Children’s dietitian Sara Mancell represented the profession on the guideline development group (GDG) for the first national evidence-based guidelines on childhood constipation.
Published this week by The National Institute for Health and Clinical Excellence (NICE), Constipation in children: diagnosis and management of idiopathic childhood constipation in primary and secondary care, provides key recommendations for the diagnosis, treatment and management of idiopathic (unknown origin) childhood constipation.
Though not life-threatening, constipation in children is very common, affecting up to 30% of the child population and it is the second most referred condition in paediatric gastroenterology, accounting for at least 25% of visits. Those suffering from it can experience social, psychological and educational problems, but early identification and effective treatment can greatly improve outcomes for children, saving time and resources.
Sara Mancell, lead children’s dietitian at King’s College Hospital, was in the team of 15 that formed the guideline development group (GDG) overseeing the process of Constipation in Children.
An independent GDG is set up for each clinical guideline being developed and members include health professionals – surgeons, doctors, nurses, health visitors – patient/carer representatives and academics.
Although she didn’t join the group via the traditional route of CV submission and interview (replacing another dietitian once the project was underway), Sara would never have thought to get involved in a GDG at first as she found the whole idea somewhat daunting:
“I thought it would be too difficult and too much of a time commitment. But the whole experience was brilliant. Everyone involved was so passionate; it is such a good way to share ideas and opinions. I only attended 15 meetings over two years, either a day or two days long so it can easily fit around a full time job. If NICE ever ask for dietitians again I would really encourage people to get involved.”
Members of the GDG have an instrumental role in the guideline production process. They look at the evidence available and consider comments made on draft versions of the guideline issued for consultation before making final recommendations.
Sara explains their role in depth: “Members of the GDG provide researchers with key words which are used for their systematic reviews. Then we are presented with a full summary of each of the included studies, evidence tables and a table of the excluded studies. Finally the research team create ‘draft’ evidence statements based on the included studies.
“We had to read through all of this information before each meeting day. As a group, we would then discuss what conclusions could be drawn from the studies and we would finalise the evidence statements and develop recommendations.”
Sara was surprised by the research findings as she was expecting dietary changes to be one of the main treatments for constipation:
“I went in thinking there would be a lot of evidence for diet playing a big role in constipation but the evidence just wasn’t there. Instead, I learnt a great deal from the nurses and doctors working with these patients day to day about the positive role of laxative alongside any changes in diet.”
The next stage involved the group being split into topic groups, Sara was topic lead for the nutrition questions, and other topics included causes, clinical management and information and support.
“Each topic group would go away and write the introduction for their relevant section and the ‘interpretation’ ie how we arrived at each recommendation. The NICE team would then put all of this information together and present it at another meeting where we could make any adjustments. The team would also contact us between meetings to check specific details. Finally, we put the guidelines out for consultation,” Sara explains.
Any comments at the consultation process were taken into account and further adjustments to the guidelines were made.
The main thing Sara has gained from her experience is an immediate change in her practice:
“In the past, if a child was referred to me for dietary advice around constipation, I would not have put that much emphasis on the importance of laxatives. Now, I always reiterate to the family how essential it is that any prescribed laxatives are taken so that their child begins to open their bowels regularly. Any dietary changes can then be made alongside regular medication.”
“I think the main message for dietitians is that first line treatment is laxatives/disimpaction.
“Many parents are worried about their children being on long term medication (laxatives) but being a member of the GDG has taught me that it is far more important for the child to have a positive experience when opening their bowels and laxatives allow them to use the toilet easily. If they are always constipated it hurts and this makes it more likely that they will withhold their stools, making them increasingly blocked.
“Once they have some positive experiences then we can more easily make long-term dietary changes, and in some cases it is possible to reduce the dosage of laxatives over time.”
Key recommendations in the guidelines include:
- Establishing during history taking if the child or young person has constipation; a positive diagnosis of idiopathic constipation is confirmed by excluding underlying causes
- Undertaking a physical examination to ascertain if the child has faecal impaction. This must be cleared before maintenance therapy is prescribed
- The correct dosage of laxatives is crucial for disimpaction
- The child must be followed up within one week to ensure the laxatives are working. It may be necessary to increase the dosage or change the laxative if the first medication has not been successful
- Once the impaction has been cleared, laxatives should be prescribed as maintenance therapy, to help the child establish a regular bowel habit. This may take some months, during which time the child needs to be seen frequently, to ensure that faecal impaction does not build up again
- If this treatment does not work, the situation should be re-assessed and the child to be referred to a specialist
- Dietary intervention alone is not recommended as a first-line treatment, but advice should be given on eating the right food and drinking enough fluids
- Parents should have a positive attitude towards children and their toilet habits, and children should be encouraged to take time to go to the loo and keep a bowel diary, recording their movements and rewarding them appropriately when they use the toilet
Jenny Gordon, NICE Guideline Development Group Chair, said:
“For years, I think there has been a lack of understanding surrounding this condition – parents are often reluctant to go to their GP, and may be very embarrassed or even ashamed if their child has constipation. We need to raise awareness of these issues, and be bolder in talking about childhood constipation, which can affect all areas of a child’s life. These guidelines are much needed and will help so many children. We now need to make sure that they are used and implemented.”
The NICE guidelines, Constipation in children: diagnosis and management of idiopathic childhood constipation in primary and secondary care were published on Wednesday 26 May 2010 and are available to download at: http://guidance.nice.org.uk/CG99
Listen to Wednesday’s edition of BBC Radio 4’s Woman’s Hour for more on the topic at: www.bbc.co.uk/programmes/b00sfhs2