Conversations about constipation

Cite this article as:
Chris Dadnam. Conversations about constipation, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31554

Like most of you I have to deal with the issues of constipation within the ED or CAU environment and most of the time it’s not the reason the child attends the department! This can then lead to a series of awkward questions and issues that parents may ask that we need to consider in order to provide safe, useful and most of all, worthwhile advice! 

So let’s go through these questions ask issues:

1. My child has a UTI, why are you talking to me about constipation? 

This is something I get asked not only when a UTI is diagnosed but other clinical conditions including; appendicitis, bedwetting, incontinence, urinary retention, obstruction, etc…. it is important that parents understand the implications of constipation, not only from a pain and symptoms point of view but also the complications surrounding it. Indeed, many parents also struggle to understand how their child, who is rolling around in agony, is only suffering from constipation (you can literally feel them questioning your medical acumen). 

During these tough times I always mention two key points. Firstly, the fact that your bowel covers the majority of your abdomen. A build up of wind and solid matter in the bowels can bring about severe griping abdominal pain, when pressing against sensitive nerves. As it covers a lot of your abdomen, when full, it will compress other structures like your child’s bladder leading to urinary infections, incontinence and retention. The second point is that stools are like a toxin your body wants to expel, when it remains in your bowels it can get into small structures like your child’s appendix and cause it to become inflamed and that leads to appendicitis.

Also, the longer the stools sit in the colon the more water is absorbed leading to harder, solid stools. This will cause a blockage and lead to vomiting and obstruction which may require surgery. 

Once parents have a better understanding of these points they’re less likely to roll their eyes at constipation! 

2. How are they constipated, they go every day? 

This in fairness is a good question, one that used to throw me quite a bit in my early paediatric years, but let’s break it down. Constipation is not simply the length of time between going to the toilet, rather it is the build up and insufficient clearance of stools in your bowels. With this in mind, a child can go daily and pass small amounts of stool but still have a backlog of faecal matter in their bowels. Therefore also question the time spent on the toilet, straining and pain during defecation. These are all signs of constipation. If you can, ask your young patients too! 

3. They already drink plenty of fluids

Don’t let this answer fool you, explore the parents’ meaning of fluids. When we are saying it, we mean clear liquids like water and squash (preferably sugar-free), but for the parents, it’s anything from water and tea, to milk and hot chocolates. Now there is a myth that milk makes us constipated but that’s simply not the case….well not entirely. Milk is indeed a liquid and it doesn’t make us constipated but it’s thicker and takes longer to digest (hence why in surgery they stress only clear liquids 4hrs before). Milk fills up the child and so reduces their intake of solid food which will be full of fibre. 

Always remember, parents may say they’ve cut out all the milk, but this may have been substituted for milky teas and hot chocolates, so double check! 

In terms of managing the milk, appreciate the difficulty the family is about to face. Wean the milk down slowly, starting with the bottles in the middle of the day, then the morning bottle and finally the night bottle. Milk shouldn’t be stopped entirely, having a 250-500ml glass of milk daily is perfectly fine. 

4. They eat a really good diet 

Whenever I get this response, I immediately think they haven’t and 99% of the time I’m right……says a lot. 

Again, this is either due to a misconception as to what a good diet is, or they don’t think it’s an important issue so they simply brush it off with this generic statement so that they can get to the medication that will actually help. Another quick way to check is to just ask the child. They normally find it much more difficult to turn a blind eye.

I always try to tackle this in one of two ways:

Tell me what they eat?

– it’s surprising how many children don’t have breakfast or any of the three square meals a day. If they do, just add in tips when you can.

Breakfast; dried fruits in cereal (especially raisins), don’t switch the cereal completely but rather mix in an all bran, so they’re still getting their tasty favourites, but now with added fibre. Toast – if it’s white bread, freeze it; it’ll keep longer and by placing it straight into the toaster means that the strands of carbs, fats and protein are bound together and form fibre.

Lunch; Try to include salad into sandwiches. If the parents say they don’t like salad then how do they expect their children too! Encourage healthy eating in the parents as well, to form positive connotations for their kids.

Dinner; any sauce can hide a multitude of veggies if blended or chopped fine enough – so get them cooking and where possible get them to encourage their kids to join in. If they cook it themselves, they’ll appreciate the food and, for some reason, enjoy it more……probably a labour of love! And it’s a great time to leave out and pick on a bowl of fresh berries or grapes, the more accessible things are the more they get eaten.

Do they eat all their fruit and vegetables?

This again leads to a classic ‘Yes’ response – which falsely reassures a lot of healthcare professionals. In truth, it’s a vague and rather inadequate question to ask. If I told you that my child eats peeled apples and pears, has a glass of orange juice and then eats loads of veggies which I boil until soft… It might make you think twice about the goodness they’re actually getting.  So I always ask – Do they eat the skins of the fruit and vegetables? How do you prepare them? The skin of most fruits and vegetables holds the majority of fibre along with different vitamins and minerals required. In all honesty, if you are peeling apples and pears, all you’re left with is sugar and water, so I tell parents to give their child the peel instead! 

Again with veggies, I tend to suggest for microwaving or steaming as people tend to overcook them when they boil them. They need a crunch as that equals fibre. Root vegetables (potatoes, sweet potatoes, carrots, butternut squash, celeriac, parsnips) – all these lovely fibre rich foods – contain most of the fibre in their skins. I tell parents to roast them, long and slow – they’ll taste better (caramelizes the sugars in the veg/skin) so children will prefer them! 

Be mindful of smoothies and fruit juices. Yes, they can count for 1 of our 5 a day (soon to be 10 a day) but they can have little to no fibre, especially with the models that separate out the pulp. The pulp is fibre!! Try to get them to have whole fruits instead or 1 x 250ml glass of fruit smoothie a day with the pulp. 

5. I have tried all this and it doesn’t work 

Before you dismiss this answer make sure you look over the medical background again (cystic fibrosis, hypothyroid disease, Hirschsprung’s). Ask these all-important questions:

  • When did they have their very first poo? It should be within the first 48 hours. Then double-check it was a good amount – small smears don’t count.
  • Have they had issues with weight gain and prolonged issues with chest problems (in cystic fibrosis, LRTIs tend to happen towards the end of their first year of life).
  • Did they have a Guthrie / heel prick test. Any developmental delay? A large soft spot on their head?

In all of these conditions, the child would have always had an issue with constipation since birth, so don’t miss them. 

Once covered, it’s important to go through what they have tried….. most parents will only have been given a packet of Movicol and told to get on with it. Look at the summary section to see how to structure a constructive management plan.

6. I’m scared they’ll starve so I give them what they want. 

How many of us have been told this with little Jonny sitting there looking larger than life?

In general, throughout the developed world, children are unlikely to starve if their parents are trying to feed them a healthy balanced diet. There are caveats to this:-

  • Autistic children or children with textural issues. 
  • Children with a background of eating disorders (bulimia or anorexia). 

These children will need extra support and input from community and nutritional teams. 

All the other children will always put up a fight (normally a good one!) but then their bodies will give in and want food. This is an important step for parents to understand, especially when the child is too young to go out and get food themselves. Make sure you tell the parents this won’t be a simple task, and the main reason children normally win, is that carers will be busy and won’t have time to tackle this problem. It’s a quick fix to give them something just so that they know they’ve eaten…….then the habit starts. I always tell parents, wait until you have a week off and prepare yourself/ yourselves for a bumpy ride. Have a united front, it’s no good if one parent plays the ‘strict/ bad guy’ whilst the other literally feeds the problem behind their back. Prepare meals and hide away the unhealthy processed snacks (or don’t buy them in the first place) and leave fruit out. Again, get the child involved in cooking, build a healthy connection with food and make it fun. Children will most likely throw tantrums at the start, but remind them that eventually their child’s body will give in and they will come for food, most likely with a grumpy face. 

Just make sure they’re hydrated with clear fluids! And NO milky substitutes. Remind the parents they’re not bad people and this will help fix things in the long run.

7. Movicol doesn’t work and I don’t want it to make their bowels lazy 

This age-old answer…..makes you wonder why we bother using Movicol? More often than not they’ve not prepared it correctly, despite the instructions being on the box. Honestly, the ways parents use Movicol; sprinkle on cereal, mix into snacks or food, add to tea….the list goes on!

Movicol is only effective when it is bound with water. After this, the parent can then mix it with a small amount of any other liquid or flavouring. Make sure they don’t add it to a litre bottle of squash as the child will have to drink the whole lot. Also, this means they don’t need the flavoured versions (which taste vile – remember when they made you try them in medical school!). 

Another myth is that “it’ll make their bowels lazy.” Explain that Movicol is not a stimulant, it is an osmotic diuretic and acts to drive the water you mixed it with into the child’s stool to make them softer and easier to pass. With this in mind, even stimulant laxatives won’t make your bowels lazy. I always say, they can be on it for the rest of their lives, it’ll never make their bowels lazy – that tends to reassure parents.

8. I tried laxatives before and they suddenly had diarrhoea so I stopped using it. 

This answer may again throw you into thinking that the laxative has done a great job in under 72 hours and fixed a months worth of constipation… it sounds too good to be true?? Well, it is. The big problem here is, if clinicians don’t pre-warn the carers what might happen after starting a laxative, it can lead to long term mistrust in both the medication and in our advice.

I always start off by setting the day to start. Aim to start the laxative at the end of the week, a Thursday or Friday, to avoid accidents in the school. They will deter the child from ever trying them again.

Once we know when to take them, always triple check they’re using them correctly… mix with water first, then add to a small volume of any other liquid for taste.

Finally, but most importantly, the change in stool. Referring to the Bristol stool chart (the only card I carry around!), I explain the child will start with Type1-3 stools. Then, they’ll have what looks like diarrhoea, brown watery smelly stools, but, of course, it’s overflow. Take the time to talk about why this happens; the Movicol is slowly moving through the hard stools, like rain trickling down a wall, in their child’s bowel. The Movicol/water mix will initially run over it but over time their stools start to soften. 

The next step, again important due to risk of pain, is the big logs. And big means big! I’ve had parents say they’ve used shears to cut up these stools in the toilet. This is essentially the wall slowly being emptied out. 

Once this is over, they will finally have the soft mushy stools. The laxative story should not end there! It is important to mention this ‘wall of stool’ has caused the bowels to stretch. This will lead to a build-up of stools again as the child won’t know when they need to go. This is reservoir constipation. It can take months to revert back to normal so I always advise to continue on with the laxatives and reduce (but not stop) the maintenance daily dose down if the child is passing clear watery liquid. Usually, treatment should continue for at least three months to treat reservoir constipation (although in some children it can be longer).

9. They don’t like my cooking. They’re vegetarian now, I’m not. 

It doesn’t have to be vegetarian, of course, this is just what an angry mum said to me once about her daughter. Parents will mention the difficulties of preparing food they’re not used to cooking, I always suggest ‘get your child involved‘. This is the perfect time to do something together (bonus points as well in tackling mental health and isolation. It gets the family talking). The child will appreciate their intent and willingness to give their lifestyle a try, which will build confidence in the relationship as well. They can get a cookbook, go online (it’s all free and easily accessible these days) and adapt their cooking style. Again. this will make their child feel more involved and interested in cooking and eating healthy foods. 

10. They don’t like fruit and vegetables. 

I think we’ve all suffered from hating vegetables and fruit at some point in our lives. I remember hating tomatoes and peppers, so I feel for any parent tackling this problem. 

There are several factors to contend with here:

  • Their child not liking the fruit because it’s unknown to them or feels texturally unsatisfactory.
  • Having access to other more ‘enjoyable’ foods such as biscuits, chocolates and crisps around the house which they can graze on and avoid these unwanted bags of goodness. 
  • Watching older siblings and parents, and copying them.

To this, I normally offer a number of solutions but be mindful that parents will have busy lives around their child’s eating habits so it has to be a conscious effort at a convenient time, like over the weekend or annual leave.  

Firstly, hide unhealthy snacks or simply reduce the amount you buy, what they don’t see they don’t know…. out of sight, out of mind technique.

Secondly, I always tell carers that they and older siblings are role models. If you’re not eating it, why should they? There should be a united front by the parents. 

Finally, get cooking and get your child involved. Any child who cooks will appreciate the food they’ve made and the sense of achievement, even if it doesn’t taste nice, they’ll love it. It’s a great time to chat over a bowl of fresh berries…

My own enthusiasm then tends to kick in. I like to say “Get creative in the kitchen!” I’ve mentioned simple things for example: make flapjacks and throw in lots of dried fruits; raisins, dates, apricots, prunes – all-natural sweetness with skinned nuts & oats. Freeze smoothies with the pulp into ice-lollies. Fruit crumbles with honey and oats… With vegetables, always remember to steam or microwave them, they need the crunch. Again if kids don’t like them…. Chop them up/ blend them and throw them into sauces, pies and mixed into other dishes. If it’s the taste they don’t like, again mixed into gravy or a tasty sauce will fix that problem! 

It is important to mention the importance of a healthy balanced diet. Food is your best medicine. This is can be true for managing many conditions; anaemia , skin problems, poor immunity, nail and hair problems..you get my point. A varied diet holds the key to a lot of management plans, and it’s important to mention this even when the child is on supplements. A classic example is the parent says we’ve fixed the iron problem with iron tablets, but they fail to realise, without vitamin C your body can’t absorb the iron through the small intestine. Therefore, they’ll be questioning why their child remains anaemic in months to come. 

11. They’ve gone back into nappies as they’re scared of using the toilet. 

This is an important issue. It’ll mean the child will probably have problems with incontinence which may be affecting their social life such as staying over at a friends houses. Yet another reason why it needs tackling. 

Always start with asking what happened? More often than not it’s a series of bad habits and untimely events that have led to a regression in the family’s good practice. It happens to the best of us. Reassure everyone and give them the positive reinforcement that they’ve identified a problem that needs to be solved. Then offer the advice below. Take your time with these parents, it would have taken a lot for them to come into an acute setting to seek advice, so try to give them some. 

A framework for managing constipation.

This is ultimately an important topic that you have or, no doubt, will see at some point in your paediatric career. Knowing how to manage it is a core skill. 

I always frame my management in 3 steps: 

1. Diet and fluid intake – take the points from the above questions. Ultimately, the parents control the diet and food at home. They, and older siblings, are the child’s role models so what they eat will influence the child’s diet too. Remind them that food is their family’s best medicine so they need to get it right. Cancel out the milky drinks, cook smart & healthy and don’t forget clear fluids.

2. Toileting – our constipation module covers this but key points; get them into a routine (20 to 30mins after dinner – to sit on the toilet). Make the toilet a fun place with all their toys and gadgets and don’t forget to get them to blow the bubbles. Optimise positioning with knees above bums when sitting, using a footstool. 

3. Medication – ensure parents are giving them correctly – mixing with water first then adding to any other liquid for taste. Make sure this isn’t a full bottle, as they’ll have to drink the lot!. Movicol doesn’t make your bowels lazy. If they’re on a disimpaction regime, think about the volume they’ll be drinking each time. It may be better to split it into thrice daily doses instead. Briefly touch on the sequence of stool changes to reduce misconceptions of overflow and diarrhoea. Lastly start Movicol towards the end of the week, Thursday or Friday to avoid accidents at school. 

End with: 

  • Referencing the ERIC constipation website. It’s a great tool for constipation and bedwetting. It talks to the parent and child, so easy to understand and explain.
  • It will take time for things to fall into place. There is no quick fix. There will be tantrums, sleepless nights and days you’ll want to give in. Hang in there and once you’re sorted you’ll wish you’d done it sooner!

Constipation Module

Cite this article as:
Team DFTB. Constipation Module, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.27243
TopicConstipation
AuthorRebecca Paxton
Duration30-60 mins
Equipment requiredNone
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

We also recommend printing/sharing a copy of your local guideline.

Billy is an otherwise well 4 year old boy who presents to A&E with a 4 week history of abdominal pain. His pain comes and goes, and seems to be worse after eating. Today he has been doubling over with pain and crying inconsolably.

He has had no fevers or vomiting. He is drinking well but parents think he is a bit off his food. His last poo was 3 days ago, and parents think it was normal but aren’t sure.

What else would you like to know?

What would you look for on examination?
How would you treat Billy?

When should he be seen again?

What is your next step if he doesn’t respond to your treatment?

Red flags – make sure learners have thought to exclude red flags in their history and examination. These include:

  • History of delay more than 48hours in passing meconium
  • Ribbon stools
  • Faltering growth
  • Abdominal distension and vomiting
  • Abnormal anatomical appearance of the anus
  • Severe abdominal distension
  • Abnormal motor development
  • Abnormal gluteal muscles or sacrum
  • Spine or limb deformity (including talipes)
  • Abnormal power, tone or reflexes
  • Safeguarding concerns
  • Ensure external examination of anus for haemorrhoids/fissures that may need treatment 
  • Treatment – assess Billy for signs of impaction and start disimpaction regime if indicated. Discuss non pharmacological treatments.
  • Counselling – prepare parents for duration of treatment, possible side effects and importance of adherence
  • Follow up – prompt and regular follow up, tailored to the families needs
  • Treatment failure – discuss reasons for treatment failure, methods to tackle common problems
  • Red flags
  • Not responding to treatment after 3 months (thyroid, coeliac, allergy) 
  • Failure to thrive
  • Safeguarding concerns

Jakob is a  9 day old baby boy who is brought to the emergency department with vomiting. He is mum’s 3rd baby. Mum is worried that he is vomiting everything he drinks, and is sleepier than she would expect. He seems distressed when awake. He is having 3-4 light wet nappies per day but has only passed a few small stools in his short life.

What else would you like to know? 

What would you look for on physical exam?

Would you order any investigations?

What is your initial management?

  • Red flags on history – delayed passage of meconium and bilious vomiting
  • Examination- look for abdominal distention, careful examination of external genitalia and anus. Document weight and weight loss.
  • Discussion of PR examination – should only be performed by experienced practitioner. May result in forceful expulsion of gas/stool (highly suggestive of Hirschsprung’s). 
  • Investigations – order in consultation with surgical team. Consider abdominal XR to assess for obstruction but keep in mind the surgical team will likely perform contrast study. Rectal biopsy (under surgeons) for definitive diagnosis. 
  • Initial management – resuscitation. NG tube and IV fluids, correction of any electrolyte abnormalities. Look for signs of sepsis (enterocolitis).

Lily is an 8 year old girl with Trisomy 21. She had an AVSD repair as an infant, and is otherwise well and takes no medications. She has been referred to A&E by her GP with worsening constipation. She has been constipated on and off for most of her life, but this has usually been easily managed with movicol. This time around, she has been constipated for 3-4 months and is passing painful, hard stools approximately once per week. Her GP started her on movicol 3 months ago, which parents say she has been happily taking but it doesn’t seem to be working. 

What else would you like to know?

What investigations would you order?

What do you think might be going on?

How would you treat Lily?

T21 and constipation. Constipation is very common in Trisomy 21. Most often it is not due to an underlying disease, but a combination of low muscle tone, decreased mobility and/or a restricted diet. However, T21 is associated with an increased risk of autoimmune disease, including thyroid dysfunction, diabetes and coeliac disease – all of which might cause constipation.

Investigations can be done in an outpatient setting, in this scenario should be followed up by a community paediatrician. Screen for all of the above.

Laxative treatment is unlikely to be entirely effective until the underlying problem is corrected. However, depending on the severity of symptoms treatment escalation is appropriate. Lily doesn’t have any symptoms if impaction, but it may be worth escalating her movicol dose or considering the addition of a stimulant laxative whilst awaiting test results.

Advanced Case 2 (20 minutes)

Georgie is a 12 year old girl with severe autism. She is non verbal. She is otherwise well, but has had trouble with constipation in the past. Her parents attribute this to her being a “picky eater”. Georgie has had abdominal pain for the last 2 weeks, and has been passing small, pellet – like stools every 4-5 days. She has been having more “accidents”, and has been back in nappies for the last 7 days. She has been seen by the GP who has diagnosed constipation and prescribed movicol. She took this as prescribed for the first couple of days, but she is now refusing her medications. Over the past 4 or 5 days, Georgie has begun to refuse all food and will only drink sips of juice with a lot of encouragement. When parents try to give her medications or take her to the toilet, Georgie becomes very upset and aggressive. Her parents are very distressed and not sure what to do.

What are your management options for Georgie? 

Children on the autistic spectrum are more likely to have problems with constipation. Often this is due to a restricted diet, but may also be due to increased levels of anxiety around toileting.

  • Georgie requires disimpaction and this is not being achieved despite the best efforts of the family. There is no right approach to this scenario. Options include
    • Optimise setting and motivators for toileting
    • Change/optimise medications – try mixing movicol into juice, try changing to lactulose, add stimulant laxative
    • Admission for washout – nasogastric tube for washout +/- enema. Strongly consider sedation
    • General anaesthetic for manual disimpaction + washout
  • Support parents and empower them in decision making process
  • Involve multidisciplinary team – community supports will be important on discharge

Macrogol laxatives may cause “lazy bowel” if used for more than 2 months. True or false?

The correct answer is false.

There is some evidence of patients developing dependence on stimulant laxatives if used long term. However, macrogols are safe to use indefinitely without complication.

Which of the following is NOT supportive of a diagnosis of idiopathic constipation?

A: Loss of appetite

B: Ribbon like stools 

C: Urinary incontinence

D: Faecal incontinence

The correct answer is B.

Ribbon like stools suggest an anorectal malformation, and any history of this warrants further investigation. Loss of appetite, urinary and faecal incontinence can all be the result of constipation or faecal impaction. 

In a child with abdominal pain, the diagnosis of UTI makes constipation less likely. True or false?

The correct answer is false.

Constipation can lead to urinary retention and UTI, and as such the two can, and often do, co-exist.  A positive urine dip or culture doesn’t rule out constipation as a cause of abdominal pain. Don’t forget to think about constipation in the child with a history of recurrent UTI. 

National Institute for Health and Care Excellence. Constipation in children and young people. London: NICE, 2014. Available at www.nice.org.uk/guidance/qs62 

The Royal Children’s Hospital. Clinical practice guideline on constipation. Melbourne: RCH, 2017. Available at www.rch.org.au/clinicalguide/guideline_index/Constipation

Zeevenhooven J, Koppen IJ, Benninga MA. The new Rome IV criteria for functional gastrointestinal disorders in infants and toddlers. Pediatr Gastroenterol Hepatol Nutr 2017;20(1):1–13.

Sampaio C, Sousa AS, Fraga LGA, Veiga ML, Netto JMB, Barroso Jr U. Constipation and lower urinary tract dysfunction in children and adolescents: a population-based study. Frontiers in pediatrics 2016;4:101.

Youssef NN, et al. Dose response of PEG 3350 for the treatment of childhood fecal impaction. Journal of Pediatrics. 2002;141(3):410-4



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Nocturnal enuresis

Cite this article as:
Mary Hardimon. Nocturnal enuresis, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23446

Kristy is a 5-year old girl; her mother has brought her in due to her having started kindie. She has been invited to have a sleepover at a family friends house however she still wets the bed most nights of the week and is wondering about how to manage this.

 

Attaining continence – both daytime and nighttime – is a developmental milestone with a significant normal variation which is affected by both genetic and environmental factors.

At 5 years of age, approximately 15% of children continue to experience nocturnal enuresis (more commonly known as bedwetting). Every year beyond this, there is spontaneous resolution in ~15% of affected children (although it should be noted that the longer duration of NE, the lower the likelihood of spontaneous resolution).

Boys are more commonly affected than girls (2:1) and there is a strong family predisposition (both parents = 77%, single parent = 43%). Only one-third of those affected will seek medical attention.

 

What is nocturnal enuresis?

Nocturnal enuresis is episodes of urinary incontinence during sleep in children ≥5 years of age. It may be further subdivided into monosymptomatic (aka uncomplicated) and non-monosymptomatic (aka complicated or polysymptomatic).

  • Monosymptomatic: incontinence is present without other symptoms of lower urinary tract/gastrointestinal tract
  • Non-monosymptomatic: incontinence associated with other symptoms including but not limited to
    • Polyuria/oliguria (8/3 times per day respectively)
    • Urgency, hesitancy, intermittency
    • Straining/holding manoeuvres
    • Weak stream, dribbling
    • A feeling of incomplete emptying
    • Pain

When episodes additionally occur during the day, it is more appropriately referred to as diurnal enuresis/incontinence.

Incontinence should be classified as primary or secondary.

  • Primary: the child has never been dry
  • Secondary: the child has been dry for a period of at least 6 months

 

Why does nocturnal enuresis occur?

Nocturnal enuresis is the result of inappropriate emptying of the bladder by the child and is the result of a mismatch between the neurones of the bladder and the conscious state of the child. This may be due to a multitude of factors including:

  • Maturation delay
  • Genetic factors
  • Nocturnal polyuria – this may be due to fluid intake, reduced response to antidiuretic hormone (ADH) and/or reduced production of ADH
  • Disturbed sleep in the child (controversial)
  • Small bladder capacity
  • Detrusor overactivity

These factors may be primary to the child (eg. genetic factors) or secondary to an underlying condition (eg. polyuria secondary to undiagnosed diabetes insipidus)

 

 


How to evaluate a child with nocturnal enuresis?

It’s almost all in the history – search for red flags!

History:

  • Onset
  • Previously dry?
  • Daytime symptoms (non-monosymptomatic NE)
  • Frequency, amount
  • Response to episodes
  • Fluid habits
  • Bowel habits
  • Sleep routines

 

Examination:

  • Height/weight
  • BP
  • Tonsillar hypertrophy/adenoidal facies
  • Abdomen (distended bladder, faecal mass)
  • Spine
  • Lower limb neurology
  • Perianal/vulval inflammation (pinworms)

 

Do you need to do investigations?

Investigations are not necessary for all patients and should be guided by history and examination. Consider:

  • Blood sugar level (fingerprick)
  • Urinalysis (m/c/s, electrolytes)

Imaging and blood tests are not routinely indicated.

 

What are the treatment options?

 

Important things to remember in treatment:

  • Tricyclic medications are not recommended as they are less effective and have a higher risk of adverse effects
  • Intranasal desmopressin is not recommended due to the risk of hyponatraemia
  • There are high rates of relapse when desmopressin is discontinued (60 – 70%) therefore best used as a short term measure (eg. for going to camp) whilst awaiting spontaneous resolution
  • Desmopressin should not be used in those who are unable to adhere to fluid restrictions (due to risk of hyponatraemia)
  • Treatments with weak evidence include elimination diet, hypnosis, retention control (holding urine for progressively longer periods), biofeedback, acupuncture, scheduled awakenings, caffeine restriction

 

Take-home messages

  • It doesn’t require treatment in those under the age of 6
  • It is common  although undertreated despite treatment options (and families potentially being eligible for funding)
  • It is usually a primary disorder rather than secondary to an underlying medical condition (although maybe particularly exacerbated by constipation)
  • Investigations are not routinely required
  • Treatment requires a motivated family, with behavioural measures and bedwetting alarms being the first line of treatment.

 

Selected references

Tu, Baskin, Arnhym et al (2019) “Nocturnal Enuresis in Childre: Etiology and Evaluation”. UpToDate.

Tu, Baskin, FAAP (2019). “Nocturnal Enuresis in Children: Management”. UpToDate.

The Royal Childrens Hospital. (2019). “Enuresis – Bedwetting and Monosymptomatic Enuresis.” Melbourne. Retrieved from: https://www.rch.org.au/clinicalguide/guideline_index/Enuresis_-_Bed_wetting_and_Monosymptomatic_Enuresis/

Thiedke C. “Nocturnal Enuresis”. American Family Physician (2003); April 1; 67(7): 1499 – 1506

Ramakrishnan K. “Evaluation and treatment of enuresis”. American Family Physician (2008); August 15; 78(4): 489 – 496.

Poop Patrol

Cite this article as:
Andrew Tagg. Poop Patrol, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.10986

It’s the one question that all parents seem to ask about their newborn – “Is this normal? How can such a small thing create such a lot of mess?” One of the things that stood out to me from Ross Fisher’s presentation on “What every Paediatric Surgeon wished you knew” was the line “There is no such thing as a normal bowel habit“. In an effort to avoid changing yet another nappy (diaper to some of you) I thought I would take a closer look.

Opioids and Constipation

Cite this article as:
Ben Lawton. Opioids and Constipation, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.6863

Opioids and constipation

 

The bottom line

-Opioids are an illogical choice for treating pain associated with constipation

-Pain needs to be treated promptly and effectively

-Abdominal pain requiring opioids should raise suspicion of a surgical diagnosis

 

Why are we talking about opioids and constipation?

This post arose from a twitter conversation that began with the question “Is it ever OK to use opioids for treating the pain associated with constipation?” some people said “No, never!

Why shouldn’t we use opioids to treat constipation?

A  universal side effect of opioid medication is constipation. In the case of codeine this comes without a useful analgesic effect in a significant proportion of the population so that one is definitely best avoided. Essentially in using opioid medication to treat constipation associated pain you are exacerbating the underlying problem.

Why should we use opioids to treat constipation?

Gone are the days when it was considered OK to leave a patient in pain so as not to reduce the physical signs that would be used to diagnose surgical disease. Pain management is one of the things that we can and should do rapidly and effectively for any patient of any age coming to see us in the ED.   Opioids are generally very effective analgesics and most staff in our departments will be comfortable with their use.

What are the alternatives?

Our usual go to medications, paracetamol and ibuprofen, are usually the first thing to try but simple interventions like hot packs are often helpful and underutilized.

How sure are we about the diagnosis?

Constipation can indeed be painful, sometimes dramatically so. It is also extremely common.   We often work on the principle that if you have a single, strong diagnosis that explains a patient’s symptoms then it’s OK to stop investigating.   There are of course exceptions to this rule. It’s an old joke that the hardest type of fracture to pick up is the second fracture and a subset of under-reporting errors in radiology has been assessed and published as being due to “search-satisfaction” or stopping looking because you have found one abnormality (1). This is relevant as although constipation can indeed cause pretty bad abdominal pain it is common enough that kids can be constipated and have appendicitis!!

What about enemas?

There are a few opinions about this but I think the role of enemas in managing constipation is extremely limited. Lots of constipated kids (indeed lots of kids in general) don’t like people putting things up their bottoms. Not only is it awkward even for fairly young children it is also often painful. Many constipated kids are in a vicious cycle of holding on because it hurts when they poo, which leads them to build up bigger and firmer stools, which makes it hurt even more when they do go to pass that stool. This not infrequently leads to anal fissures. These are exquisitely tender and do not respond well to being poked with plastic tubes. If constipation is an ongoing problem for a child then further visits to doctors or other health care professionals are likely and these become more difficult for the practitioner and, more importantly, distressing for the child if they come with a fear or even an expectation of someone hurting them.

Are enemas safe?

Microlax™ products are advertised for use in babies (they even have tips for use in infants on their website). Sodium phosphate or “fleet” enemas may be appropriate in older children but in smaller children and especially with repeat dosing the phosphate load carries a very real risk of causing hypocalcaemia with hypocalcaemic tetany having been reported after just 2 doses (2). It is hard to imagine many circumstances in which a phosphate enema is truly the best option for any child under 5. Certainly repeat dosing should be approached with extreme caution in any paediatric patient.

When should I call a surgeon?

The diagnosis of constipation really requires the consideration and exclusion of more sinister causes of abdominal pain. The usual red flags (bilious vomiting, significant abdominal distension, well localized pain, etc) should be actively sought and not overlooked should their presence be found. In this author’s opinion the repeated need for opiates to treat abdominal pain in children should be considered a red flag in itself and in most practice environments should prompt the involvement of the surgical team in the child’s care.

 

For more on constipation take a look at our week long series:- 

The basics

Understanding constipation

Treatment

Evidence on tough topics

Advice and information for parents

 

References

  1. Berbaum KS et al satisfaction of search in diagnostic radiology. Invest radiol 1990 feb;25(2):133-40
  2. Craig JC et al. phosphate enema poisoning in children. Med J aust 1994 Mar 21;160(6):347-51

Crack the back?

Cite this article as:
Andrew Tagg. Crack the back?, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.8591

A recent article in the Australian press has once again shone a spotlight on the practice of neonatal spinal manipulation by chiropractors.

Infantile colic can be hard on parents. As Ben points out here there is very little that we can do about it. It occurs in up to 30% of infants and peaks at around 6-8 weeks of age. It can severely impact the ability of both parents to bond with their child as they become progressively more deprived of sleep. Chiropractic therapy has been around since 1895 when Daniel David Palmer performed a manipulation on a partially deaf janitor and reportedly cured him of his affliction.

 

Is there any evidence that manipulation is of benefit in infantile colic?

A number of studies including this randomised controlled trial, suggest it is of no benefit though a small study by Wiberg et al compared spinal manipulation with dimethicone and noted a statistically significant reduction in hours spent crying in children that had seen the chiropractor. The same has been said to be true of occipital-sacral decompression -another manipulative technique. However, if you look more closely, the trials that show benefits are unblinded and thus open to bias.

The long term follow-up of these children suggested that they are much better two months after the treatment, but one must also consider the natural history of the disease. Colic disappears with time and so parents, who often subjectively report on their child’s symptoms using a crying diary, will always notice a reduction in colic and may falsely attribute it to the therapy. A short cut review by Hughes and Bolton (2002), agreed to the lack of efficacy when compared to placebo in the treatment of infantile colic, but suggested that parents might benefit from the time spent with the chiropractor. In a time-poor traditional health care system, private practitioners with more time to spend may exert a more powerful placebo effect.

Manipulation has also been suggested to be of benefit in a number of other gastrointestinal conditions such as reflux, constipation and inflammatory bowel disease, as well as unrelated disorders such as autism and ADHD.

Commentary in the chiropractic press suggests that given the lack of evidence of benefit for any standard treatment, that manipulation should be also be considered. The evidence there relies on small, single randomized trials coupled with case series and reports.

 

We often seem to do a lot of things in medicine with no clear evidence of benefit. Is there any evidence of harm with spinal manipulation?

It has been suggested that lack of benefit in some trials may be related to a dosing effect – the negative trial of Olafsdottir used up to three treatments only, whereas the positive trials extended the course of treatment. The theory being that just three treatments was not enough to make a difference but when the ‘dose’ of manipulation was increased to a full course then the benefit becomes more apparent. An audit of practice at a teaching practice in the UK suggested reactions occurred in 1 in 100 children with no serious adverse events reported. A recent literature review by the Journal of Manipulative and Physiological Therapeutics (the journal of the American Chiropractic Association) reported three deaths caused by high-velocity extension and rotational spinal movements. As well as death, a number of other adverse events have been reported including subarachnoid haemorrhage and paraplegia.

A recent article by a medical ethicist suggested that:

Any attempt to manipulate the immature, cartilaginous spine of a neonate or a small child to correct a putative chiropractic subluxation should be regarded as dangerous and unnecessary. Homola S. Pediatric Chiropractic Care: The Subluxation Question And Referral Risk. Bioethics. 2016 Feb 1;30(2):63-8.

With no clear evidence of benefit and certainly evidence of potential harm one wonders what the official bodies think about the manipulation of infant’s spines.

The Chiropractic Board of Australia has the following position statement on its website:

Current research indicates that the incidence of serious adverse events, either directly from manual therapy or indirectly by delayed or misdiagnosis, is rare but real. Given the lack of good quality evidence about chiropractic care of children, more research is required to better understand this issue.

However, this goes against the recommendations of the Chiropractic and Osteopathic College of Australia:-

…COCA expresses concern with respect to chiropractors, osteopaths and others, who employ spinal manipulation when providing care for children with non-musculoskeletal conditions. These non-musculoskeletal conditions include conditions such as colic, asthma, bed wetting and otitis media.

The best available evidence is either inconclusive or does not support the use of manual therapy for the treatment of non-musculoskeletal conditions in children [1,2]. In COCA’s view it is inappropriate to provide treatment that has been shown to be ineffective or where there is insufficient evidence to support its use when other available treatment options have been demonstrated to be beneficial.

And the president of the Australian Medical Association in 2013, Steve Hambleton, stated:-

We know there’s more and more chiropractors treating children for all sorts of things like infantile colic, like bed-wetting, like middle ear infections, all sorts of things for which it’s simply biologically implausible that manipulation…or doing anything with the spine is going to make any difference…You shouldn’t be doing anything with a young person…without significant levels of quality evidence.

 

Please read some of the literature and draw your own conclusions.

 

 

Selected references

Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Archives of disease in childhood. 2001 Feb 1;84(2):138-41. Full text here

Hughes S, Bolton J. Is chiropractic an effective treatment in infantile colic?. Archives of disease in childhood. 2002 May 1;86(5):382-4. Full text here

Ernst E. Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials. International journal of clinical practice. 2009 Sep 1;63(9):1351-3. Full text here

Wiberg JM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. Journal of manipulative and physiological therapeutics. 1999 Oct 31;22(8):517-22.

Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 2007 Jan 1;119(1):e275-83.