Constipation cases are more frequent to paediatricians than of any other illness. It has severe health resource implications and the prevalence of constipation among the children ranges from 4-35%. American studies have revealed that the average cost of constipation cases among the children is about $3.9 billion per year. This report basically aims to highlight the precautionary measures and the NICE guidelines (National Institute of clinical Excellence) on constipation. It provides an insight on the importance of improving the toileting habits or consuming more fibres and laxatives. With a more profound patient and parental understanding, there exists a potential to deliver a positive benefit to the children who suffer from this problem.
ROME III classification has defined functional constipation as two or more of the following features in a developing child who is less than 4 years of age and the symptoms occur once every week (at least) and continue for two or more than two months. The features can be faecal incontinence per week at least once, large diameter stools that may in some case obstruct the toilet, two or less than two defaecations per week, presence of a large faecal mass in the rectum, any signs of hard or painful bowel movements or history of excessive volitional stool retention or retentive posturing. The Paris concensus on Childhood constipation Terminology group (PACCT) has defined non retentive faecal soiling as passage of the stools in an unappropriate place and occurring in children below 4 years of age (Benninga M, Candy DC. Et al. 2005). The major symptom of constipation is the infrequent stools or reduction in the bowel movement. If infrequent stools was the only criteria for diagnosis then 50% of the true cases would be missed completely. Therefore, another symptom is pain. Children may complain of pain when they pass out stools. This pain generally occurs in the abdomen while defaecation. In some cases even blood may be passed along with the stools (Loening-Baucke V. 2007). Next is soiling or faecal incontinence. It contributes to the diagnosis in almost 90% of the cases (Loening-Baucke V. 2007). It is involuntary and often stains the underwear. If it occurs in larger amount it can be mistaken to be diarrhoea.some children have the habit of straining their muscles to withdraw their stools. They try techniques to prevent the anal to relax. Such habits also lead to constipation and the children with such habits are generally found standing stiffly in a corner or squatting. More often there can be blood in the stools. This is a sign of fissures which consequently cause painful defaecation. Hence the perineal examination should deal with the test for infections, fissures, fistulae or even tags. It should also be taken care of that in many children (infants) rectal bleeding is often due to cow’s milk protein allergy rather than constipation (Arvola T, Ruuska T, Keranen J, Hyoty H, Salminen S, Isolauri E. 2006; du TG, Meyer R, Shah N. et al. 2010). Lastly, there have been certain urinary symptoms also that are associated with constipation. Children with constipation suffer from urinary incontinence and may even suffer from enuresis (Loening-Baucke V. 2007).
The diagnosis of constipation is usually done through the study of clinical history of the patient and the medical examination. The clinical history encompasses the symptoms and the other red flags for the presence of that disease. A physical examination for constipation should involve abdominal examination to know the amount of faecal loading. Following this there should be neurological assessment of the spine and the lower limbs. Another important analysis is the perineal examination which helps in identification and diagnosis of perianal cellulitis or anorectal anomalies. According to the NICE guidelines, the perineal test should be performed by the profession who knows how to identify anorectal anomalies or Hirschsprung’s disease. If any child is presented with abdominal pain then the case of constipation should be treated as differential diagnosis (Loening-Baucke V, Swidsinski A. 2007). One third of the children with autism are missed from actual diagnosis of constipation if the clinical criteria alone is considered to make the diagnosis (Afzal N, Murch S, Thirrupathy K, Berger L, Fagbemi A, Heuschkel R. 2003). It is simultaneously also important to watch for the growth failure or overflow of diarrhoea with mucus or blood, fatigue or pallor or the failure to respond to any conventional treatment that has been prescribed or suggested. Children who suffer or show signs of inflammatory bowel conditions may be also presented with constipation. The NICE guidelines also suggest that it should be understood that like fever, constipation may be a symptom and not a diagnosis. The childhood cases of constipation are generally dealt with in four major steps. The very first of them is the education about the identification of the signs and the symptoms of constipation. The next step is the disimpaction, followed by prevention of the condition in which there is reaccumulation of faeces in the intestine. This is usually done by prescribing laxative treatment or a placebo treatment. As per the NICE guidelines, there is only one limited evidence of the success rate of laxative treatment being higher than that of the placebo treatment. However, according to the guidelines it is also right to prescribe lactulose for children who are less than a year old and this is the preferred first choice treatment. For children who are less than an year old, both lactulose and polyethylene glycol (with or without electrolytes) can be used as the first choice treatment. The last step in the treatment guidelines is a continuous follow up for atleast six months so that the condition does not relapse and the bowel movements are maintained (Thomson MA, Jenkins HR et al. 2007).
Often constipation is treated as a serious condition that requires majority of clinical sessions and laboratory based tests like the plain abdominal X ray. This test, although highly subjective, may still remain the best option to diagnose the cases of uncertainity. Another option is to get an ultrasound done. According to Brijos’ Ultrasound (USS) is optimal method for the diagnosis of constipation. Due to constipation the transverse diameter of the rectal ampulla enlarges with age and thus influences the measurements of ultrasound result (Bijos A, Czerwionka-Szaflarska M, Mazur A, Romanczuk W. 2007). However, NICE recommendation ought to be followed so that effective treatment outcomes can be achieved. The parent and patient’s education pertaining to the aetiology of constipation is very important. On the other hand, the parents should also keep in mind the symptoms, signs, principles of management, critical threshold, etc of the illness. NICE recommends that the children should not be held responsible for the action of soiling and this fact should be explained to the parents (NICE Guidelines 2010).
Moreover, NICE also recommends that the family should strictly adhere to the treatment plan which includes the medication routine as well as the toileting habits. Also the psychological aspects related with the illness should be dealt with in the very first meeting with the physician. With children the most common difficulty is experienced when they suffer from abnormal bowel movements but are unable to explain their problem. It is therefore the responsibility of the parents to look after their children’s regular toileting habits and monitor if they are facing any kind of problems. Apart from this the diet has to be taken care of as well. NICE recommends that the fibre intake should be optimised (NICE Guidelines 2010, Guimaraes EV, Goulart EM, Penna FJ. 2001, Jennings A, Davies GJ, Costarelli V, Dettmar PW. 2009). Studies have shown that the children who have normal defaecation pattern have a better intake of fibres as compared to the children who suffer from constipation. NICE also suggests that disimpaction is important in several cases where the maintenance therapy or treatment has to work efficiently (NICE Guidelines 2010). An increasing dose of polyethylene glycol (PEG) is generally recommended as a first line treatment along with a stimulant as an accessory component. Initially, the family should be prepared for worsening of the overflow of soiling initially. Since the work of a stimulant is to cause excessive abdominal pain initially, it is important to commence these treatment on the weekends or on the holidays because the implications on the children can be hard to deal with. According to NICE guidelines the initial phase of the treatment is also characterised by increases diarrhoea in the patients. In such cases it is strictly advised to continue with the treatment rather than stop it midway (Miller MK, Dowd MD, Fraker M. 2007).
Once disimpaction has been accomplished, NICE recommends laxative treatment that is used to ensure that the child has symptom free and regular soft movements of the bowel (NICE Guidelines 2010). PEG is preferred as the first line of treatment but a stimulant laxative senna is usually added if required or substituted if PEG is intolerated by the child. During this time period, the child should be asked to use the toilet regularly specifically after 15-20 minutes of having meals. NICE also recommends that the thumb rule of passing atleast 1-2 soft stools a day, should be followed or aimed for. When the child starts showing improvement, the laxative treatment should be reduced gradually and not completely with drawn suddenly. The choice of laxative varies depending upon the region. For an instance, the cases of constipation that arise in UK, are often treated with Lactulose, Macrogols and Senna. Some of the other laxatives include mineral oil, erythromycin, magnesium hydroxide, etc. According to the National Institute of Clinical Excellence (NICE) guidelines for irritable bowel syndrome (IBS), there is a positive diagnosis only if the patient is suffering from abdominal pain or any sort of discomfort that is put to end or relieved when the patient defaecates or passes stools in varying frequency. The other to mandatory features can be from the following list: altered passage of the stools, bloating of the abdomen, distension, hardness or condition worsening when something is eaten or mucus is passed (NICE Guidelines 2010).
The physical examinations and the clinical history should be taken before hand before going into or adopting to go for organic aetiology and the active investigations. If there are evidences of slow colonic movement, then this may point to the presence of a neuronal disorder of the intestine and this may require the patient to undergo colonic manometry and the full fledged biopsy for the purpose of accurate diagnosis (NICE Guidelines 2010). Certain factors, other than the biological factors like the adverse family dynamics, bullying or child abuse should also be laid stress upon. Simultaneously children who suffer from psychological or psychiatric disorders should also be considered on a similar level because they may face serious trouble and difficulty in coping with the toileting routine or habits. For such cases, NICE recommends non punitive and negotiated interventions that target the behaviour and simultaneously the medicinal and dietary treatments (NICE Guidelines 2010). This plan of treatment can be aided with a multi disciplinary team that includes the nurses and the other experienced clinical staff. In certain cases there may be requirement of play therapists or the psychologists who can help the children in improving their toileting habits and helping them learn the methods of relaxation for toileting. Furthermore, parents also engage dieticians who can give their sincere inputs on the fluid intake, optimum fibre intake and the requirement of fibre content in the diet. All these measure help in dealing with the difficult behaviour of the children with constipation and also help in solving the case without the fear of having to face any serious complications. However, whatever method is followed it is always advised that the NICE guidelines are followed for procuring the most effective treatment plan so that a correct plan of action is traced and there are reduced adverse effects (Afzal, N., Tighe, M. and Thomson, M. 2011).
The NICE guidelines are important to be followed because they are strictly based on the systematic reviews of the best evidence that is available and also considers the cost effectiveness of the treatment and the prescription. When, in any case, if the minimal evidence is available, then the recommendations are provided on the basis of the experience and the opinions of the Guideline Development Group (GDG) and their decision upon what makes it called a good practice (Ezcurra, L., Ullman, R., Gordon, J. 2010). Therefore, the physicians as well as the parents need to take care that they adhere to these guidelines as they are testes and clinically approved. Constipation, being a serious problem, needs to be first diagnosed correctly and then treated with the first line of defense, following which further options are explored, if there are no positive health outcomes.
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