1 / 41

Constipation and Enuresis

Constipation and Enuresis. Katie Mallam Paediatric Update for Primary care 9 th October 2012. Constipation – Why?. Common Prevalence 5-30% 1/3 become chronic (>8 weeks) = soiling Debilitating Social, psychological and educational consequences Cost

elisa
Télécharger la présentation

Constipation and Enuresis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Constipation and Enuresis Katie Mallam Paediatric Update for Primary care 9th October 2012

  2. Constipation – Why? • Common • Prevalence 5-30% • 1/3 become chronic (>8 weeks) = soiling • Debilitating • Social, psychological and educational consequences • Cost • Longer duration = longer, more intensive treatment • Varying advice = angry parents

  3. Constipation – NICE • Standardise approach • Early treatment • Reduce consequences and cost • No need to remember history and examination: http://guidance.nice.org.uk/CG99/Questionnaire

  4. Constipation? 2 of …….. * Breast fed babies can go up to a week without opening bowels *

  5. Constipation? http://www.childhoodconstipation.com/Extra/Documents.aspx

  6. Constipation? 2 of …….. * Breast fed babies can go up to a week without opening bowels *

  7. Constipation – Causes • Mostly idiopathic • Rarely • Hirschsprung’s • Neurological NB lumbosacral abnormalities • Anorectal malformations • Hypothyroid • Coeliac • Cystic fibrosis (but normally diarrhoea due to fat malabsorption) • Cow’s milk protein intolerance • Associations • Cerebral palsy • Autism • Down’s syndrome (NB beware hypothyroidism and Hirschsprung’s)

  8. Constipation – History 1

  9. Constipation – History 2 Faltering growth = treat and do coeliac and TFT (refer)

  10. Constipation – Examination No PR in primary care NB perianal strep

  11. Perianal streptococcal infection Swab Treat infection and constipation

  12. Constipation – Examination No PR in primary care NB perianal strep

  13. Constipation – It’s NICE • No need to remember history and examination: http://guidance.nice.org.uk/CG99/Questionnaire < 1 year ≥ 1 year

  14. Constipation – Actions • Red (or amber) flags • Refer paeds • No red flags • Reassure • Explain constipation and treatment (could just do briefly and give patient information using resources in ‘Explain 2’ slide) • Treat

  15. Constipation – Explain 1 • Rectum gets used to being full: normal reflexes and power are reduced = ‘baggy’. • Reduced sensation and overflow: soiling is not intentional • Need to ‘get empty and stay empty’ for rectum to shrink back and recover reflexes and sensation: takes time

  16. Constipation – Explain 2 • Tameside = comprehensive leaflet • Patient.co.uk = very good, can print pdf leaflet • ERIC = lots of info for professionals and parents/patients (age banded) http://www.eric.org.uk/ • NICE ‘template letter’

  17. Constipation – Treat • Get empty, stay empty! • Faecal impaction? • Soiling • Abdominal mass • Movicol, movicol, movicol! • NB different strengths e.g. Paed Plain = no taste • ‘Softeners’ • Movicol, Lactulose, Docusate (also squeezes) • ‘Squeezers’ • Senna, sodium picosulphate, bisacodyl • Doses as per BNFc or NICE

  18. Constipation – Get empty • Disimpaction • Aiming for liquid and no more lumps = messy • Review after 1 week • Movicol • If not tolerated = stimulant laxative +/- lactulose • If not worked after 2 weeks = add stimulant laxative and urgently refer to Paeds • Enemas and manual evacuation only if all else failed

  19. Constipation – Stay empty 1 • Maintenance • Until rectum no longer stretched and reflexes return • Laxatives do not make bowel lazy: may need for several years and should be gradually reduced • Movicol • If not tolerated = stimulant +/- lactulose, or docusate alone • If not effective = add stimulant

  20. Constipation – Stay empty 2 • Behavioural • Non-punitive (I say ‘training the subconscious’) • Regular toileting after meals • Foot support, sit forward (rock and pop!), bubbles, books • Diary and rewards (things under their control) • NB school (NB ERIC info) • Use school nurses and HV

  21. Constipation – Stay empty 3 • Fluids Page 15, NICE Quick Reference Guide http://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf

  22. Constipation – Stay empty 4 • Diet • High Fibre = fruit, veg, high fibre bread, wholegrain breakfast cereals, baked beans • Activity

  23. Constipation – Failed treatment • Disimpaction has failed if not responded to Movicol after 2 weeks: • Urgent referral to Paeds (or Bladder and Bowel Specialist Nurse) • Maintenance has failed: • In those aged <1 year, if not responded after 4 weeks • Refer paeds • In those aged ≥ 1 year, if not responded after 3 months • Check no red flags • If red flags = refer paeds • No red flags = refer to the Bladder and Bowel Specialist Nurse Service

  24. Constipation Toolkit • RED FLAGS, refer paeds • History and examination questionnaireshttp://guidance.nice.org.uk/CG99/Questionnaire • Bristol Stool Chart • EXPLAIN: Tameside leaflet • IMPACTED? GET EMPTY, STAY EMPTY! • Medical: usually Movicol Paed Plain as per BNFc • Non Medical: see Tameside leaflet and fluid rqmts on page 15 of NICEhttp://www.nice.org.uk/nicemedia/live/12993/48754/48754.pdf • If fails, add stimulant • Disimpaction failure, refer paeds • Maintenance failure, refer Bladder and Bowel Specialist Nurse

  25. Enuresis - definitions • Incontinence • uncontrollable leakage of urine • Enuresis • Incontinence of urine when sleeping: usually say Nocturnal • Bedwetting: ‘involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology’ (NICE) • Primary • Secondary = previously dry for ≥ 6 months

  26. Urinary Incontinence – History 1 • Secondary (especially recent): • UTI • Diabetes (drinking overnight) • Constipation • Neurological: spine and lower limb exam • Emotional/behavioural difficulties: consider psychology Urine dipstick NB same day referral if suspect diabetes

  27. Urinary Incontinence – History 2 • Pattern of bedwetting • Variable volume, >1 per night: could be Overactive Bladder • Daytime symptoms • Urgency, Frequency >7/day, Infrequent <4/day, straining, pain • Consider UTI, Overactive Bladder, Neuro/Uro cause • Urine dipstick • If significant, refer to consider investigation/treatment of those symptoms first • Toileting patterns • NB School • Fluid intake • Check not restricting Diary

  28. Urinary Incontinence – History 3 • Effect on child/YP/family • Social (sleep-over), self-esteem • PMHx: • UTI • Developmental, attention or learning difficulties: consider specific management

  29. Urinary Incontinence – Examination • Primary Nocturnal: not required according to NICE • Secondary Nocturnal or Daytime Symptoms: • Genitalia • Abdomen • Spine • Lower limb neuro

  30. Urinary Incontinence – Referral • RED FLAGS = recurrent UTI, Diabetes, examination abnormalities: • refer paeds • No red flags • Nocturnal only: • refer HV or school nurse • Day only, or Nocturnal with daytime symptoms: • refer to Bladder and Bowel Specialist Nurse

  31. Enuresis – NICE • Principles of Care • Not their fault: non-punitive management • Tailor management to child/YP and parent/carer • Consider parental support • Do not exclude <7y • Reassure

  32. Enuresis • Prevalence

  33. Enuresis – NICE • Principles of Care • Not their fault: non-punitive management • Tailor management to child/YP and parent/carer • Consider parental support • Do not exclude <7y • Reassure • Trial of BASICS • <5y: encourage toilet training if not done already and trial out of nappies at night

  34. Enuresis – Management BASICS! • Fluids: avoid caffeinated (and ?fizzy and blackcurrant) • Regular toileting 4-7/day • NB double voiding if Overactive Bladder symptoms • Trial out of nappies/pull-ups: offer alternatives • Reward system: for agreed behaviour (not dryness)

  35. Enuresis – Information • NHS choices: concise, for parents http://www.nhs.uk/Conditions/Bedwetting/Pages/Introduction.aspx • Patient.co.uk: concise, for parents http://www.patient.co.uk/health/Bedwetting.htm • ERIC: all ages, parents, professionals http://www.eric.org.uk/

  36. Enuresis – Alarm • High long-term success rate (weeks) • But need commitment and can disrupt sleep • Contraindications: • < 1-2 wet nights/week • Parental distress or negativity (consider parental support) • Need training • Hence referral to HV/school nurse • http://www.patient.co.uk/health/Bedwetting-Alarms.htm • Encourage to combine with reward system • Get up and go to toilet, help change sheets

  37. Enuresis – Desmopressin • Rapid, short-term results (sleep-over) • Alarm is inappropriate or undesirable • Inform them: • many relapse when treatment is withdrawn • how desmopressin works • fluid restriction from 1 hour before until 8 hours after taking desmopressin • that it should be taken at bedtime • how to increase the dose if the response to the starting dose is not adequate • that treatment should be continued for 3 months • that repeated courses can be used • Stop during sickle cell crises or D&V http://www.medicinesforchildren.org.uk/search-for-a-leaflet/desmopressin-for-bedwetting/

  38. Enuresis – Other treatments • Only on advice of specialist • Anticholinergic with desmopressin • Oxybutinin • If: • Not responded to desmo+/-alarm • Daytime symptoms • Imipramine • Gradual increase and withdrawal • Warn re dangers of OD • http://www.medicinesforchildren.org.uk/search-for-a-leaflet/

  39. Secondary: think other causes esp Diabetes Examine if Secondary or Daytime Refer all? Red flags = paeds Others = HV/school nurse/BBSN Basics Give/direct to information Urinary Incontinence – Top tips

More Related