Digging deep into safeguarding again this month with thanks to Nicci Wotton, head of safeguarding at Imperial, London, UK. A reminder of useful apps for our young patients and pointers to documents that govern our safeguarding responsibilities in the UK and internationally. Do leave comments below.
An emphasis on children’s psychological support this month, particularly around bereavement during Covid. A couple of useful links to PIMS-TS information for GPs and families, a bit more on bites with a safeguarding slant and what to do with constipation when Movicol is not the answer.
Do leave comments below.
with thanks to Dr Edward Dallas, paediatric registrar.
Constipation is <3 stools per week, often hard and large or rabbit droppings, often painful, possibly with overflow. Its prevalence is around 5-30%!
Most is idiopathic/functional, but the clinician must rule out red flag symptoms such as:
- Constipation from birth
- Delay in passing meconium <48 hours from birth, could suggest Hirschsprung’s or Cystic Fibrosis
- Abdominal distension with vomiting, could suggest obstruction
- Leg weakness or motor delay, could suggest neurological or spinal cord problem
- Ribbon stool pattern, could suggest anal stenosis (usually presents <1 yr)
- Faltering growth, could suggest coeliac disease or hypothyroidism
Remember that breast fed babies can have long periods between stooling. The introduction of cow’s milk based formulas can lead to constipation. Constipation often plays a big part in bedwetting and daytime continence issues. Examine the abdomen and spine in a child with enuresis.
The aetiology of constipation is multifactorial and includes: pain, fever, inadequate fluid intake, reduced dietary fibre intake, toilet training issues, the effects of drugs, psychosocial issues, and a family history of constipation. Primary school children who can’t quite organise themselves to empty their bowels before going to school and then won’t use the toilets at school often get bunged up quite quickly after starting school.
Management of idiopathic/functional constipation:
The management of functional constipation has 6 main components:
1– Education (demystification)
2- Fluids and diet
3- Regular toilet habit (behavioural) and exercise (re-training)
4- Disimpaction (if in doubt, disimpact!)
5- Maintenance laxatives
6- Regular follow up and support
Diet and Lifestyle advice e.g., regular toilet breaks with praise, star chart etc.
Reassurance, with sources of information & support:
- NHS: https://www.nhs.uk/conditions/baby/health/constipation-in-children/
- ERIC: https://www.eric.org.uk/what-is-constipation
- The Poo in You – Constipation and Encopresis Educational Video from Children’s Hospital Colorado
Longstanding constipation is unlikely to get better without medication. If left, it gets worse so please ensure you start the child on treatment before considering referral.
Usually start with a “Dis-impaction regime” which includes increasing doses of Paediatric Movicol, often adding Senna after a few days if the child still seems to not be passing the lumps. See https://pathways.nice.org.uk/pathways/constipation.
(A parent’s guide to dis-impaction can be found here: https://www.eric.org.uk/pdf-a-parents-guide-to-disimpaction)
If Movicol is not tolerated, try:
Bisacodyl tablets e/c 5mg (swallow whole)
OR Sodium picosulfate liquid 5mg/5mL
See NHS Lothian formulary for age-appropriate dosing at https://www.ljf.scot.nhs.uk/LothianJointFormularies/Child/1.0/1.6/Pages/default.aspx
Once dis-impacted, the child should be switched to a Maintenance regime to allow muscles and nerves to return to normal. This will take at least 6 months. Don’t stop medications too early!
Paediatric Movicol 1-4 sachets/day
If over 12 years old, use adult Movicol / cosmocol 1-2 sachets per day
Lactulose and Senna – see BNFc or the NHS Lothian formulary for suitable doses. Lactulose is bad for teeth. All laxatives can be diluted with squash, fruit juice, water or milk.
Regular follow-up and support. Aim to wean off once the child has had soft stools for at least 6 months.
With thanks to Dr Isabel Wilson, paediatric registrar with experience of working with refugees and internally displaced people in southern Europe.
Public Health England has developed a course on PFA in Covid-19. Almost 100,000 people have already signed up to learn how to give practical and emotional support to individuals traumatised by their experience of lockdown or Covid-19 itself. Sign up at https://www.futurelearn.com/courses/psychological-first-aid-covid-19
Testicular torsion this month – a surgical emergency with good outcomes if operated on less than 6 hours since the pain started.
Also, links to helpful health and well being websites for young people and to good ECG CPD for psychiatrists and GPs. A bit more on ADHD and a round up of neck lumps in infants, assessment and management.
Do leave comments below.
Safeguarding issue again this month. Round up of CPD resources and a reminder of how much demonstrable child safeguarding CPD health professionals have to do per 3 year cycle. Also some support groups for your patients and a quiz on social media sites – in case you thought you were ahead of the game…
From left to right: Dubsmash (high risk of bullying), Snapchat (overall safety rating – average), Smule (official age rating 13+), We chat (high risk sexual and bullying), Twitch (“it’s hard to censor because it’s live”), YouTube (“people write mean things in the comments on videos”). Follow the links to read about each site’s safety profile and find out what kind of thing your own children and your young patients are using the individual sites for.
Social media sites are here to stay and preventing children having access to them is not likely to be a successful parental pastime. https://www.net-aware.org.uk/ is an O2 and NSPCC project which looks at the safety of social media sites and gives parents tips on how to protect their children while they are using them.