Assessing and managing constipation

Constipation in children with palliative care needs

Constipation is the infrequent or difficult passing of a stool that is usually hard. It is a common symptom and can be very distressing for both the child and the carer but can be managed effectively with a combination of diet and medication.

Causes of constipation

Constipation is caused by either functional, drug or disease-related factors.

Functional

Functional causes include inactivity, dehydration, incorrect diet, fear or pain when passing a stool, lack of privacy and embarrassment.

Side Effects

Side effects of medication such as opioids, chemotherapy, iron and anti-depressants can cause constipation.

Disease related

Disease related causes of constipation. Examples can include cystic fibrosis, cerebral palsy, abdominal tumours or masses.

When managing constipation in a child, treat and correct any underlying causes or reversible factors where possible. It is important to also explain to the child and the family that it might take a few days and different strategies to resolve any constipation issues.

Symptoms of constipation can be very uncomfortable, thus affecting quality of life. Some of those uncomfortable symptoms include bloating, flatulence, nausea, vomiting, painful defecation, fissures, overflow due to stool stones.

If the child is approaching end of life, focusing on comfort care, rather than aggressive management of the constipation, may be more appropriate.

Assessing constipation in children

1.   Take a full history by determining the following from the parents (and the child if they are old enough):

  • How long has constipation been a problem?

  • What are the size and consistency of the stools? Is there any leaking of liquid stool?

  • How often are stools passed – daily, weekly, sporadic?

  • Is there any anal pain or bleeding (fresh blood) when passing the stool?

  • How often does the child eat and what foodstuffs are included in the diet?

  • How mobile is the child?

  • What is the child’s daily fluid intake?

  • What medication is the child currently taking?

  • Are there any psychosocial issues like depression or anxiety?

  • Is the child vomiting and /or complaining of any abdominal pain?

2.  Complete a physical examination of:

  • The abdomen, listening for bowel sounds, looking for distension and feeling for any tenderness or palpable masses.
  • The anus and perineum to identify any fissures, abscesses or tears.
  • General status looking for signs of dehydration, malnutrition – either underweight or overweight.

Managing constipation in children with palliative care needs

Non-pharmacological strategies for managing constipation

Parents or caregivers should be encouraged to maintain a positive and supportive attitude throughout treatment and expect gradual improvement. Other strategies can include:

  • Education
    Education is the first step in treatment. Explain that faecal incontinence occurs from involuntary overflow of stool and not from voluntary defiance. Be supportive and don’t punish a child who has soiled his or her underwear. Parents should be encouraged to maintain a positive and supportive attitude throughout treatment and expect gradual improvement.

  • Dietary adjustments
    Simple changes in diet and routine help relieve constipation in children. A diet rich in fibre can help form soft, bulky stool- (apricots, prunes, plums, raisins, beans, whole grains, vegetables); decrease intake of constipating foods such as milk, yoghurt, banana, cheese. Start slowly, adding just several grams of fibre a day over several weeks to reduce the amount of gas and bloating that can occur in someone who’s not used to consuming high-fibre foods.

  • Adequate hydration
    Oral intake and appetite is often decreased in a palliative or end of life situation. Increasing both fluid intake and/or fibre poses a challenge and can have detrimental effects like bloating, nausea, vomiting and further worsen constipation if fibre is increased without sufficient fluids. GIT function is altered due to disease progression and metabolism is slow. In patients with limited oral intake, small amounts of fluid that are high in fructose content can be tried. Remember to monitor urine output.

  • Increase exercise
    Encourage ambulation, regular activity/exercise regimen to maintain bowel motility and function keeping in mind that tackling constipation via increasing physical activity in a very ill child might not always be possible.

  • Behavioural therapy
    Encourage frequent and regular daily bowel routines e.g. try to get the child to pass a stool every morning after breakfast. Both a detailed input and output history needs to be taken continuously to establish if constipation is evident as well as to monitor efficacy of interventions.

  • Adjust the environment
    Provide privacy and a quiet environment for anticipated bowel movements. Adjust toilet seats where necessary so the child is sitting upright. Where possible the feet should be placed flat on the floor to help with support and allow abdominal muscles to contract better. Positioning the child upright can be helpful as it helps stimulate bowel action.

  • Comfort and pain relief
    Massaging the child’s stomach helps in relaxing the intestinal muscles and regulating bowel movement. Abdominal massages by applying pressure on the area a little below the navel, can be tried to stimulate peristalsis and boost comfort. It can be a soothing and comforting measure for the child. Placing a warm hot water bottle on the abdomen has been helpful in terms of relieving cramps or bloating related to constipation. Where necessary assist, support and comfort during bowel movement where this has become a painful experience. Try lubricating the anus with KY Gel or Vaseline, distract with different measures and encourage the child through the process.

  • Use natural remedies
    Local herbal laxatives or foods can include coffee from the coffee Senna tree; dried crushed paw-paw seeds- 1-5 teaspoons at night; castor oil- 1 teaspoon to 1 glass of milk; 2-3 teaspoons of honey in a cup of milk, early morning on an empty stomach.

Pharmacological treatment of constipation for children with palliative care needs

Although non-pharmacological and preventative measures will help, pharmacological treatment is often necessary, as often the underlying cause of constipation is unavoidable.  The classification of oral laxatives are either predominantly softening or predominantly stimulating peristalsis.

As different laxatives have different methods of action, a decision should be made as to the which type of laxative to use. Children that are on long term opioids should ROUTINELY be placed on a laxative.

A combination of stool softener and a stimulant laxative is recommended, and should be chosen on an individual basis, but the potency, propensity to induce colic pain, and the ability to swallow large volumes of liquid are all factors that should be carefully considered when matching treatment to patients.

Types of laxatives

Action

Laxative

Predominantly softening Liquid paraffin
Bulk forming laxatives e.g. methyl cellulose, Ispaghula husk
Docusate sodium
Lactulose
Saline laxatives e.g. magnesium hydroxide
Predominantly peristalsis stimulating Anthracenes e.g. Senna, Danthron
Polyphenolics e.g. Biscadoyl, Sodium Picosulphate