Constipation in Children Failing treatment: What to do? Frances Connor .

Constipation in Children
Failing treatment: What to do?
Frances Connor
Paediatric Gastroenterologist
[email protected].
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