Paediatrics: Constipation and soiling

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.