Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Constipation
CONSTIPATION
A decrease in the frequency and bulk or liquid content of the stool. The term constipation refers to the character and consistency of the stool rather than to the frequency of bowel movements. Constipation is characterized by stools that are small, hard, and dry.
Encopresis refers to the syndrome of fecal soiling or incontinence secondary to constipation or incomplete defecation. It occurs in a child over 4 years and may be involuntary or intentional.
I. Etiology
A. Mechanical or anatomic (e.g., megacolon, anal stricture, obstruction)
B. Psychological
1. Disruption of child’s routine
2. Improper toilet training techniques, such as early, aggressive training
3. Encopresis
C. Withholding: With a busy, active lifestyle, child ignores urge to defecate.
D. Anal fissure: Withholding due to pain
E. Dietary: Too little fiber, too much milk
II. Incidence
A. Frequently seen in childhood and adolescence, both as a chronic and as an occasional interruption of normal bowel patterns
B. Often a familial complaint
III. Subjective data
A. Decrease in frequency of stools
B. Stools hard, dry, and small, or unusually large
C. Straining with bowel movement
D. Pain with defecating
E. Staining: Intermittent or constant
F. Recurrent abdominal pain in approximately 60%
G. Pertinent subjective data to obtain
1. Usual pattern of elimination
2. Description of stools
3. Duration of constipation
4. Frequency of episodes of constipation
5. Detailed dietary history
6. Use of laxatives
7. Treatment tried and its effectiveness
8. History of difficult bowel training
9. Psychosocial factors
10. Availability of bathroom facilities and other factors, such as privacy
11. Enuresis (occurs in about 30% of children with encopresis)
IV. Objective data
A. Abdominal examination
1. Inspection for abdominal distention and bowel sounds
2. Auscultation for bowel sounds
3. Percussion
4. Palpation; stool palpable in lower left quadrant (LLQ)
B. Anus: Fissures
C. Rectal examination
1. Check for normal placement of anus and that anal sphincter is intact and a stricture is not present.
2. Rectum may be dilated and full of stool.
D. Check for hypotonia, normal growth patterns, hyperreflexia, and signs and symptoms of systemic disease that may cause constipation.
V. Assessment
A. Diagnosis of constipation and its underlying cause is usually made by a detailed history. An abdominal flat plate (KUB) may be done to confirm diagnosis.
B. Differential diagnosis
1. Normal straining of infancy: Stools are soft.
2. Hirschsprung’s: Staining or soiling is rare; ampulla is empty on rectal exam; history of constipation present since birth.
3. Encopresis: Staining; feces in the rectal ampulla
VI. Plan
A. If constipation is significant when the child presents, a pediatric Fleet enema may be indicated for immediate relief.
B. Retrain bowels.
1. Encourage child to sit on toilet for 5 minutes, 20 minutes after meals.
2. Explain gastrocolic reflex.
C. Osmotic and lubricant laxatives
1. Miralax (more than 6 months): 0.7–1.5 gm/kg/d or
2. Lactulose: 1 mL/kg/d in 1–2 divided doses (maximum 60 mL/d) or
3. Mineral oil: 1–3 mL/kg/d. Do not use in infants, children with GER, and children with neurological impairment, may be aspirated.
4. Once stools are soft, daily dosage can be reduced.
5. Continue use for 2 to 3 months until regular bowel habits are established.
D. Dietary changes: Increase fiber, fluids, fruits, vegetables.
E. If child is toddler and not completely toilet trained, put him or her back in diapers and eliminate all pressure (e.g., from parents, grandparents, other caretakers).
F. Constipation with encopresis
1. Initial “clean out”: Fleet enema for 1 to 5 consecutive days. Do not use if child has pain with defecation or anal fissure.
2. Mineral oil: 15–30 mL/year of age up to 240 mL/d. Give until stools are loose to the point of incontinence, then decrease dosage gradually until child has 1 to 2 soft stools daily. Do not use in children with GER or neurological impairment because of danger of aspiration.
or
3. Miralax: 1–1.5 gm/kg/d for 3 days
4. Titrate dosages up or down depending on response. It may take 3 to 4 weeks to determine the optimum dose.
6. “Toilet” at regular intervals, 20 minutes after meals.
7. Increase dosage of water-soluble vitamins (vitamin B complex and vitamin C) while on mineral oil.
8. High roughage diet: Bran, cereals, vegetables, fruits
9. Do not put pressure on child; treatment must be approached in a calm, relaxed manner.
10. Repeat clean out in 2 weeks if child is not free from soiling.
11. Contract with child and family for regular follow-up to ensure regimen is effective.
G. Anal fissure
1. Stool softeners as above
2. Sitz baths
VII. Education
A. Avoid laxatives and enemas for simple constipation (except as initial “clean out”)
B. Every person’s bowel habits are unique; a daily bowel movement may not be the norm for everyone.
C. Dietary changes
1. Increase water intake.
2. Increase high-residue foods (green vegetables and fruits).
3. Include bran and whole-grain products in diet.
4. Reduce intake of cheese and milk, which may be constipating.
D. Gastrocolic reflex is a mass movement of colon contents occurring about 20 minutes after a meal.
E. With a busy lifestyle, the child may not take time to go to the bathroom.
F. Make sure that a bathroom is available for child when needed. If child is of school-age, discuss with the school nurse, and make arrangements for private bathroom time after lunch.
G. Make bathroom time relaxed and unhurried.
H. Keep special books—such as normally forbidden comic books—for relaxation in the bathroom.
I. If child is a small preschooler, toilet may be too big; instead, use a small, portable one.
J. Stool softeners are not laxatives and are not habit forming. They prevent excessive drying of stool and are not effective if child is withholding.
K. Mineral oil, lactulose, or milk of magnesia may be administered in juice.
L. If away from home, child may not use bathroom facilities because of unfamiliarity with them or their lack of cleanliness or privacy.
M. Review toilet training techniques (see p. 178).
1. When to start: Child indicates readiness
2. How to proceed
N. Explain physiology of constipation to parent:
1. Because of discomfort from either a hard stool or an anal fissure, child withholds stool.
2. Stool collects in the rectum and, over time, rectum dilates and propulsive peristaltic action decreases.
3. As volume of rectum increases, sensation decreases.
4. Constipation becomes self-perpetuating and often more severe with time.
5. In encopresis, because of the enlarged rectal vault, the external anal sphincter relaxes, allowing loose or mushy stool to leak out around firm stool in rectum. Child has no sense of need to defecate and little or no control over leakage.
O. Water-soluble vitamins are B vitamins (thiamine, riboflavin, nicotinic acid, pyridoxine) and vitamin C.
P. Because excesses of water-soluble vitamins are excreted in the urine, the danger of toxicity is low.
Q. Use “gold star chart” with appropriate rewards for compliance.
VIII. Follow-up
A. Telephone call in 1 week to report; repeat telephone contact at intervals indicated by scope of problem.
B. If child is old enough, have him or her make the telephone calls.
C. With chronic constipation or encopresis, recheck every month until rectal vault has returned to normal size.
D. Treatment for constipation or constipation with encopresis may take from as little as 6 months to as long as 2 to 3 years.
IX. Complications
A. Encopresis
B. Anal fissure
C. Impaction
X. Consultation/referral
A. Constipation with encopresis: Refer for psychological evaluation if child has poor response to treatment or exhibits emotional problems in other areas.
B. Recurrent fecal impaction
C. Failure to thrive