Pediatric Primary Care (79 page)

c.  Stool for occult blood, ova and parasite, giardia antigen.

d.  Consider lactose breath hydrogen test to rule out lactose intolerance.

H.  Differential diagnosis.

1.  Irritable bowel syndrome (IBS).

2.  Infection: UTI, intestinal parasite.

3.  Lactose intolerance: positive lactose breath test or okay after no lactose in diet after 2-week trial.

4.  Constipation.

5.  Inflammatory bowel disease (Crohn's disease, ulcerative colitis): associated with melena, hematochezia, and/or diarrhea. Possible weight loss, growth delay. Physical exam may reveal abdominal tenderness, multiple anal fissures/skin tags, possible joint symptoms. Refer to pediatric gastroenterologist.

I.  Treatment.

1.  Most valuable treatment is establishment of therapeutic relationship with patient and family. Discuss possibility of FAP at first visit.

2.  Can do trial of lactose-reduced diet. Eliminate caffeine.

3.  Trial of fiber supplementation: may regulate intestinal motility. American Academy of Pediatrics (AAP) recommends: child's age + 5 = grams of fiber/day.

4.  Counseling: self-hypnosis, biofeedback.

5.  Symptom diary.

J.  Follow up.

1.  Arrange for clinic visit about 1 month after diagnosis of FAP.

2.  Telephone contact for any changes in symptoms.

K.  Complications.

1.  School absence or avoidance, decreased participation in extracurricular activities.

2.  Interference with peer relationships.

L.  Education.

1.  If physical exam normal, reassure family that it is unlikely any specific cause will be found.

2.  Acknowledge pain is real, not fabricated.

3.  Insist on return to normal, daily activities, school participation.

4.  Educate family about reaction to the pain: may be altered reaction to pain or secondary gain if too much attention is given to symptom.

5.  Discuss prognosis: Pain may persist for months or years.

III. COLIC

A.  Often defined by “rule of 3”: crying for 3 hours a day on 3 days a week for 3 weeks. during first 3 months of life in otherwise healthy infant. Diagnostic criteria: Must include all of the following in infants from birth to 4 months of age:

1.  Paroxysms of irritability, fussing, or crying that starts and stops without obvious cause.

2.  Episodes lasting 3 or more hours/day and occurring at least 3 days/week for at least 1 week.

3.  No failure to thrive.

B.  Etiology.

1.  Unknown, probably multifactorial.

C.  Occurrence.

1.  Most studies estimate incidence rates of up to 25% of infants. Equal incidence among males and females, all socioeconomic levels, breastfed versus bottle-fed.

D.  Clinical manifestations.

1.  Inconsolable crying for 3 or more hours per day, often clustering in afternoon or evening. Episodes seem to have a clear beginning and end.

2.  Associated symptoms may include pain facies/grimacing, clenched fists, taut/distended abdomen, drawing legs up to abdomen, flatus.

3.  Crying often described as more intense than normal crying.

4.  Ask parents to describe quality, frequency, duration, timing of crying.

5.  Ask about any other symptoms such as vomiting, regurgitation.

6.  Detailed diet history, including mother if breastfeeding.

7.  Frequency, consistency of stool, hematochezia.

8.  Alleviating or aggravating factors.

9.  Medications given to baby or that breastfeeding mother is taking.

10.  Ask about coping skills of caregivers and opportunity for respite.

E.  Physical findings.

1.  Weight/length/head circumference, temperature, vital signs.

2.  Complete physical exam.

3.  Abdominal exam may reveal mild distention.

4.  Check baby for evidence of incarcerated hernia, testicular torsion, hair tourniquet.

5.  Observe caregiver and infant: assess caregiver's anxiety, coping skills.

F.  Diagnostic tests.

1.  No test to diagnosis colic: made by history and physical exam.

G.  Differential diagnosis.

1.  Inappropriate feeding: Assess infant's intake by history.

2.  Milk protein intolerance or allergy: usually associated with vomiting/ diarrhea. May have history of hematochezia.

3.  Constipation: hard or dry stools regardless of frequency.

4.  Incarcerated hernia.

5.  Parental stress tension, poor coping.

6.  Testicular torsion: testis tender, cord thickened/shortened.

7.  Gastroesophageal reflux (GER).

H.  Treatment.

1.  Consider 2-week trial of hypoallergenic formula. Avoid sorbitol-containing fruit juices.

2.  Encourage continued breastfeeding; trial of caffeine elimination from mother's diet.

3.  Swaddling of infant, rhythmic movement, gentle massage, warm baths.

4.  “White noise” such as soft music.

5.  Avoid overstimulation. Avoid exposure to tobacco smoke.

6.  Counsel parents: alleviate guilt about cause of colic, need for respite. Reassure them: Infant is not in pain. Acknowledge importance of problem, discuss prognosis.

I.  Follow up.

1.  Frequent clinic and/or telephone follow up may be necessary to assess any formula changes, parental coping skills.

2.  Plan to see baby 2 weeks after initial diagnosis.

J.  Complications.

1.  Poor parental coping skills.

2.  Disruption of maternal-infant relationship.

3.  Child abuse.

K.  Education.

1.  Discuss normal crying patterns. Infants cry more in first 3 months of life than at any other time. Crying increases at 2 weeks and usually peaks in second month with gradual decline thereafter. Pattern of crying different in all babies.

2.  Explain that taut/distended abdomen and flatus are probably result of, not cause of, crying. Reassure them that infant not in pain.

3.  Alleviate parental guilt and discuss range of emotions may be experiencing.

4.  Stress need for respite: Suggest parents leave baby with reliable caregiver for few hours. Infant may sense tension in parents if do not allow themselves a break.

5.  Trial of hypoallergenic formula may be indicated, but multiple formula changes are not warranted and should be discouraged. There is minimal if any evidence that lactose intolerance plays a role.

IV. CONSTIPATION

A.  Delayed or difficult defecation for 2 weeks; passage of hard and/or dry stools.

B.  Etiology.

1.  Functional: most common, no underlying pathology.

a.  Diet low in fiber/fluids; sudden change in diet (e.g., formula/breast to cow's milk).

b.  Lack of exercise, obesity.

c.  Stool withholding secondary to painful defecation (“pain-retention cycle”).

d.  Family history.

2.  Outlet dysfunction: Hirschsprung's disease, anterior ectopic anus, tethered spinal cord (secondary to occult spinal dysraphism), anal stenosis.

3.  Metabolic/gastrointestinal: celiac disease, hypothyroidism, hypercalcemia.

4.  Other: cystic fibrosis, malnutrition, sexual abuse, cow's milk protein intolerance (infants), medications (e.g., narcotics).