Idiopathic constipation – the NICE way to assess and treat it

In Ireland, children with constipation commonly present to their general practitioner. According to Nicholson, up to 10% of children have experienced constipation. Constipation with faecal incontinence soiling occurs in 4% of pre-school children and 2% of school children.¹

There are a variety of definitions for constipation. It is usually associated with having infrequent bowel movements (usually less than three per week), hard dry stools which are sometimes small in size and are sometimes difficult to pass.² Idiopathic constipation cannot be explained by anatomical or physiological abnormalities. Between 90-95% of constipation is idiopathic. Of the rest there is an organic cause (see Table 1), which presents most frequently in the neonatal period. 

According to the National Institute for Health and Care Excellence (NICE) Guidelines 1: Constipation in children and young people, 2010,³ early identification of constipation and effective treatment can improve outcomes for children and young people. Without early diagnosis and treatment, an acute episode of constipation can lead to anal fissure and become chronic. By the time the child is seen they may be in a vicious cycle of painful defaecation, withholding behaviour and worsening constipation.

Audit

Historically, once a child has been referred to surgical outpatients for review they will be seen at a consultant’s clinic and have a detailed history taken and a physical examination performed. If a red flag has been identified further investigation is deemed necessary. The colorectal/ stoma clinical nurse specialist (CNS) will also be linked in with the child to provide support and education regarding constipation. The CNS will also provide the much needed follow up care.

Over the past few years we have noticed a steady rise in patients with constipation referred for further investigation. The majority of patients have been referred from tertiary centres.

In view of this we decided to carry out a retrospective audit of patient medical charts to look at what assessment tool (if any) was used in the initial outpatient visit and how many patients had ‘red flags’ identified that warranted further investigation. 

NICE guidelines 

We used the NICE guidelines as our gold standard to measure current practice in the assessment and management of these children.

NICE guidelines recommend the following:

History-taking to establish constipation (stool patterns and symptoms)

Identify ‘red flag’ and refer to experienced healthcare professional

Physical exam (anal, abdomen, lumbosacral/gluteal, gait and reflexes)

Disimpaction

Maintenance therapy

Provide information and support.

We studied a group of 45 patients that had been referred to the colorectal/stoma CNS service via the surgical outpatients department. These 45 patients included 24 were females, 21 males and they had a mean age of 8.2 years. We first looked at where the patients were referred from: 20 from a paediatrician in another hospital, 18 from GP, four from the emergency department and three from other consultants in the hospital. 

Of the 45 patients, 40 required hospital admission with varying lengths of stay; 10 stayed for longer than a week, 21 patients stayed for up to six days, and nine stayed as a day case.

We examined whether or not a full assessment was carried out in line with NICE guidelines recommendations. We found that although the patient had been assessed and examined, there was no format to the procedure. Some patients did not have a full history taken or complete physical examination performed. 

During admission to hospital a variety of investigations were performed. The purpose of these investigations was to rule out an underlying cause. The least invasive investigation used was the Plain Film of Abdomen (PFA). This helped to establish the degree of constipation and if a faecaloma is present as physical exam alone will not always give you this information. This is imperative in prescribing the correct treatment plan for the child. The NICE guidelines states that the PFA should only be requested by a specialist consultant.

Our most noteworthy finding in this audit is that 21 patients had a rectal biopsy under a general anaesthetic. The NICE guidelines³ suggest that a rectal biopsy should not be performed unless a red flag is identified. Of these 21 patients only five had a red flag identified.

A variety of medication was used to treat constipation. NICE recommends the use of macgrogol plus electrolytes (Movicol paediatric formula) as the first-line treatment for disimpaction and then to add a stimulant laxative if Movicol is not effective on its own.³ The majority of these patients had been treated at a local level by a GP or paediatrician and we found it was difficult to establish which medications and dose the children had tried already. All 40 patients admitted required disimpaction: 20 with oral medication and 20 with an olive oil retentive enema followed by phosphate enema. All patients were prescribed a combination of oral medications as maintenance treatment on discharge.

Follow up is vital part in the treatment of constipation. Close follow up by telephone and regularly scheduled hospital visits are essential. A multidisciplinary team approach is required for successful treatment and the child’s cooperation is the most important component.  Gradual improvements and occasional setbacks are to be expected. The majority of the 45 patients are still closely followed up in the hospital. Routinely the CNS will perform a weekly phone call to discuss progress with the parents and three-monthly OPD to see the consultant.

Child and parental education is essential. We have developed a booklet called The Poo Passport ⁴ to encompass the following:

Part 1

For use by doctor – these pages are removable and are to be placed in the child’s healthcare records

An assessment tool

Treatment plan, medication dosage and how to administer an olive oil enema

Part 2

Information for parent and child on normal bowel function, constipation, medication, fluids, fibre, exercise and toileting

Diary section for child and parent to complete daily. Here the child and parents can document daily fluid, fibre and medication intake, and also type of stool passed.

With appropriate treatment, close follow up and adjustments to medication, we have achieved great success in treating idiopathic constipation. However, there is no quick fix; treatment requires time and patience. Parents and children must understand the condition and that medication is necessary for a certain length of time, ie. until such time that a regular passage of a soft bowel motion is established. 

Medication should be reduced or discontinued only under the advice of a healthcare professional in order to avoid a relapse of constipation.¹

Children’s Continence Ireland 

Children’s Continence Ireland, which was founded in 2015, is an independent group of healthcare professionals and patient representatives working together to improve services and to promote best practice in children’s continence care. 

The aim of the group is to standardise and promote best practice for children with continence issues in Ireland. The group aims to identify areas for improvement and streamline information and documentation across Ireland and promote a clear pathway for children with continence issues. 

It is a multidisciplinary group; current members include paediatricians, clinical nurse specialists, continence advisors, public health nurses and physiotherapists. New members are always welcome, contact Ann Costigan, Email: childrens.continence@gmail.com

References

1. Nicholson A. Diagnosis and management of constipation in children. WIN 2013; 42-44
2. Heaton KW, Radvan H, Cripps H. Defecation, frequency and timing and stool form in the general population. A prospective study. Gut 1992; 33(6): 818-24
3. National Institute of Health and Care Excellent. Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. 2010; bit.ly/1zWt2FU
4. The Poo Passport – In the community from one year of age. (see http://www.olchc.ie/Children-Family/Parent-Patient-Information-leaflets/Poo-Passport-in-the-community-from-1-year-of-age-.pdf)