Pediatric Primary Care (80 page)

C.  Occurrence.

1.  Accounts for about 3% of visits to general pediatrics, 25% to pediatric gastroenterology.

D.  Clinical manifestations.

1.  Hard bowel movements (BMs), usually infrequent. May be dry, small (incomplete evacuation).

a.  Size, consistency, frequency of BMs: Ask when change in stool became apparent.

b.  Stool-withholding symptoms (hides for BM, crosses legs, dances around).

c.  Blood associated with stool.

d.  Fecal soiling in underwear of previously toilet-trained child.

e.  Did child pass meconium within first 48 hours of life?

f.  What treatments have been instituted thus far?

2.  Associated symptoms: abdominal pain/distention, poor appetite, irritability.

3.  Other important questions: Diet history, any changes? Child on any medications? Child toilet trained? Any possibility of sexual abuse?

E.  Physical findings.

1.  Height/weight: Plot on growth curve.

2.  Complete physical exam with attention to:

a.  Abdomen: Assess for fecal masses, particularly in lower quadrants. Assess for distention, tenderness.

b.  Anus: Assess for placement, fissures, erythema. Digital exam to assess anal tone, quality of stool present. Observe for soiling at anal opening.

c.  Lower back: Assess for tuft of hair over lumbar sacral area or deep sacral dimple above gluteal crease. Assess for deviated gluteal crease.

d.  Assess muscle tone throughout, deep tendon reflexes (DTRs).

F.  Diagnostic tests.

1.  Testing not usually necessary.

2.  Abdominal flat-plate X-ray to assess fecal load if question diagnosis/to tailor disimpaction.

3.  X-ray of lumbar/sacral spine: assess for occult spinal dysraphism if abnormality on L/S spine area and/or history of lower extremity weakness. If abnormal: MRI.

4.  Labs only if red flags in history/physical exam: serum electrolytes, calcium, lead level, thyroid function (TSH, free T4). Celiac screen (total serum IgA and tissue transglutaminase IgA) and sweat test if poor growth.

5.  Unprepped barium enema: if history of delayed passage of meconium, to assess for transition zone associated with Hirschsprung's disease.

G.  Differential diagnosis.

1.  Vast majority have functional constipation, diagnosis by history and physical exam.

2.  Infant dyschezia: at least 10 minutes of crying and straining before passage of soft stools in healthy infant younger than 6 months of age. Reassure, self-limited.

3.  Encopresis: constipation with fecal soiling.

4.  Hirschsprung's disease: absence of ganglion nerve cells in colon to varying degrees. Usually have history of delayed passage of meconium. May have thin caliber stools, abdominal distention, failure to thrive. No stool in rectal vault on digital exam.

5.  Structural: anterior ectopic anus, anal stenosis.

6.  Sexual abuse.

7.  Side effect of drugs such as narcotics.

8.  Cow's milk protein intolerance: anal irritation/fissures, subsequent stool retention.

H.  Treatment.

1.  Stool softeners: Most children will benefit from stool softener as first-line treatment. May be needed for longer than 2 weeks

a.  Lactulose/sorbitol: 1 mL/kg/dose bid, maximum 30 mL bid. Must be ingested quickly. May mix in beverage. Good choice for infants who don't respond to dietary management.

b.  Polyethylene glycol/PEG 3350 (Miralax, Glycolax): for children older than 1 year of age and younger than 3 years start with 2 teaspoons in 4 ounces of any noncarbonated beverage/day; older than 5 years can increase to 17 g (1 heaping tablespoon) in 8 ounces beverage/day. Stir powder well to dissolve; excellent palatability and acceptance. Titrate dose to achieve soft stools.

c.  Mineral oil: Never give to infants younger than 1 year or patients at risk for aspiration (e.g., neurologically impaired). Difficult to regulate dose, start with 1-3 mL/kg/day. Rarely used.

d.  Milk of magnesia: 1-3 mL/kg/day (400 mg/5mL). Avoid in infants.

2.  Laxatives/cathartics: used for disimpaction only, usually over period of 1-3 days.

a.  Magnesium citrate: older than 2 years: 1-3 mL/kg/day in single or divided doses.

b.  Senna: 2-6 years: 2.5-7.5 mL/day; 6-12 years: 5-15 mL/day.

c.  Bisacodyl: younger than 2 years: 1-2 tablets/dose.

3.  Enemas/suppositories: for disimpaction only, over 1-3 days.

a.  Glycerin suppository: for children younger than 2 years.

b.  Bisacodyl suppository: older than 2 years: 0.5-1 suppository/day.

c.  Pediatric Fleet enema: older than 2 years: 1-2 times/day for 1-3 days.

4.  High-fiber diet: AAP recommends age + 5 g fiber/day. Infants: prune or pear juice good choice for stool softening.

5.  Toilet training, not yet trained: Delay until constipation resolved. Trained: Encourage scheduled time on toilet bid following meal, for 5-10 minutes. Provide footstool.

6.  Positive reinforcement for toilet sitting, successful passage of stool.

I.  Follow up.

1.  Close telephone contact after disimpaction, to monitor response to stool softeners.

2.  Refer to pediatric gastroenterology if patient unresponsive to treatment, red flags in history, or abnormal test results.

3.  Refer to pediatric surgery if Hirschsprung's disease/anal abnormalities concerns.

J.  Complications.

1.  Encopresis.

2.  Anal fissure (treat with stool-softening agents, diet, topical cream, e.g., Anusol).

3.  Delayed toilet training.

K.  Education.

1.  Reassure family if history and physical consistent with functional constipation. Explain pain-retention cycle.

2.  Reassure that stool softeners are not habit forming and are necessary part of breaking pain-retention cycle. Stool softeners are often given daily for a minimum of several weeks.

3.  Parents may report child unable to have BM despite effort; explain that what appears to be straining may be child's attempt to withhold stool to avoid pain.

4.  Avoid chronic use of laxatives, enemas, suppositories.

5.  School-age children frequently avoid using bathroom at school for BM.

6.  Explain normal defecation patterns: not necessary to have BM every day; goal is passage of soft, comfortable stools in good quantities.

7.  Instruct family to call if soiling occurs or if child not responding to treatment.

V. DIARRHEA, ACUTE

A.  Noticeable or sudden increase in frequency and fluid content of stools; usually infectious, self-limited lasting for 2 weeks. Diarrhea is a symptom, can result from disorders involving digestive, absorptive, secretory functions of intestine.

B.  Etiology.

1.  Infectious: intestinal.

a.  Viral: rotavirus, adenovirus, Norwalk.

b.  Bacterial: salmonella, shigella,
Clostridium difficile, Escherichia coli
0157:H7.

c.  Parasite: giardia, cryptosporidium.

2.  Infectious: outside GI tract: may be concurrent symptom of systemic illness.

3.  Dietary, medications, toxic ingestion.

4.  Other: intussusception, HUS, appendicitis, UTI.

C.  Occurrence.

1.  Common symptom in children.

2.  Most commonly caused by infection in older infants/children.

3.  Dietary changes or indiscretions common in early infancy.

D.  Clinical manifestations.

1.  Increased frequency, fluid content of stools.

a.  Frequency, consistency of diarrhea?

b.  Hematochezia, melena, mucus, or pus in stool.

c.  Any fecal incontinence in toilet-trained child?

d.  Anyone else in family/school or daycare have diarrhea?

2.  Possible associated symptoms: abdominal pain or cramping, fever, vomiting.