Education of the child and family of the physiology of constipation and mechanism of overflow soiling is important. Below are some tips, tricks, and generally things not to forget.
What other recommendations can I give?
You can mix the PEG 3350 with other fluids:
- Whichever Macrogol PEG you use, you can then mix this with cordial, juice, milk or pretty much whatever you like, to disguise the taste.
- Advise the parent to increase fibre and water intake in their child’s diet.
- Dietary modifications can make a huge impact. Fibre such as beans, whole grain, cereals and fresh fruit and vegetables are good for improving the symptoms. Foods without fibre (cheese, meat, processed food) should be limited. Plenty of fluids will help keep the stool soft but milk should be limited to less than 500ml per day.
- It may be worth referring the child to a dietician for further advice.
- Daily exercise is recommended to improve bowel motility. A 30 minute walk each day can improve regularity of bowel motions.
Use a foot stool:
- The best position for defaecation is squatting, as there is better alignment of the recto-anal angle.
- By placing a stool under the child’s feet, placing the knees above the anus, you are improving the recto-anal angle, thus relieving any obstruction to stool outflow (Sikirov).
- For most children with constipation, going to the toilet has now become a negative experience. It is important to encourage parents to give positive feedback to the child when they pass a stool and not to berate them if they were unable to.
- Sitting on the toilet should not be an unpleasant experience so encourage the parents to let them read a book, listen to music, or play a computer game.
- Reward systems are a good way to aid this positive reinforcement. A good suggestion is using a star chart or bowel diary, where the child gets a sticker every time they sit on the toilet and an extra sticker when they pass a stool. The child can then be involved in deciding a reward for a certain number of stickers gained.
- Teach the parents about the gastro-colic reflex – i.e. increased motility of the colon in response to stretch in the stomach after eating.
- Therefore, the most likely time for the child to pass stool approximately 15-20 minutes after food (Lowery et al)
If behavioural techniques fail, consider referral to a paediatric occupational therapist for further advice.
Where can I find a good information sheet?
Good information sheets:
- NICE Guidelines: http://www.nice.org.uk/guidance/CG99.
- Movicol website: Incorporates a stool diary and Bristol Stool Chart. http://www.movicol.com.au/file/Movicol%20DL%20Patient%20Leaflet%2010pp.pdf
- Osmolax website http://www.keypharm.com.au/conditions/osmolax.php
- RCH Melbourne: http://www.rch.org.au/kidsinfo/fact_sheets/Constipation/
Good websites to refer parents to:
- Childhood Constipation: Great website with interactive tools. In the ‘Extra information’ section there is a book called ‘Talking About Constipation’ that parents can print off and read with their child.
- Education and Resources for Improving Childhood Continence: www.eric.org.uk
Bracewell M, Bunce N. Movicol Paediatric Plain: A Treatment for Constipation in Children. Sussex Community NHS. 2009 July. http://gp.westernsussexhospitals.nhs.uk/wp-content/uploads/gpsiteweb/Leaflet11movicol-AssetID=354390&type=full&servicetype=Attachment.pdf
Sikirov BA. Primary Constipation: An underlying mechanism. Medical Hypotheses. 1989 February;28(2):71-73.
Lowery S, et al. Habit Training as Treatment of Encopresis secondary to Chronic Constipation. Journal of Pediatric Gastroenterology & Nutrition. 1985 June;4(3):397-401.