Quality Standards
Issued: May 2014
QS62

Constipation in children and young people

Introduction

This quality standard covers the diagnosis and management of idiopathic constipation in children and young people (from birth to 18 years). For more information see the topic overview.

Why this quality standard is needed

Constipation is the inability to pass stools regularly or empty the bowels completely. It can cause hard, lumpy stools, which may be large or small. Constipation is common in childhood. It is referred to as 'idiopathic' if it cannot be explained by anatomical or physiological abnormalities. The exact cause of idiopathic constipation is not fully understood but factors that may contribute include pain, fever, dehydration, dietary and fluid intake, psychological issues, toilet training, medicines and family history of constipation.

Estimates for the prevalence of idiopathic constipation vary from 5% to 30% of children and young people, depending on the criteria used for diagnosis, and are at their highest in toddlers. It is estimated that 1 in 100 children and young people aged between 11 and 18 years have idiopathic constipation. Children and young people with Down's syndrome or autism are particularly prone to idiopathic constipation, as are those with physical disabilities, such as cerebral palsy, in whom idiopathic constipation may be related to impaired mobility. There is also a higher prevalence in children and young people in local authority care.

Symptoms become chronic in more than one-third of children and young people with constipation, and constipation is a common reason for referral to secondary care. Morbidity may be under-reported because some people are too embarrassed to seek advice.

Inpatient data from hospital episode statistics for England in 2012/13 show that there were 13,135 finished consultant episodes for constipation in children and young people aged under 18 years, of which 79% were emergency admissions.

Early diagnosis and treatment are important to prevent chronic constipation. However, people often do not recognise the signs and symptoms of constipation. If constipation is not treated an acute episode can lead to anal fissure and constipation can become chronic. Children and young people and their families are often given conflicting advice and practice can be inconsistent, making treatment potentially less effective and frustrating for all involved.

Continence problems (including soiling) can have a significant emotional impact on children and young people, and managing these problems can be stressful for parents and carers. Many children and young people experience social, psychological and educational consequences that need prolonged support.

Children and young people with idiopathic constipation can present to different types of healthcare professionals, such as GPs, pharmacists, school nurses, health visitors, practice nurses, continence advisors, paediatricians or a specialist continence service.

The quality standard is expected to contribute to improvements in the following outcomes:

  • Rates of accident and emergency department attendance and unplanned hospitalisation for constipation in children and young people.

  • Rates of recurrent constipation and/or impaction in children and young people.

  • Parent or carer satisfaction with information and advice.

  • Children and young people who are able to manage their constipation to their satisfaction.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable quality improvements within a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2014/15

Domain

Overarching indicators and improvement areas

4 Ensuring that people have a positive experience of care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving children and young people's experience of healthcare

4.8 Children and young people's experience of outpatient services

Table 2 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

Indicators

1.3 Pupil absence

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.5 Child development at 2–2.5 years (under development)

Coordinated services

The quality standard for constipation in children and young people specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole constipation care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to children and young people with constipation.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality constipation service are listed in Related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating children and young people with constipation should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting children and young people with constipation. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision-making process about investigations, treatment and care.