Constipation

Constipation is a common problem in childhood; depending on the criteria used to diagnose the condition, the prevalence may be as high as 30%, and in one‐third of those the condition becomes chronic (NICE, 2010).

The cause of constipation may be dietary, an underlying disease or as a result of psychological factors, or it may be idiopathic and therefore have no known cause. It may also be as a result of defects in filling or emptying of the rectum, such as in Hirschsprung disease, stricture or stenosis. Constipation in infancy is uncommon and most often associated with changes of diet, such as from breastfeeding to cow’s milk due to the protein content. The most common time for the condition is during toddler and childhood years when withholding of stool may be the cause because of the unpleasant sensations associated with defecating. In the older child it is more commonly associated with lack of fibre in the diet and a sedentary lifestyle. Children and young people with physical disabilities and associated impaired mobility are more prone to constipation.

Signs and symptoms may include: abdominal pain, abdominal distension, hard painful stools, a decrease in stool frequency, excessive flatulence, lack of appetite, general malaise, constipation with faecal soiling (encopresis), and irritability. Diagnosis is made on a thorough history of stool frequency and consistency, and a physical examination. Early diagnosis and treatment of an acute episode of constipation is important in order to prevent the condition becoming chronic. Early identification of constipation and effective treatment can improve outcomes for children and young people (NICE, 2010).

The first line of treatment for constipation that has no underlying pathological cause is dietary management. However, for children with impacted faeces an enema and/or laxatives will be administered, accompanied by both behavioural interventions and dietary modification to ensure a balanced diet and adequate fluid intake. The goals for management are to restore and maintain regular toileting routines and evacuation of stool. Nursing care focuses on teaching patents about normal bowel patterns in children and the appearance of a normal stool. Families need reassurance that establishing normal patterns can take time and they need to be persistent and consistent, and provide the child with positive reinforcement.

Vomiting

Vomiting is one of the most common symptoms in childhood. In infants it is normal to regurgitate small amounts of milk, called posseting, but in childhood it is often due to gastroenteritis. It may also be associated with other conditions, see Table 12.2 for some of the causes. The history of vomiting and associated symptoms may help to identify the cause. Vomiting in childhood is usually self‐limiting with no treatment required; however, complications can occur and these may include: dehydration, electrolyte imbalances, aspiration or malnutrition.

The vomiting reflex is under the central nervous system control, specifically the medulla. Nausea, meaning the desire to vomit, is a sensation that may be induced by a number of causes including inner ear, visceral or emotional stimuli. It may lead to retching due to contraction of the abdominal muscles.

A thorough history should be taken to ascertain the underlying cause alongside a physical examination to identify any abdominal pain or dehydration. The type of vomitus and its relation to meals or specific foods, behaviour and any accompanying pain need to be ascertained. It is also important to assess for the presence of constipation, diarrhoea or jaundice. Other causes, such as urinary infections, brain tumour, and any anatomic abnormalities, need to be ruled out with diagnostic tests, such as blood and urine analysis, X‐ray, and brain scan. If a cyclic vomiting pattern is present, it may indicate an eating disorder such as bulimia, and therefore a psychiatric assessment may be needed.

If the vomiting persists for more than 24 hours, parenteral fluids may need to be considered in order to correct or prevent dehydration. Anti‐emetic drugs are usually only administered in cases of extensive post‐operative vomiting, chemotherapy‐induced vomiting, or for travel sickness. Nursing care is determined by the cause of the vomiting but in general includes observing the type of vomit, placing the infant or child who is vomiting in a position to prevent aspiration, cleaning the mouth after vomiting to prevent the acid damaging teeth, assessing for dehydration, carrying out routine observations and encouraging small amounts of fluid regularly when tolerated. Once vomiting has ceased, fluids and small amounts of diet can be encouraged.

Gastro‐oesophageal reflux

Gastro‐oesophageal reflux (GOR) refers to the return of gastric contents into the oesophagus, and is a common symptom affecting 40% of infants and young children (NICE, 2015a). The cause of GOR is a poorly functioning gastro‐oesophageal sphincter, which normally prevents stomach contents from regurgitating back into the oesophagus. Some positing of milk is considered normal in newborns following a feed; however, regurgitation that continues or increases requires further investigation. Infants with reflux are at risk of aspiration and apnoea, particularly if lying down.

GOR usually begins before the infant is 8 weeks old and may occur several times a day, but this lessens in frequency over time. It is important to reassure parents that in well infants, with no symptoms other than effortless regurgitation, 90% of cases usually resolve before they are 1 year old and do not require further investigation (NICE, 2015a). There is an increased prevalence of GOR in premature infants, children or young people with obesity, hiatus hernia, diaphragmatic hernia or oesophageal atresia repair, and children with a neuro‐disability.

Other symptoms include heartburn, regurgitation, epigastric and retrosternal pain, and weight loss, and most sufferers are irritable. Infants with GOR, particularly premature infants, are at risk for aspiration and apnoea. Diagnosis is made on the symptoms and an upper GI contrast study for those with persistent or recurring symptoms. In infants with unexplained bile‐stained vomiting, an upper GI contrast study will be done urgently in order to rule out more serious disorders, such as intestinal obstruction (NICE, 2015a).

Treatment depends on the severity and cause of GOR. Initially in infants, feeding with thickened feeds and upright positioning may be enough for milder cases. Feeding smaller amounts more often may help to reduce abdominal distension and associated reflux. Frequent winding throughout a feed also helps to prevent the build‐up of abdominal wind associated with feeding. Depending on the healthcare provider, pharmacological treatment may be administered; this would depend on the cause of the problem and the severity. In some cases where there is failure to thrive or persistent weight loss enteral tube feeding may be considered. Surgery for GOR is only performed when medical therapy has failed and complications develop (see Table 12.3).

Nursing management focuses on ensuring the infant or child receives adequate nutrition. Daily weights and plotting infant or child weight and height on a percentile chart will monitor growth. Sandifer syndrome is the abnormal posturing that may occur in cases of severe acid reflux and may be mistakenly diagnosed as a seizure.

Hirschsprung disease (Fig. 12.1)

Hirschsprung disease (congenital aganglionic megacolon) is a congenital anomaly that causes inadequate motility due to the absence of parasympathetic ganglion cells in the affected areas of the intestine, mostly the recto‐sigmoid region of the colon. This lack of motility leads to mechanical obstruction of the intestine and a distended sigmoid colon. The incidence is 1 in 5000 live births and is more common in males than females (Ball et al., 2015); in many cases it has a familial pattern.

The age of onset will determine the clinical manifestations of the disease. In newborn infants there may be a failure to pass meconium in the first 48 hours, abdominal distension, feeding intolerance and bilious vomiting. In the older infant or child there may be a history of ribbon‐like foul‐smelling stools, visible peristalsis, easily palpable faecal mass, failure to thrive, chronic progressive constipation, which may be accompanied by episodes of faecal impaction.

Diagnosis is made on the history and physical examination. An abdominal X‐ray will show the distended colon and a lack of stool in the rectum. A rectal biopsy will be performed to confirm the absence of ganglion cells. Treatment is to remove the aganglionic portion of the bowel and a procedure consisting of pulling through the normal bowel to the end of the rectum to replace the removed portion. If the area of colon affected is too large for an immediate pull‐through or it is inflamed, a temporary colostomy may be created and surgery performed later. Following the pull‐through procedure incontinence and stricture may occur, requiring dilations or bowel retraining. Surgery is usually delayed in infants until they are 10 months old.

Nursing care is focused around observing for infection and ensuring adequate nutrition, maintaining hydration, pain management and providing support to the child and family. One very serious complication in infancy is enterocolitis, which can be fatal if not recognised early. Following a pull‐through operation it is important to monitor the return of bowel function. If a colostomy is performed, post‐operative stoma care and parent and child education in the care of a stoma will be needed.