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A common problem
Childhood constipation is a common problem to which both paediatric and psychological perspectives can usefully be brought to bear. The case presented here is an extreme example and, as such, shows some of the pitfalls as well as providing a platform for the presentation of a way of understanding multidisciplinary intervention which might facilitate successful management, not only of childhood constipation, but in a broader clinical context.
THE CASE
Reason for referral
A 5 year old boy was referred to a child mental health service with phobic avoidance of defecation and refusal to take medication or comply with Malone antegrade continence enemas (ACE).1 There was a long standing history of constipation predating the ACE procedure, but anticipated improvements after surgery had failed to materialise.
Background information
He was a wanted child, but the pregnancy was plagued with hyperemesis and fatigue. His mother, who had experienced problems breast feeding her children by an earlier marriage, bottle fed him from the outset. She became depressed but received no treatment for this. He was perceived as hungry and not easy to settle, and his feeds were thickened with baby rice given from 4 months. By 8 months he was very constipated, producing hard faecal pellets with occasional blood, and screaming when he needed to defecate. Dietary measures were followed by increasingly large doses of bulking and stimulant laxatives. Anal stretch and evacuation of faeces under general anaesthesia produced, according to the hospital notes, an “enormous cast of the rectum” and left him “inconsolable”. Appropriate investigations proved normal. At the unusually young age of 2 years, and despite the recommendation of one paediatrician that psychological opinion be obtained, he was admitted for an ACE procedure. It should be noted that this occurred before the publication of case reviews revealing that the ACE carries a relatively poor prognosis …