Constipation and Poo Problems in Children

This resource provides insightful information on constipation and related issues in children, including causes, symptoms, treatments, and the impact on bowel and bladder health. It covers various topics such as bowel actions, medications, normal bowel function, and the significance of recognizing and addressing constipation in children. The content emphasizes the importance of identifying and managing constipation effectively to prevent long-term complications.

• Childrens Health
• Constipation
• Bowel Problems
• Bladder Health
• Pediatric Care

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1. Constipation and poo problems Fiona Boorman The Children s Bowel & Bladder Charity

2. Poo & constipation how it works Explain it with knitted bowel.....normal inc. function/gut biome, sampling -gas or solid. stretch receptors, peristalsis, ano-rectal sling/position, reabsorption- 2nd hand poo water Constipation, effect on bladder,day and night UTI, stool-holding, reduced sensation to bowel/bladder. Bowel may not fully recover hhhhhhh The Children s Bowel & Bladder Charity

3. Medications taken- (IMPORTANT as some contributingto constipation) Pain relief- ines Anti-muscinarics/anti-cholinergics Iron Diarrhoea treatments, kaolin, loperamide Antacids e.g.Gaviscon Muscle relaxants e.g.Baclofen Antispasmodics e.g.Buscopan Tricyclic antidepressants Glycopyronnium Bromide ...plus more. hhhhhhh The Children s Bowel & Bladder Charity

4. Frequency of bowel actions and type How often is normal? What should poo look, feel and smell like? (Use POO DIARY,for 2 weeks before first appointment.) Babies For information on managing 'Breast fed babies' download ERIC leaflet of that name (infant dyschezia)up to 9 months, poor coordination intra-ab pressure and pelvic floor hhhhhhh What is constipation? The Children s Bowel & Bladder Charity

5. Constipation-what is it? Always ask!! Constipation- what is it? ROME III Criteria(2006) ROME IV (2016) R Must include 2 of the following in the last 3 months Less than 3 poos per week Poo is lumpy or hard 1 episode of soiling per week History of retentive posturing Faecal mass in abdomen History of large diameter stools. (Bog blockers) (International agreement on classification of G.I disorders.OME III Criteria ..Must include The Children s Bowel & Bladder Charity 5

6. Constipation Causes........ (NICE 2010 ) Don t attribute to life style. Always treat! IDIOPATHIC- No organic cause DEHYDRATION- Poor drinking more of a problem than diet....think about tube fed too. STOOL HOLDING usually starts with viral illness+ temperature+ poor fluid intake =hard poo. -leading to anal fissure. Or nappy rash=sore bottom=holding on, poo dries out more=hard, painful poo, more holding. OTHER PROBLEMS. Downs Syndrome, Cerebral Palsy, Hypermobility. ASD FAMILIAL. Family Gut/ family habits/family normal ? The Children s Bowel & Bladder Charity

7. Frequency of bowel action and type Frequency Adults 3 per day to 3 per week Children minimum-alternate days Type. 1-3 treat (1,2 more aggressively) 4 perfect 5-6 Being treated? Fruit? 'normal'for breast fed or toddlers diarrhoea 7 Tummy bug? if not 'ill', overflow or overtreatment. Consider colour, how digested. hhhhhhh Overflow poo- Sticky and offensive, The Children s Bowel & Bladder Charity

8. Any soiling, amount? Make sure we are talking about same thing! Is child aware before? i.e. hides after? denial (how have carers reacted?) Soaking box-dont need to hide pants Where? Only at home? they have some control. Encopresis- Are they saying something?(normal stool, wrong place, empty rectum). Smudge Is it just wiping? partial poo? Resisting impulse, tortoises head! HOLDING. Thinking about child wearing protection, is it permission to use it? Is it parental or childs' anxiety? WIPING ability, test, 'hand over hand' ,wet wipes, encourage independence, reward. hhhhhhh The Children s Bowel & Bladder Charity

9. Does the child use the potty/toilet/neither? Are they a failed toilet training? or family that doesnt 'do' TT. Does child have problem with facilities? Lack of sensation( constipation)/denial/refusal, unpick the issues Regular toileting programme. When (20-30 mins after meal/snack/school/bath?) How long for? Equipment, seat/stool, blowing things (why) Attitude Reward Consistency hhhhhhh The Children s Bowel & Bladder Charity

10. Large girth stools (over 2 inch diameter in adults) A lot of poo is accumulated before stretch receptors activated, or child resists as long as possible. Bowel so overstretched-reduced sensation,reduced tone unlikely to resolve completely. Suggests previous or current constipation, with/without holding. Keep poo soft and regular sit/blow Small stools If hard, constipation If ribbon-like, consider stricture, polyps, hirschsprungs or poor fibre. Abnormal stools What should you see in them? Malabsorption? Fail to thrive? Referral to Paediatrician? hhhhhhh The Children s Bowel & Bladder Charity

11. Abdominal pain, distension,pain on defaection Teach abdo pain=go for a poo, part of normal toilet training Resistance can cause pain! Distension can be poo or gas (methane)leading to farting, bad breath, faltering learning, anorexia. hhhhhhh Pain on defaecation- Sheer size Fissure (skin tag suggests previous) Sore bottom, rash, strep or thrush. The Children s Bowel & Bladder Charity

12. Red Flags Which are red flags? Anorexia, nausea, vomiting and faltering growth-signs of obstruction.Can be obstruction due to constipation or physical problem eg Hirschsprungs Urgent GP/Paediatrician appointment hhhhhhh Safeguarding concerns? discuss, refer. The Children s Bowel & Bladder Charity

13. Associated behaviours Night poos Atypical after night feeds finish, may suggest stool- holding. Straining, all fuss no action? BLOWING is better! Stool witholding/toilet avoidance/only in nappy Usually assoc. with previous constipation, ASD, Control, fear, history. Better in nappy than not! (J Rodgers leaflet- Child who will only....B&BUK) hhhhhhh Smearing- Type A Type B The Children s Bowel & Bladder Charity

14. Has child been seen by GP or qualified other? (No DRE thanks) Before starting treatments may get child checked for...... Spinal anomaly (agenesis, SB occulta, lipoma) neuropathics probably limited chance of continence. Abdo check (may not show constipation, still treat if history recommends) Anal area for debris,rash, tags, fissures. Blood in stools? Reflexes if child ataxic. hhhhhhh Ano-rectal anomaly and hirschsprungs more prevalent in Downs. The Children s Bowel & Bladder Charity

15. When to treat? If faecal impaction ASAP! Suitable time? Small amount of Macrogol increases soiling.Parents lose heart! Children only need to have a couple of symptoms to have constipation, so treat rather than 'wait and see'. hhhhhhh Treatment unlikely to harm, non treatment will! The Children s Bowel & Bladder Charity

16. Educate everyone! Share your knowledge, it may help many others!! Child is NOT to blame, get a bowel! to explain sensation loss..,time off school, pads if needed. Kids can access ERIC. Patience-Macrogol more inhaler than antibiotic (25% off after 6 months) hhhhhhh NICE Guidelines Constipation in children and young people CG99 The Children s Bowel & Bladder Charity

17. DISIMPACTION ERIC Parents guide to disimpaction https://www.eric.org.uk/pdf-a-parents-guide-to-disimpaction If your child has been constipated for more than a few days your doctor or nurse may say that they need to follow a disimpaction regime. This means giving laxatives in sufficiently large quantities to clear out all the accumulated poo. It is important to follow their advice; if you give a standard dose of laxative it is likely to soften the poo but not stimulate the bowel to empty fully. This means that symptoms such as soiling may get worse rather than better! hhhhhhh NICE Guidelines Constipation in Children and Young People (CG99) recommend disimpacting with paediatric macrogol sachets as follows: The Children s Bowel & Bladder Charity

18. How to prepare Macrogols (Movicol, CosmoCol and Laxido are all names of macrogols) How to prepare macrogol laxatives can be a stumbling block for some parents, so we've created this factsheet to explain how to mix them correctly. Macrogol laxatives work by binding with water and delivering it to the large bowel. It is therefore essential to mix it with the correct amount of water or it will not work! Paediatric sachets should be mixed with at least 63mls water PER SACHET Adult sachets should be mixed with at least 125mls water PER SACHET Empty the sachet of powder into a cup/glass/bottle. First add the right amount of water and stir until the powder has dissolved and the water is clear. The resultant liquid can be mixed with anything your child likes, to encourage them to drink it, e.g. squash, juice, hot chocolate, milk. Do not mix the powder straight into the milk/juice/flavoured drink it needs to bind with the water first. Tips Formula fed babies. Mix the macrogol with 63mls previously boiled water per sachet. Top up to the right volume of water for the baby s feed and add the formula powder. Mix well. If your child does not like the taste, try mixing the macrogol earlier and chill it in the fridge it will last 6 hours after mixing (Laxido) or 24 hours (CosmoCol and Movicol). Try a flavoured macrogol, e.g. Movicol Chocolate, Orange/lemon/lime CosmoCol. hhhhhhh The Children s Bowel & Bladder Charity

19. Post Disimpaction NEVER treat constipation with lifestyle changes, they come after. Maintenance dose of medication, only very slow reduction. 6-8 good drinks per day, less milk. Explain 'secondhand poo water' Increase fibre, veg, fruit, whole grains,oats, for WHOLE family. pre mix baby milk has natural lactulose. More exercise. e.g. trampoline, walking, dancing. hhhhhhh Follow up, parents to learn to spot signs of return of constipation, less poo, pain, size/type, behaviour- ask GP to keep meds on repeat for sometime as relapse common. The Children s Bowel & Bladder Charity

20. Food intolerances and allergies Number rising....cows milk allergy more common in those.... born by caesarian living in urban environments had early antibiotics who have atopic parents gives constipation or sloppy poo. Ref. to Paediatrician or dietician, see local advice. Currently babies given Nutramigen. Anti histamines may be used, ADVICE is currently to re- challenge. Toddler Diarrhoea-more than 4 + loose stools for 4 weeks +,no FTT, increase fat reduce fibre and fruit/juice, try probiotics (no proof), food diary. Loose stools, investigate, if Loperamide used be cautious ,opiate, use short term, reduce slowly. Wheat intolerance, encourage alternatives, refer on. hhhhhhh The Children s Bowel & Bladder Charity

21. If Macrogol alone is not enough Lactulose (only useful if child well hydrated- most constipated kids arent!) Stimulants- Bisacodyl tabs, Sodium Picosulfate syrup, Senna Suppositories- Bisacodyl, Glycerine or Lecicarbon C hhhhhhh Enema- Microlax, Fletchers Bowel washouts, Qufora, Peristeen and more ACE TENS Colostomy, land of last resort! The Children s Bowel & Bladder Charity