Health visitors play a key supportive role to the families of infants and toddlers experiencing constipation, says expert Dr Jenny Gordon. Offered in tandem with an effective treatment plan, this lessens distress and discomfort and helps to ensure that it does not develop into a chronic condition.
Introduction
Constipation is very common in childhood and is currently estimated to affect between five to 30% of the population1. Constipation is described as the “passage of abnormally delayed or infrequent passage of dry, hardened faeces often accompanied by straining and/or pain”2, it is rarely life threatening and therefore you might expect it to have little impact on health. The reality, however, is very different; with many babies and children requiring medical and nursing support due to the condition causing great misery and discomfort.
Why early diagnosis is vital
Constipation is not a disease, but a condition with a collection of signs and symptoms that may not always be recognised, resulting in delayed diagnosis and treatment. It is, therefore, important to identify and treat constipation early in order to prevent an acute episode of constipation becoming chronic.
Constipation is termed idiopathic when it cannot be explained by any underlying abnormalities. Although the exact aetiology is not fully understood, a number of factors can contribute to the condition, such as pain, dehydration, reduced fluid intake, psychosocial factors and a family history of constipation. While parents describe painful stooling as the most important factor in constipation, few relate the presence of soiling to constipation and therefore they do not always recognise it early enough.
It is also known that many people delay seeking help, possibly because they may think that they should be able to treat the condition themselves, that it will resolve on its own, that they won’t be taken seriously by health professionals, or that they may be thought of as “bad parents”3. Health professionals need to raise awareness of the problem by talking about it, so that people can get help and support in order to prevent persistent problems.
In newborns and preschool children a health visitor may be the first point of contact for families. The National Institute for Health and Clinical Excellence (NICE) published a clinical guideline in May 2010 to help provide a consistent, coordinated approach to the best care for children with idiopathic constipation4. The case studies that accompany this article are used to highlight common issues.
Infant case study 1: Susie
Four-month-old Susie is a first born child for parents Mike and Jane. Jane had a normal delivery and breast-fed Susie for three months before returning to work. She now combines bottle and breastfeeding. Susie was unsettled at first, but soon got into a pattern of bottle-feeds during the day and twice daily breastfeeds in the morning and evening. She was also sleeping through the night but now wakes more frequently and is red in the face and grunting when she tries to pass a stool. She often doesn’t pass anything in spite of the straining and it can take three to four days before she has a dirty nappy. Her mother thinks she is in pain and also wonders if she is waking because she is hungry. She wonders if she should increase her feeds or introduce weaning foods. Her sister-in-law has a four-month-old baby who has started weaning and sleeps all night and has a dirty nappy several times a day. Jane worries that something is wrong with Susie. Normal stool frequency in infants and children ranges from an average of four per day in the first week of life to two per day at one year of age. The normal adult range of three per day to three per week is usually attained by four years of age13.
Expert diagnosis 1: Susie
Every child is an individual. It is important to establish idiopathic constipation from a history and physical examination to exclude any underlying causes. Health professionals can ask about the amount and consistency of stool passed in addition to the frequency. It may be that when Susie appears to be in pain and “grunting” that she is simply vocalising the sensation of wanting to open her bowels. Constipation would be indicated by large, hard stools or small pellet-type stools5,6.
Anal fissures
The most common cause of pain is an anal fissure (a tear of the anal canal), most commonly due to the passing of a large hard stool. Anal fissures are common in babies, but mostly seem to affect those aged six to 24 months. The fissure causes severe pain that may result in the baby withholding stools in an effort to avoid further pain. Untreated fissures set in motion a cycle of negativity towards bowel movements, constipation caused by withholding, which in turn results in increasing pain7-9. Health professionals should confirm the diagnosis and reassure families that there is a suitable treatment.
Treatment plan
NICE (2010)4 recommends that the child can start oral laxative therapy with disimpaction if required, followed by maintenance. The dose should be monitored as well as the response, and treatment should be continued for several weeks after a regular bowel habit has been re-established. NICE highlight the importance of offering families regular follow-ups and support, with families reporting that they value both written and verbal information about what to expect and the best ways to access any additional support4.
Toddler case study 2: Elliot
Elliot is 17 months old. When first weaned he would eat anything, but since his mother introduced lumpy foods and finger foods he is hardly eating anything except for fish fingers, rusks and chocolate buttons. He passes hard, lumpy and dry stools every three to four days. Elliot’s mother reports that he hides behind the sofa and “dances” around when trying to pass stools. On the days he passes stools Elliot becomes irritable and red in the face, with an increase in crying, and screaming.
Expert diagnosis 2: Elliot
Elliot’s constipation may have been caused by dehydration. Sometimes during the weaning process toddlers do not drink enough water. Elliot may also have had a feverish illness, when it is very common for the child to become dehydrated. Encourage plenty of water and diluted fresh fruit drinks in the diet. Try to encourage them to eat fruit, which can be pureed or chopped, depending on their ability to chew. The experience of families eating together plays a role in teaching children to eat “by example”, in that they watch others eating food that may be unfamiliar to them and will eventually copy what they see. It is important to persevere with a variety of foods and encourage healthy eating, while concurrently dealing with the constipation challenge.
Treatment plan
Elliot is displaying classic withholding behaviour, often perceived as straining to pass a stool when in fact he is holding on to prevent the passage of a painful stool. The withholding of stools for a long period of time results in distension of the rectum and causes the nerves, which signal the urge to go to the toilet, to become insensitive and habituated. This often results in the loss of soft or liquid stool from the bowel known as “soiling”10. It is recommended not to use dietary interventions alone as a first-line treatment.
Instead, constipation can be treated with laxatives and a combination of non-punitive, age appropriate behavioural interventions4.
Conclusion
This article acknowledges that constipation can sometimes be difficult to recognise given the diversity of presenting symptoms. However, whilst there is no single treatment, it is known that early identification and effective treatment leads to far better outcomes10-12. Health professionals will find NICE guidelines useful in making a diagnosis4 and these will also help in managing the condition for families. Tools on the NICE website include care pathways, costing tools and audit templates, which allow health professionals to assess the quality and consistency of the care provided4.
