Запор у детей и молодого поколения
Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care
NICE Clinical Guidelines, No. 99
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2010.
vicious cycle – порочныйкруг
conflicting advice – противоречивыесоветы
frustrating – разочарование
withholding or straining – удержаниеилинапряжение
irritable – раздражительный
disabilities – ограниченныевозможности
cerebralpalsy – ДЦП
Bulk-formingagents - массо-образующие агенты
over-the-counter – вышедозы
softeners – размягчили
irritable bowel syndrome – синдромраздраженногокишечника
Rectal prolapse – выпадение прямой кишки
Without early diagnosis and treatment, an acute episode of constipation can lead to anal fissure and become chronic. By the time the child or young person is seen they may be in a vicious cycle. Children and young people and their families are often given conflicting advice and practice is inconsistent, making treatment potentially less effective and frustrating for all concerned. Early identification of constipation and effective treatment can improve outcomes for children and young people. This guideline provides strategies based on the best available evidence to support early identification, positive diagnosis and timely, effective management. Implementation of this guideline will provide a consistent, coordinated approach and will improve outcomes for children and young people.
Constipation is common in childhood. It is prevalent in around 5–30% of children, depending on the criteria used for diagnosis. Symptoms become chronic in more than one third of patients and constipation is a common reason for referral to secondary care. Morbidity may be under-reported as people may not seek advice because they are embarrassed.
The exact cause of constipation is not fully understood but factors that may contribute include: pain, fever, dehydration, dietary and fluid intake, psychological issues, toilet training, medicines and familial history of constipation. Constipation is referred to as ‘idiopathic’ if it cannot be explained by anatomical or physiological abnormalities.
Many people don't recognise the signs and symptoms of constipation and few relate the presence of soiling to constipation. The signs and symptoms of childhood idiopathic constipation include: infrequent bowel activity, foul smelling wind and stools, excessive flatulence, irregular stool texture, passing occasional enormous stools or frequent small pellets, withholding or straining to stop passage of stools, soiling or overflow, abdominal pain, distension or discomfort, poor appetite, lack of energy, unhappy, angry or irritable mood and general malaise.6
Painful defecation is an important factor in constipation but it is not always recognised; ‘withholding’ behaviours to prevent passage of painful stools are often confused with straining to pass stools. Families may delay seeking help for fear of a negative response from healthcare professionals. It has been suggested that some healthcare professionals underestimate the impact of constipation on the child or young person and their family.This may contribute to the poor clinical outcomes often seen in children and young people with constipation.
Soiling is debilitating but rarely life threatening, so it might be expected to have little impact on healthcare provision. But many children and young people experience social, psychological and educational consequences that require prolonged support.
Some children and young people with physical disabilities, such as cerebral palsy, are more prone to idiopathic constipation as a result of impaired mobility. Children and young people with Down's syndrome and autism are also more prone to the condition. It is important that assessment and ongoing management for these children and young people happen in the same way as is recommended for all children and young people.
Without early diagnosis and treatment, an acute episode of constipation can lead to anal fissure and become chronic. By the time the child or young person is seen they may be in a vicious cycle. Children and young people and their families are often given conflicting advice and practice is inconsistent, making treatment potentially less effective and frustrating for all concerned. Early identification of constipation and effective treatment can improve outcomes for children and young people.This guideline provides strategies based on the best available evidence to support early identification, positive diagnosis and timely, effective management. Implementation of this guideline will provide a consistent, coordinated approach and will improve outcomes for children and young people.
Treatment for Constipation
How do doctors treat constipation?
Treatment for constipation may include the following:
Changes in eating, diet, and nutrition
Changes in your eating, diet, and nutrition can treat constipation. Thesechangesinclude
- drinking liquids throughout the day. A health care professional can recommend how much and what kind of liquids you should drink.
- eating more fruits and vegetables.
Exercise and lifestyle changes
Exercising every day may help prevent and relieve constipation.
You can also try to have a bowel movement at the same time each day. Picking a specific time of day may help you have a bowel movement regularly. For example, some people find that trying to have a bowel movement 15 to 45 minutes after breakfast helps them have a bowel movement. Eating helps your colon move stool. Make sure you give yourself enough time to have a bowel movement. You should also use the bathroom as soon as you feel the urge to have a bowel movement.
Your doctor may suggest using a laxative for a short time if you’re doing all the right things and are still constipated. Your doctor will tell you what type of laxative is best for you. Over-the-counter laxatives come in many forms, including liquid, tablet, capsule, powder, and granules.
If you’re taking an over-the-counter or prescription medicine or supplement that can cause constipation, your doctor may suggest you stop taking it or switch to a different one.
Bulk-forming agents. Bulk-forming agents absorb fluid in your intestines, making yourstool bulkier. Bulkier stool helps trigger the bowel to contract and push stool out. Be sure to take bulk-forming agents with water or they can cause an obstruction or a blockage in your bowel. They can also cause bloating and pain in your abdomen. Brandnamesinclude
Osmotic agents. Osmotic agents help stool retain fluid. Stools with more fluid increase your number of bowel movements and soften stool. Older adults and people with heart orkidney failure should be careful when taking osmotic agents. They can causedehydration or a mineral imbalance. Brand names include
Stool softeners. Stool softeners help mix fluid into stools to soften them. Doctors recommend stool softeners for people who should avoid straining while having a bowel movement. Doctors often recommend stool softeners after surgery or for women after childbirth. Brandnamesinclude
Lubricants. Lubricants work by coating the surface of stool, which helps the stool hold in fluid and pass more easily. Lubricants are simple, inexpensive laxatives. Doctors may recommend lubricants for people with anorectal blockage. Brandnamesinclude
If these laxatives don’t work for you, your doctor may recommend other types of laxatives, including
Stimulants. Stimulant laxatives cause the intestines to contract, which moves stool. You should only use stimulants if your constipation is severe or other treatments have not worked. Brandnamesinclude
People should not use stimulant laxatives containing phenolphthalein. Phenolphthalein may increase your chances of cancer. Most laxatives sold in the United States do not contain phenolphthalein. Make sure to check the ingredients on the medicine’s package or bottle.
If you’ve been taking laxatives for a long time and can’t have a bowel movement without taking a laxative, talk with your doctor about how you can slowly stop using them. If you stop taking laxatives, over time, your colon should start moving stool normally.
If over-the-counter medicines do not relieve your symptoms, your doctor may prescribe one of the following medicines:
Chloride channel activator. If you have irritable bowel syndrome (IBS) with long-lasting or idiopathic—meaning the cause is not known—constipation, your doctor may prescribelubiprostone (Amitiza).Lubiprostone is a chloride channel activator available with a prescription. Research has shown lubiprostone to be safe when used for 6 to 12 months. This type of medicine increases fluid in your GI tract, which helps to
- reduce pain or discomfort in your abdomen
- reduce your need to strain when having a bowel movement
- increase how often you have bowel movements
Guanylate cyclase-C agonist. If you have IBS with long-lasting or idiopathic constipation, your doctor may prescribe linaclotide (Linzess) to help make your bowel movements regular. Linaclotide is a guanylate cyclase-C agonist that eases pain in your abdomen and speeds up how often you have bowel movements.
If you have problems with the muscles that control bowel movements, your doctor may recommend biofeedback to retrain your muscles. Biofeedback uses special sensors to measure bodily functions. A video monitor shows the measurements as line graphs, and sounds from the equipment tell you when you’re using the correct muscles. By watching the monitor and listening to the sounds, you learn how to change the muscle function. Practicing at home can improve muscle function. You may have to practice for 3 months before you get all the benefit from the training.
You may need surgery to treat an anorectal blockage caused by rectal prolapse if other treatments don’t work. You may need surgery to remove your colon if your colon muscles don’t work correctly. Your doctor can tell you about the benefits and risks of surgery.
How do doctors treat complications of constipation?
Doctors can treat or tell you how to treat complications of constipation. Hemorrhoids, anal fissures, rectal prolapse, and fecal impaction all have different treatments.
You can treat hemorrhoids at home by
- making dietary changes to prevent constipation
- applying over-the-counter hemorrhoid cream to the area or using suppositories—a medicine you insert into your rectum—before bedtime
Talk with your doctor about hemorrhoids that do not respond to at-home treatments.
You can treat anal fissures at home by
- making changes in your diet to prevent constipation
- applying over-the-counter hemorrhoid cream to numb the area or relax your muscles
Your doctor may recommend surgery to treat anal fissures that don’t heal with at-home treatments.
Your doctor may be able to treat your rectal prolapse in his or her office by manually pushing the rectum back through your anus. If you have a severe or chronic—long-lasting—rectal prolapse, you may need surgery. The surgery will strengthen and tighten your anal sphincter muscle and repair the prolapsed lining. You can help prevent rectal prolapse caused by constipation by not straining during a bowel movement.
You can soften a fecal impaction with mineral oil that you take by mouth or through anenema. After softening the impaction, a health care professional may break up and remove part of the hardened stool by inserting one or two gloved, lubricated fingers into your anus.