist nurse).

 

 

Short-term constipation with no soiling

Soften retained stool, e.g. oral Movicol®, lactulose or docusate.

Colonic stimulant orally, e.g. oral senna. Continue until bowel pattern regular and then decrease.

 

Long-term and soiling

 

Soften retained stools for at least a week, e.g. lactulose/ docusate/ Movicol®).

Oral colonic stimulant, e.g. senna, single daily dose until stool passed.

If no stool passed consider using:

   oral bowel evacuation preparation;

   enema;

   manual evacuation as a last resort (necessary if evidence of impaction).

 

Maintenance treatment

 

Increase dietary fibre and fluid.

 

Regular bulk laxative.

 

Regular colonic stimulant.

 

·Persist with medication for at least 6mths.

 

·Behaviour management may be needed to establish toilet routine.

 

Assessment by a clinical psychologist and family therapist if there is a degree of family discord.

In resistant cases treatment will need to be continued for longer.

 

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Paediatrics: Community child health : Paediatrics: Constipation and soiling |


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