The Poo Passport

1 1 The Poo Passport Patient name: _____ Date of Birth: _____ GP Name: _____ Date of Referral: _____ Seen By Consultant: _____ Date of next appointment: _____ 2 Contact details Colorectal/ Stoma CNS Ann Costigan & Stephanie Orr 014096100 bleep 752 PATHWAY OF TREATMENT FOR CONSTIPATION TREATMENT Referral to Surgical OPD Reviewed by Surgeon Complete A, B, C section Treat impaction if needed according to treatment plan Diagnosis Idiopathic Constipation Underlying Cause Follow up Refer back to source With Poo Passport and treatment plan for follow up. Treatment plan Refer to CNS OPD appt.

2 Name: _____HCRN: _____ 3 Section A: Key components of history-taking Name: _____ HCRN: _____History-taking: Childhood constipation 1 year and older Stool patterns and symptoms: indicate by circling the correct response for each question Stool type is based on the Bristol Stool Form Scale Does the child or young person have a bowel movement (poo) fewer than three times a week (stool type 3 or 4)? See pg 15 YES NO Does the child or young person pass large hard stools? YES NO Does the child or young person pass rabbit droppings (type 1) YES NO Have you noticed any soiling (very loose, very smelly stool passed without sensation) in recent days?

3 YES NO Does the child or young person have poor appetite that improves with the passage of a large stool? YES NO Does the child or young person experience abdominal pain that comes and goes with the passage of stool? YES NO Is there evidence of retentive posturing (ie. typically straight-legged, tiptoed, back arching posture)? YES NO Does the child or young person strain when passing stools? YES NO Does the child or young person experience anal pain? YES NO Has the child or young person had any previous episodes of constipation or the present symptoms? YES NO Have you noticed any cracks or tears in the anal region? YES NO Does the child or young person bleed when passing stools? YES NO Total number of YES answers Two or more YES answers indicate constipation 4 Section B: Key questions to diagnose idiopathic constipation If the result of part 1 indicates constipation use these questions to excluding underlying causes and establish a positive diagnosis of idiopathic constipation.

4 Tick findings in relevant box 1. When was the onset of constipation? After a few weeks of life Indicates idiopathic constipation Birth or first few weeks of life Indicates an underlying disorder 2. When did the child pass meconium? Within 48 hours after birth (in term baby) Indicates idiopathic constipation More than 48 hours after birth (in term baby) or not at all Indicates an underlying disorder 3. Does the child or young person pass ribbon stools ?? Yes Indicates an underlying disorder 4. Are there any concerns about the growth and general wellbeing of the child? No: generally well, weight and height within normal limits, fit and active Indicates idiopathic constipation Yes: faltering growth1 Possible idiopathic constipation 5.

5 Does the child or young person have a good diet with adequate fluid intake? No Indicates idiopathic constipation 6. Is the abdomen of the child or young person distended and are they vomiting? Yes Indicates an underlying disorder If any symptoms indicate an underlying disorder, refer the child or young person urgently to a healthcare professional with experience in the specific aspect of child health that is causing concern. Do not treat them for constipation. 1 If the history-taking and/or physical examination show evidence of faltering growth treat for constipation and test for hypothyroidism and coeliac disease. See also Coeliac disease: recognition and assessment of coeliac disease (2009) NICE clinical guideline 86.

6 5 Section C: Key components of physical examination to diagnose idiopathic constipation 2 Tick findings in relevant box Normal appearance of anus and surrounding area Indicates idiopathic constipation Abnormal appearance / position / patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus, anteriorly placed anus, absent anal wink Indicates an underlying disorder Soft abdomen: flat or distension that can be explained because of age or excess weight Indicates idiopathic constipation Gross abdominal distension Indicates an underlying disorder Normal appearance of the skin and anatomical structures of lumbosacral/gluteal regions Indicates idiopathic constipation Abnormal: asymmetry or flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi or sinus, hairy patch, lipoma, central pit (dimple that you can t see the bottom of), scoliosis Indicates an underlying disorder Normal gait.

7 Normal tone and strength in lower limbs Indicates idiopathic constipation Deformity in lower limbs such as talipes Abnormal neuromuscular signs unexplained by any existing condition, such as cerebral palsy Indicates an underlying disorder Reflexes present and of normal amplitude Indicates idiopathic constipation Abnormal reflexes Indicates an underlying disorder 2 If either the history-taking or the physical examination show evidence of possible maltreatment treat for constipation and refer to NICE guidance on When to suspect child maltreatment , NICE clinical guideline 89 (2009). 7 TREAMENT PLAN 1. Bowel clear-out Bisacodyl 1-5 yrs old 1 tablet a day for 3 5 days >5 yrs old 2 tablets a day for 3 5 days OR Movicol Paediatric Plain (sachets per day) Age(yrs) Day 1 2 3 4 5 6 7 2-4 2 4 4 6 6 8 8 5-11 4 6 8 10 12 12 12 2.

8 Prevent recurrence/ Maintenance Movicol Paediatric Plain 1-2 sachets a day (dose can be titrated up). Children who withhold need very soft stools for months. Less than 1year old can use lower doses ( - 1 sachet should be used initially) May add: Senokot 2-6 yrs: mls ( ) <6 yrs tablets( )not recommended 6-12yrs: 5-10mls or 1-2 tablets ( ) >12 yrs: 10-20mls or 2-4 tablets(15-30mgs) OR Liquid Paraffin can be used in children over 1yr if not at risk of aspiration. Dose = 1-2mls/kg/day AND/OR Lactulose can be used in children under 1yr <1mt: 1ml/kg 1mt-1 year: twice a day 1-5 years: 5mls twice a day 5-10 years: 10mls twice a day >10 years: 15mls twice a day AND/OR Senokot (liquid 15mgs/10mls, tablet ) 2-6 yrs: mls ( ) 6-12yrs: 5-10mls or 1-2 tablets ( ) >12 yrs: 10-20mls or 2-4 tablets (15-30mgs) 3.

9 Bowel training Establish regular bowel habit: See Constipation in the next section 8 Specific plan for _____ Date: _____ For bowel clear out: _____ Maintenance therapy: _____ Please do not discontinue medications without speaking with a medical professional. Daily plan: key points Medication as prescribed (Clear out and maintenance) Toileting 20-30 mins after main meals with correct positioning Increase fluid intake Regular meals, normal balanced diet Regular exercise 9 CONSTIPATION Constipation is a very common condition in children and occurs when your child does not pass a stool often enough (less than 3 times per week). However, there are also some children who appear to be doing a poo every day, but in fact they are not emptying their bowel properly and only passing small amounts of stool.

10 CONSTIPATION WITH SOILING Some children with long-term constipation may also have a soiling problem. This is caused by overflow of loose stool around the blockage created by the hard, impacted bowel motions; your child is then unable to control the soiling. Soiling is usually because of constipation. Soiling is a source of major tension within a family where the parents believe that the soiling is intentional. The child through shame or fear may hide the soiled underwear thus confirming the parent s impression of bad behaviour. CAUSES OF CONSTIPATION Poor diet and/or low fluid intake Avoidance of passing stool (often a consequence of the fear of pain when passing stool or embarrassment) Medical conditions that affect the bowel Whatever the cause, the initial treatment and management is the same 10 ADVICE TO PARENTS/CARERS Remember that the child is not soiling deliberately Make tackling the problem a joint effort Help the child to keep a diary of diet, fluid intake and bowel activity.