As Practice Nurses, we complete a lot of 4 year old health checks & it was becoming blaringly obvious that there is a significant percentage of children that still co-sleep, don’t sleep, are not toilet trained, refuse to use a toilet, have chronic constipation or all of the above! The Federal Government, in November 2016, decided to halve the funding a 4-year-old health check within a General Practice setting would receive, therefore it became more difficult to conduct these assessments impacting the rate of identification & management of these concerns [1]. At the Oakden Medical Centre, we are extremely fortunate to have Dr. Michaela Baulderstone, a GP who specialises in children’s health. She works as a brilliant mediator between General Practice & Specialist Care. After speaking with Michaela, we decided to team up & now we have the “Potties & Pillows Clinic”.
The ‘Potties’ section of the clinic significantly revolves around chronic Constipation with associated Nocturnal Enuresis (Bedwetting), & ‘Unique Challenges’, such as those children with learning difficulties, autism or inappropriate toileting behaviours.
Childhood constipation is a worldwide problem, with prevalence as high as 29% of children being diagnosed in some countries [2]. Ansari et al [3] states that ‘Childhood constipation is emerging as a significant public health problem’. In Victoria, the average annual cost to our health care system to treat childhood constipation was $5.5 million dollars, which includes over 8000 admissions to hospital each year.
Constipation is defined as difficulty in passing stools or incomplete or infrequent passage of hard stools [4]. Traditionally, the relief of constipation is thought to be an avoidance of any hard or formed stools. Ideally, stools are to be frequent & firm or a number 4 on the Bristol Stool Chart. What is the Bristol Stool Chart? The Bristol Stool Chart is a medical aid designed to classify faeces into seven groups depending on how much time the poo has spent in the colon [5].
There are many different types of constipation as child can present with such as a ‘sneaky poo’ or ‘soiling’. Even though it may present as diarrhoea of sorts, a child can experience a sneaky poo & soiling which is an overflow of faecal matter from a blockage higher in the colon. ‘Sneaky Poo’ is a term brought to light by Terry Heins & Karen Ritchie in the late 1980’s. They are/were Clinical Psychologists who wrote a booklet ‘Beating Sneaky Poo’ & it’s still available through the WCH website [6]. They referred to Sneaky Poo as a character who was naughty & got Minky into trouble by appearing at all the wrong times & Minky couldn’t control when Sneaky Poo was going to arrive. By comparison, a Sneaky Poo is a bowel motion, a formed piece of poo that sits nicely in the pants/nappy unawares whereas soiling is a ‘skid mark’ where the child was holding on to the motion but a smear was transferred onto the underwear. You can have one without the other or they may appear in collaboration & are a sign of Chronic Constipation. When you have a full rectum & a hard collection of poo higher in the colon, your nerve receptors along your rectum & anus switch off &the body can’t identify when there is a poo in the reservoir any more. This is how Sneaky Poos are not felt & also how chronic constipation compounds.
The Royal Children’s Hospital guidelines recommend Osmolax or Movicol as the first line of management [7]. Movicol has electrolytes within the powder form therefore there is less chance of dehydration when trying to get things moving & it also can be bought in different flavours, which is also an added benefit when working with kids! On the other hand Osmolax is easier to titrate dosages & is completely flavourless. Both have their advantages, therefore parents are able to use whichever they feel is easiest in their household setting. Above all, healthy eating, regular toileting & consistent dietary management for these children is the best practice & avoids unnecessary hospital admissions [8].
Once a Bristol 4 stool is consistent, the child has to continue with the titrated medication for at least 6 months before the above mentioned nerve receptors turn back on. Constipation is not a quick fix & unfortunately the impact that constipation has on child’s life is phenomenal. It quickly affects their mental health, social interactions, friendships & physical wellbeing. It can also impact on the parent’s lives as well due to parents being afraid of ‘how will they start kindy’, ‘who will be their friend’ & ‘will they have be able to attend a sleep over’.
Many of the children that present to the Potties & Pillows clinic with constipation, also have bedwetting on a background of autism &/or intellectual disability. It is overwhelming for both the child & parent to manage both at the same time, therefore we concentrate on one at a time. It’s very difficult to treat bedwetting whilst being clogged up, so constipation is the priority & we find that often the bedwetting can resolve itself. The treatment protocol doesn’t change for these children, only the way we present it & troubleshooting is a little more complex. Within the Potties & Pillows clinic, we work with reward charts, prizes & positive reinforcement in association with frequent visits for encouragement & a review of progress.
In summary, with appropriate toilet training, encouraging healthy dietary habits & if required medication intervention, the impact on our public health could be significantly decreased.
[2] Childhood constipation as an emerging public health problem
[4] Better Health Channel - Constipation
[5] Continence Foundation of Australia - Bristol Stool Chart
[6] Womens & Childrens Hospital - Sneaky Poo
[7] RCH Clinical Practice Guidelines
[8] Potentially avoidable hospitalisation for constipation in Victoria, Australia in 2010-11.
