SMJ 2004 49(3): 98-100
Aim To assess the outcome at one year of a cohort of patients referred to outpatient clinics with soiling.
Method Retrospective case note audit of 34 children referred to hospital outpatients over a four month period with soiling stated as the main problem in the referral letter.
Results After one year, 29% of the 34 children studied were discharged to patient satisfaction, 38% defaulted from follow up, 24% were still attending outpatient clinics and 9% had been referred back to source. Coexisting pathologies, in particular enuresis and family stress, were found in several of the children. At the time of referral, 44% of new patients and 89% of re-referrals had symptoms present for longer than 12 months. Only 18% of the children were receiving treatment at the time the referral was made.
Conclusion Constipation is often undiagnosed until the problem is well established with soiling present, which makes treatment a long and often difficult process. It is necessary to consider the wider social and family issues when managing a child with constipation and soiling. Hospital based general medical and surgical outpatient clinics may not be the ideal setting in which to deal with these problems.
Key words constipation, soiling, outcome
Introduction
In children, constipation with overflow soiling is a problem frequently seen presenting to a wide variety of hospital outpatient clinics. Compliance
with treatment can be poor and there are often coexisting pathologies and poor social circumstances, all of which may contribute to a sub-optimal
outcome.
We looked at all referrals to the outpatient department of the Royal Hospital for Sick Children in Glasgow over a four month period, in which the principal complaint indicated in the referral letter was soiling. A retrospective case note audit was carried out to assess outcome in these children one year after the first appointment was offered.
Over the four month audit period, 34 children were referred to outpatient clinics with a soiling problem. The majority were referred by their general practitioner (table I). One child was referred jointly by the general practitioner and the Department of Child and Family Psychiatry. 41% of these were referred to general medical clinics, 35% to general surgical clinics and 24% to community outreach clinics around Glasgow. Age at referral ranged from 2 years to 15 years (table II), with a male to female ratio of 2:1. Of these, 74% were new referrals and 26% were re-referrals to this hospital.
The referral diagnoses are presented in table III. For the purpose of our study “encopresis” was defined as the passage of normal stool in abnormal places. The “constipation” category included both simple constipation and constipation with overflow soiling. The “mixed” category included children with any combination of constipation, encopresis and enuresis. Of the four children who fell into the category of “other”, one had faecal incontinence secondary to a previous imperforate anus and subsequent pull-through surgery, the second had toilet aversion, the third abdominal pain in association with school refusal, and the fourth child had an unknown diagnosis as he failed to attend his first appointment and was not recalled.
Results
Deprivation
category scores were collated for each patient based on their postcode sector 1.
20 of our 34 patients (58%) resided in areas of worst deprivation, classified as
deprivation categories 6 and 7. This is slightly more than the general Glasgow
population, of whom 50% live in areas within categories 6 and 7 2.
We went on to look at the duration of symptoms in these children at the time of referral. In 44% of new referrals and 89% of re-referrals, symptoms had been present for more than 12 months prior to referral to hospital outpatients, in many cases for several years. Duration of symptoms ranged from 6 months to 15 years. Despite this, only 6 of the 34 children (18%) had received any treatment for their symptoms prior to the first consultation. These children had received varied combinations of osmotic, stimulant and bulk-forming laxatives, with one child receiving treatment in the form of enemas.
Of interest, several coexisting pathologies were identified in many of the children referred with soiling, and these are outlined in table IV. This illustrates that enuresis and family stress were the most common coexisting problems in this group of children. For many families the child’s problems will undoubtedly have contributed to the stress within the household, but for some children soiling may be a manifestation of pre-existing environmental stress factors.
It is important to note that some children were being bullied at school, while some were refusing to attend school altogether. This clearly has educational implications for these children, which could be resolved by appropriate treatment and support for the child and family.
Some children experienced more than one of the above coexisting factors, however this is likely to be an underestimate of the true extent of the problem given the retrospective nature of the study.
The case notes of all 34 children were examined to identify their status one year after the first outpatient attendance. A large proportion (38%) defaulted, i.e. never attended or failed to attend follow up after one or more visits. Less than a third (29%) were discharged to patient satisfaction, and 24% were still attending outpatients one year later. A further 9% were referred back to source. These were children in whom other therapy was being considered, for example counselling for alleged child sexual abuse in one case, and the referral was for exclusion of organic pathology only.
Management of constipation and soiling differed between the medical, surgical and community clinics. This included variations in the drug therapy used, and in the frequency of follow up visits.
Discussion
Constipation in childhood is a common problem 3,4, which is often not diagnosed in the early stages. Many clinicians are unaware that 96% of young children open their bowels at least every other day 4,5, leading to late diagnosis often when overflow soiling is present and constipation is relatively resistant to treatment. This leads to a protracted treatment course 6,7, often complicated by non-compliance and failure to attend follow up, as illustrated by our results. The large number of patients who defaulted is concerning, and there are a number of possible explanations for this. Firstly, families often see a different practitioner at each visit, which may lead to confusion if these professionals offer conflicting advice. Secondly, on many occasions there were some months between the first consultation and subsequent follow up appointments. This can leave families feeling unsupported and contributes to loss of motivation and non-compliance with treatment. Previous studies have demonstrated that chronic constipation in children can persist for many years 8, and our findings support this.
Within the Royal Hospital for Sick Children, children with constipation and soiling may be seen by physicians or surgeons, with mental health professionals involved in selected cases. The fact that referrals can be made to any of these different clinics illustrates the lack of consistent referral patterns from primary care, which results in inconsistency in management strategies. Due to pressures on outpatient clinic waiting lists, it is common for children not to receive further appointments if they have failed to attend on one or more occasions. These factors make the effective long term management of constipation and soiling very difficult, and there is therefore a need to establish a consistent structured approach to treatment. Patients and their families require a clear plan to follow in the interval between outpatient clinic appointments, of which both they and the primary care team are fully aware.
We have taken steps to address these issues within the Royal Hospital for Sick Children. The Community Children’s Nursing Team (formerly the Paediatric Home Care Team), set up in 1994, provides home-based care and support to children with constipation and soiling and their families, with favourable results 9. We also have a multidisciplinary working group, developing a management strategy for children with constipation and soiling for use within the hospital setting. This group is hoping to develop guidelines for use by primary care physicians and by nursing colleagues within school health, paediatric liaison, health visitors and district nursing.
It is vitally important that all professionals dealing with constipation and soiling in paediatric practice provide clear consistent advice and follow a structured management plan in order to obtain satisfactory outcomes in this challenging group of patients. In addition, the importance of family support should not be under-estimated. Further studies should be carried out to determine if regular outpatient review, in conjunction with home-based treatment and support, improves the outcome for these children.
References
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