Constipation in Children Failing treatment: What to do? Frances Connor Paediatric Gastroenterologist Frances_Connor@health.qld.gov. What to do between macrogol and MACE Overview • Importance • Assessment and treatment: back to basics • Tools for resistant cases – Flow sheet – Check list • Specific treatments in detail Long term follow-up in childhood constipation Van Ginkel R, et al. J Pediatr Gastroenterol 1999;31:178 Recovered patients No. of 413 patients 418 404 400 100% 99.5% 99.3% No. of patients reached for follow up Total no. of patients 375 96.3% 304 300 94,4% 250 96.8% 200 215 195 98.1% 94.9% 40.1% 44.6% 54.4% 56.6% 30.4% 100 110 61.6% 64.3% 92.7% 63.7% 41 69.4% 0 0 ½ 1 2 3 4 Years of follow-up 5 6 7 8 Long term follow-up in childhood constipation 5-year follow-up Number of patients Staiano A et al. Dig Dis Sci 1994; 39: 561 18 16 Recovered Not recovered 14 12 10 8 6 4 2 0 <1 >1-2 >2-4 >4-6 >6-8 Age of onset (years) >8-10 Are disorders of defecation a “benign problem”? • Children with constipation: ↓ quality of life • Children with spina bifida: faecal incontinence main problem keeping a child from attending regular schools • Adults with myelomeningocele: faecal incontinence as the factor most significantly associated with the inability to work or marry Are disorders of defecation a “benign problem”? * 100 Quality of Life in Constipated Children p<0.05 for constipation vs all others 90 P e d s Q L S c o re s 80 70 * 60 50 40 30 20 10 0 Constipated GORD IBD Healthy Youseff et al. JPGN 2005 41:56-60 QPGHAN Guidelines: Medication-Resistant Cases •39 organic causes of constipation listed in the table about differential diagnosis •At the primary care level think about Hirschsprung’s disease, hypothyroidism, spinal defects, coeliac disease, lead ingestion, hypercalcaemia, cows milk allergy •Referral to Pediatric Gastroenterologist only in box 20 QPGHANS Guidelines The guidelines provide recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. Key points: Education, reassurance, elimination of fecal impaction, close follow-up, and prolonged maintenance treatment are essential for successful treatment QPGHAN Guidelines: Medication-Resistant Cases •39 organic causes of constipation listed in the table about differential diagnosis •At the primary care level think about Hirschsprung’s disease, hypothyroidism, spinal defects, coeliac disease, lead ingestion, hypercalcaemia, cows milk allergy •Referral to Pediatric Gastroenterologist only in box 20 Clinical Approach • Thorough History (including FHx) • ? Normal bowel habit at one stage ? Precipitating event ? With-holding behaviours • Thorough Examination • Weight & Height vs Midparental Ht • Investigations if Indicated – Red flag symptoms – Medication dependent/resistant (esp. NO soiling) Factors Suggestive of Organic Disease • Perianal disease • Blood in stools (gross or occult) • Extraintestinal symptoms IBD • Fever • Weight loss or delayed growth • Rashes/lumps/sores • Arthralgia/arthritis • Red/sore eyes • Mouth ulcers Symptom s Suggestiv • Delayed meconium (HD) e of Organic • Thin strip-like stools (HD) Disease • Vomiting, especially bilious (HD, pseudo-obstruction) • Urinary symptoms • Abnormal lower limb neurology Back to Basics: 2 Key Questions 1.Are they withholding? 2.Did they get enough medicine? Commonest cause: Functional faecal retention Commonest cause: Functional faecal retention • Normal passage of meconium • Normal stooling initially • Trigger event (+/- lost in the mists of time) • With-holding (***) • Enormous stools • Soiling/skid marks when “trying” Normal Faecal Retentio nStretched Weak Numb Leaks Rectum is empty until just prior to defecation Recognising Functional Faecal Retention What The Parents See: • • • • • Child is “trying so hard” Red face Straining Appropriate smells “Only a little bit comes out” Recognising Functional Faecal Retention ASK: • What does the child do when they need to poo? • What position do they take when they need to poo? Recognising Functional Faecal Retention Withholding Positions • Stiff as a board (standing/lying) • Tip toes • Crossed legs • Braces against furniture • All fours • “Trying” to pass a motion sitting on floor with legs drawn up/curled in a ball Recognising Functional Faecal Retention: Fearful of Defecation • Cries/screams • Hides • Needs reassurance • Requests nappy • Denies need to go Recognising Functional faecal retention: Common Triggers • Toilet training • Disrupted routine (eg illness, travel, arrival of new sibling) • Entering day care/ kindergarten/school – especially if toilets lack privacy • A single episode of painful/hard stools for any reason Major principles of treating childhood constipation • Eliminate fear by softening stools • Rectum must be emptied and kept empty until: – fear gone – normal bowel habit established • Overflow incontinence is caused by faecal impaction-- it indicates the need to increase (not decrease) the stool softener dose • Prolonged maintenance treatment with completion of toilet training is essential before drugs are discontinued Goal of treatment Treatment • Educate • Remove blame • Explain damage to bowel : it’s numb and weak! • Emphasise treatable nature/reversible • Soften stools ++ • Correct posture/position How to do a poo? Correct Positions: How to do a poo: Not toilet trained Defer toilet training Allow nappy Squat After meals: Play at low table Play “ducks” Parental reassurance Praise ++ any poo Feet supported Knees higher than bottom Knees apart Leaning forward Elbows on knees Privacy (*School) Medications • Stool softeners: – PEG 3350 (Movicol™, Osmolax ™, Clearlax™) – Paraffin oil (Parachoc™) – Lactulose (Duphalac™) • Stimulant laxatives – Senna (granules, tablets) – Bisacodyl (tablets) – Sodium Picosulphate (Durolax SP Medication Strategy • Stool softeners: texture Aim: stool as soft as “wet cement” • +/- Stimulants: frequency Aim: daily –Rescue (no stool for 48hours) –Regular if necessary Choice of Softening Agents • PEG 3350 (Movicol™) more effective Voskuijl et al Gut 2004;53:1590–1594. than lactulose • Paraffin more effective than lactulose Urganci et al Ped Int 2005;47 (1):15 • Lactulose only useful in babies • PEG 3350 registered for use in children: safest, most effective medication Choice of Softeners: 1. PEG 3350 2. Paraffin/parach oc 3. Lactulose/sorbit ol •Taste preferences •Ease of disguising •Expense How Long To Treat? (Treatment Duration) • No RCTs: empiric recommendations • In general: – Brief history: minimum of 3 months Rx – Chronic history: minimum of 6 months • Minimum 6 months after last soiling last withholding/fears fully toilet trained for stool Treatment of Faecal Impaction Nasogastri c Golytely washouts: Ancient history? Disimpaction: Dose Response of Oral PEG 3350 Youssef N, et al. J Pediatr 2002;141:410-4. * * * = p<0.005 100% 90% 60% % patients disimpacted 50% 0.25 0.5 1 grams/kilogram/day x 3 days 1.5 Movicol Home Washout • See Norgine guidelines for dose if large fecal mass • 3 days high dose: Roughly: 1 sachet daily - toddlers/preschool 1 sachet bd - primary school 2 sachets bd - secondary school • On a weekend (toilet access) • More if needed • Follow with maintenance Rx • Enemas/suppositories a last resort PEG effective and safe in infants and Loening-Baucke J Peds 2005;146:359 toddlers Mean effective dose: 0.78g/kg/day Michail et al JPGN 2004; 39:197 Effect of 8-wk maintenance treatment with PEG 3350 Pashankar DS, Bishop WP. J Pediatr 2001; 139: 428 Pre- Rx On Rx p value Painful defecation 75 % 0 < 0.0001 Blood in stools 40 % 0 0.033 Fear of defecation/ stool withholding 70 % 5% <.0001 Abdominal fecal mass 44 % 0 .0029 Rectal feces present 83 % 22 % .0006 Dilated rectal vault 78 % 11 % .0001 PEG vs lactulose (RCT n=91) • Both ↓ encopresis frequency (p=NS) • Total elimination of faecal incontinence: PEG (56%) > lactulose (29%) (p<0.05) • PEG 3350 (vs lactulose): ↓ abdominal pain ↓straining ↓ pain at defecation • PEG tasted worse Voskuijl et al Gut 2004;53:1590–1594. When to Refer to Occupational Therapist/Bowel Training Program: 1.Child old enough to comply (generally developmental age of >4 years). 2.Failure to respond to initial medical management: Ongoing stooling difficulties despite adequate medication and basic instructions from treating doctor on correct stooling posture/actions/timing of attempts. 3.Lack of progress after initial improvements. Commonest reasons for treatment failure: • 1. Insufficient dose - Stools not soft enough (stool texture not “wet cement”) • 2. Insufficient duration - Treatment ceased prematurely • 3. Treatment not given regularly (need daily soft stools for months) • 4. Trigger factors recur, persist or new factors occur causing relapse • 5. Alternative diagnosis Is functional constipation ever refractory to adequate treatment? When treatment fails, reassess compliance and the key points: Key points: Education, reassurance, elimination of fecal impaction, close follow-up, and prolonged maintenance treatment are essential for successful treatment Review barriers to compliance, efficacy of drug regimens When treatment fails, reassess. Key question: Was the child ever given enough medicine to keep the stool as soft as wet cement for a minimum of 6 months? “She won’t take the medicine” When treatment fails: “He wouldn’t take the medicine”: •Disliked taste •Side effects: •nausea •oil leak •abdominal pain •Control issues When treatment fails: Child refused medication: •Movicol: •Drink bottle •Cold/ice •Juice/cordial/smoothie •Fruit puree •Non-flavoured: Movicol Jnr, Osmolax, Clearlax When treatment fails: Child refused medication •Parachoc: •Milk shake •Icecream/yoghu rt When treatment fails: Trouble-shooting Medication Problems: •Nausea: Movicol delays gastric emptying Consider Parachoc •Oil leak: treat backlog/ increase dose change agent •Abdominal pain: Not a side effect of softeners (Except lactulose) When treatment fails: Child Refused Medication: Control Issues •Refuses: Incentives/ Star Charts Occupational therapist When treatment fails: Not enough medicine/ Stopped Too Soon •Parental concerns re safety •Well meaning advice •Expense •“Seemed to be better” Old wives talesNo. 1 Laxatives are dangerous because they cause permanent damage to the bowel if you use them too much. Safety of Stimulant Laxatives: "Melanosis” coli • Yes: stimulant laxatives cause structural damage to surface epithelial cells • NO convincing evidence impairment of enteric nerves or intestinal smooth muscle • NO reliable data to link chronic use of stimulant laxatives to cancer Wald. J Clin Gastroenterol 2003;36(5):386 Safety of Stimulant Laxatives • The risks of laxatives have been overemphasized • This has minimized their rational use by physicians. • May be used chronically when patients fail to respond adequately to softeners alone • Can combine with softeners in sufficient amounts to soften the stool • Dose should be titrated to effect. • Bisacodyl may be used if anthraquinone Wald. J Clin Gastroenterol 2003;36(5):386–389 laxatives are unsatisfactory. Reassure Patients “Immunise” against false information • Laxative medications used as directed are SAFE • There are lots of wives tales about laxative medicines – that they are dangerous or paralyse the bowel. • These wives tales are because in the olden days laxative medicines sometimes contained poisons that did paralyse the bowel • That used to make a lot of money for the laxative companies. • Modern laxatives don’t contain poisons Useful statements in educating families • Recently, world experts in constipation and reviewed the science behind these wives tales and found them not to be true • Many people you meet may not be aware of this recent information • These days, laxatives are SAFE • Not “habit forming” • Don’t make the bowel “lazy” • Won’t become “dependent” Useful statements in educating families • Won’t damage the bowel • Not treating the bowel problem can damage the bowel and make it ‘lazy’ • Stimulants can make cosmetic changes of “tanning” the lining – no effect on bowel function – resolves on ceasing medication. • If you have concerns about the medication, discuss them with your doctor before changing the treatment plan No. Old wives tales… 2 Paraffin is dangerous because it leaches all the vitamins out of your body. Paraffin and Fat Soluble Vitamins: • • • • Up to 4 months Rx Children Mild ↓ serum beta-carotene No change in serum retinol and alphaClark J. Am J Dis Child 141(11):1210-2, 1987 Nov tocopherol • NB Avoid use in aspiration risk – lipoid pneumonia New Safety Data on Older Agents: Softeners • Dose related side-effects in excess (diarrhoea) • Non-absorbed sugars – side effects from fermentation (cramps, flatulence, nausea) • NO evidence of adverse effects of prolonged use of softeners Choice of Softening Agents • PEG 3350 (Movicol™) more effective than lactulose Voskuijl et al Gut 2004;53:1590–1594. • Paraffin more effective than lactulose Urganci et al Ped Int 2005;47 (1):15 Diet • Well balanced • Adequate fluids • Adequate fibre • Avoid excess cows milk No. Old wives tales… 3 Lots of fibre helps in bad constipation Only if small, hard (narrow calibre) stools and no impaction. Once wide calibre stools or faecal mass or encopresis: makes it WORSE!!! Failed Trial of Adequate Treatment - Why? Old Paradigm New Paradigm Chronic constipation is a behavioural/learning Chronic constipation is an organic or disorder behavioural/learning disorder Common causes: Behaviour/Learning: avoidance of defecation Adverse life event (esp painful defecation) Defiant behaviour Intellectual disability Common causes: Behaviour/Learning: avoidance of defecation Adverse life event (esp painful defecation) Defiant behaviour Intellectual disability “New” Identifiable Organic and Motility Causes: Colonic dysmotility (eg STC) Outlet obstruction (eg Pelvic floor dyssynergia, food allergy) (Plus rare organic cause): Cystic fibrosis, Hirschsprung’s disease, coeliac disease, hypothyroidism, lead poisoning, spinal abnormality (Plus rare organic cause): Cystic fibrosis, Hirschsprung’s disease, coeliac disease, hypothyroidism, lead poisoning, spinal abnormality Adapted from Southwell B, et al. J. Paediatr. Child Health (2005) 41 (1): 1–15 Initial treatment of medication-resistant constipation: (resistant to a minimum of 6 months adequate laxative therapy) Adequate stool softening, Withholding/ Retentive behaviours yes Ongoing symptoms behaviour modification: occupational therapy or psychologist no Bloods for calcium renal & thyroid function, lead and coeliac done & are normal Dairy elimination Risk factors for food protein allergy ? (see check list) yes Elimination diet Under 3 years, no known reactions to non-dairy foods? 5 food elimination Dairy, soy, wheat, corn, egg) no Urinary symptoms ? Ongoing symptoms Spinal MRI done and normal? yes no Symptoms of obstructed defecation ? Ongoing symptoms yes Suggests pelvic floor dyssynergia yes Biofeedback (surface EMG) Ongoing symptoms no Spinal MRI and rectal biopsy done & are normal Nuclear colonic transit study: >50% retention in right colon at 48 h ? Outlet obstruction yes Slow transit constipation transit to rectosigmoid under 6hours yes Suggests food allergy: elimination diet if not already done Trial transcutaneous electrical stimulation using interferential current (experimental) Ongoing symptoms: biofeedback if not already, else refer motility or surgeon Initial treatment of medication-resistant constipation: (resistant to a minimum of 6 months adequate laxative therapy) Withholding behaviours Food allergy Spine Pelvic Floor Hirschsprung’s disease Slow transit constipation Withholding behaviours? Assess barriers to compliance Adequate stool softening Behaviour modification: occupational therapy or psychologist Not Withholding: Do Basic Bloods • Thyroid function • Coeliac serology (TTG IgA, Total IgA) • ELFTs • Lead level