Flowchart - Constipation Every child must be fully assessed using the appropriate Continence Assessment Form. If constipation is identified, follow the flowchart below to ensure the child receives the correct assessment, treatment and management. The ‘pop-up’ information boxes suggest who might deliver each intervention. In England the local CCG (Clinical Commissioning Group) can clarify who is commissioned to do so. Information to support the commissioning of children’s continence services can be found in the PCF’s Paediatric Continence Commissioning Guide. In Scotland and Wales, ask your GP, Health Visitor or School Health Nurse for advice on who provides local continence care. Back to the Children's General Continence Flowchart Constipation identified by GP GP to inform/refer to School Health Nursing / Health Visiting / Children’s Community Nursing / Learning Disability Team Constipation identified by School Health Nursing / Health Visiting / Children’s Community Nursing / Learning Disability Team Child to be referred to GP DEMYSTIFICATION Discuss causes Explain symptoms Discuss treatments Explain prognosis CHILD TO BE ASSESSED for underlying organic cause: Check appearance of anus and surrounding area to exclude anorectal anomaly Check lower limb neurology and appearance of spine to exclude neurological link e.g. spinal anomaly Check for abdominal mass Check for faltering growth See 'Constipation in kids' poster for visual guide to red flags WHO DOES THIS?Physical examinations are usually performed by doctors – this might be your GP, school doctor or paediatrician. Some nurse specialists / practitioners also do physical examinations Breastfed baby? Provide Breastfed Babies and Constipation No concerns. Idiopathic constipation diagnosed If concerns refer as appropriate Found or suspected ASSESS FOR FAECAL IMPACTION: use a combination of history taking and physical examination – look for overflow soiling and/or faecal mass. DO NOT use rectal examination unless specifically indicated WHO DOES THIS?It may be apparent from discussion between child/parent and School Health Nurse / Health Visiting / Children’s Community Nursing / Learning Disability Team that the child is impacted. The doctor or nurse providing their prescription will confirm the suspicion DISIMPACTION: Demystify, reassure, educate Provide leaflet ERIC’s Guide to Children's Bowel Problems for information including toileting advice Disimpact following NICE Guidance – use oral paediatric macrogol in increasing doses until watery stool passed Write to GP to request macrogol laxative if necessary – see Template Letter for GP re Macrogols Provide A Parent’s Guide to Disimpaction, How to Prepare Macrogol Laxatives Offer to contact school re potential absence - see Template Letter for School re Disimpaction WHO DOES THIS?The paediatric macrogol is usually prescribed by the GP or paediatrician. Some nurses prescribe too. The information may be provided by them but may be supplemented by the School Health Nurse / Health Visiting / Children’s Community Nursing / Learning Disability Team and/or ERIC Not impacted MAINTENANCE: Demystify, reassure, educate Offer Poo Diary Signpost to ERIC for further information/reassurance and advice on toileting, children’s disposable pads etc Provide leaflet ERIC’s Guide to Children's Bowel Problems Do not use dietary interventions alone as first-line treatment Continue oral macrogol titrating dose to achieve at least one soft stool per day. Write to GP to request macrogol laxative if necessary – see Template Letter for GP re Macrogols Provide family with How to Prepare Macrogol Laxatives Reassure regarding safety of long term use of laxatives Advise family to maintain adequate fluid intake and dietary fibre Advise daily physical activity Advise regular toileting programme – offer Toileting Reward Chart Advise re management of any Smearing WHO DOES THIS?The paediatric macrogol is usually prescribed by the GP or paediatrician. Some nurses prescribe too. The information may be provided by them but may be supplemented by the School Health Nurse / Health Visiting / Children’s Community Nursing / Learning Disability Team and/or ERIC NICE Guidelines on constipation in children and young people Constipation pathway Quality standard Peristeen transanal irrigation system FURTHER INTERVENTIONS: Child to be offered a range of rectal interventions to manage ongoing bowel emptying problems and prevent soiling Stepwise approach to be used, offering smallest and least invasive options first – see ERIC Poo Ladder Write to GP to request chosen intervention - see Template Letter for GP re rectal interventions See Links to Bowel Equipment Product Information for prescribing information Provide leaflet ERIC's Guide for Children living with Complex Bladder and Bowel Problems GP to ensure child receives annual review - by GP or by Paediatric Continence Service or equivalent Symptoms improved Symptoms ongoing Provide information and leaflets as appropriate and discharge Refer to Paediatric Continence Service or equivalent local service using Referral Form