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THE SCOOP ON POOP Management of the Constipated Patient in the Pediatric Setting John T. Stutts, MD, MPH University of Louisville Department of Pediatrics.

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Presentation on theme: "THE SCOOP ON POOP Management of the Constipated Patient in the Pediatric Setting John T. Stutts, MD, MPH University of Louisville Department of Pediatrics."— Presentation transcript:

1 THE SCOOP ON POOP Management of the Constipated Patient in the Pediatric Setting
John T. Stutts, MD, MPH University of Louisville Department of Pediatrics Division of Pediatric Gastroenterology

2 Disclosure The speaker has been a part of the speaker bureau for Abbott Nutrition in the past.

3 Definition Constipation: “A delay or difficulty in defecation, present for ≥ 2 weeks and sufficient to cause significant distress to the patient.”1 Encopresis: “The involuntary loss of formed, semi-formed, or liquid stool in the child’s underwear, in the presence of functional constipation after the child has reached a developmental age of 4 years.”1

4 Constipation: Prevalence
As many as 3% of visits to the primary care physician.1 As many as 25% of visits to the pediatric gastreoenterologist.1 16 – 37% of otherwise healthy 4 to 11 year old children have constipation.2-6

5 In Your Clinic ….. Constipation is the #1 cause of abdominal pain.
If the chief complaint is abdominal pain …. think constipation until proven otherwise.

6 In Your Clinic ….. A question not to ask:
Is your child constipated? A better question that will give you a clearer picture: How many days does your child skip between bowel movements?

7 Functional vs. Organic Functional Constipation
An umbrella term describing persistent, difficult, infrequent or seemingly incomplete defecation without evidence of a primary anatomic or biochemical cause.7 Accounts for greater than 95% of constipation-related symptoms in children and infants, except those during the neonatal period when organic causes are more likely.7

8 Functional: Etiology 3 critical time periods
Introduction of cereals/solids Toilet training Start of school

9 Functional Infant Dyschezia
At least 10 minutes of straining and/or crying before successful passage of soft stool in an otherwise healthy infant < 6 mos of age. The symptom is due to failure to relax the pelvic floor during the defecation effort and resolves spontaneously.8

10 Functional Fecal Incontinence
In children with constipation, there is no clear difference in the pathophysiology or psychology between children with and without fecal incontinence.9

11 Functional: Treatment
2 phases to treatment Phase 1: The Cleanout Phase 2: Maintenance Phase 1 is arguably the most important!

12 Functional: Cleanout Options
Enemas Phosphate Enemas Adult (≥ 3 yoa) Pediatric (< 3 yoa) SMOG (Saline, Mineral Oil, Glycerin) Milk and Molasses Magnesium Citrate 1 oz per year of age to a max of 10oz once daily x 3-6 days not for infants/toddlers Polyethylene glycol “multiple doses” vs “the gallon”

13 Functional: Maintenance Options
Osmotic Polyethylene glycol (1 capful = 17 grams) 3 yoA ½ capful Q day 6 yoA ½ capful BID *10 yoA 1 capful BID 13 yoA 1 – 1 ½ capfuls BID 18 yoA 1 – 2 capfuls BID

14 Functional: Maintenance Options
Osmotic Milk of Magnesia ≤ 1 year tsp BID 2 – 6 years 2 tsp BID 7-8 years 1 T BID ≥ 9 years 2 T BID Lactulose 1 – 3 mL/kg/day

15 Functional: Maintenance Options
Lubricant Mineral Oil Not recommended Lipoid pneumonia if aspirated Stimulant Senna ≤ 2 yrs ¼ - 1 tsp BID 2 – 4 yrs ½ - 1 tsp BID 5 – 6 yrs 1 tsp BID 7 – 9 yrs 1 tablet BID ≥ 10 yrs 2 tablets BID

16 How do we come off the Laxative?
Fiber is the KEY! Wean the laxative slowly!! AGE DOSE 1 – 3 years 15 grams/day 4 – 8 years 20 grams/day 9 – 12 years 25 grams/day ≥ 13 years 30 grams/day

17 So when is it more than just CFC?
The question of Organic etiology…

18 Organic Constipation Organic causes are responsible for fewer than 5% of cases of constipation in children.

19 Organic Constipation Anatomic Neuropathic
Anal stenosis Imperforate anus Anteriorly displaced anus Pelvic mass (sacral teratoma) Metabolic Hypothyroidism Hypercalcemia Hypokalemia Cystic Fibrosis Diabetes Mellitus Celiac disease MEN type 2B Neuropathic Tethered cord Intestinal nerve/muscle disorder Hirschsprung's disease Visceral myopathies Abnormal abdominal musculature Prune-belly Down syndrome Gastroschisis Connective tissue disorders Scleroderma

20 Organic Constipation Medications Miscellaneous Opiates Antacids
Phenobarbital Miscellaneous Cow’s milk protein intolerance Lead ingestion Botulism10,11

21 Cow’s Milk Protein Allergy/Intolerance
0.3 – 7.5% of normal infants Think about this in the infant who has constipation in association with rhinitis, dermatitis or bronchospasm Options: Dairy elimination for the breast feeding mother Casein Hydrolysate formulas Elemental amino acid-based formulas12,13

22 Hirschsprung's disease
More than 90% of normal infants, but only 10% of infants with Hirschsprung's disease, pass meconium within the first 24 hours of life.14

23 Hirschsprung's disease
A motor disorder of the colon caused by failure of neural crest cells to migrate completely during colonic development. The result … the affected segment of the colon fails to relax causing a functional obstruction.14

24 Hirschsprung's disease
Consider in the following circumstances: Delayed passage of meconium (after 48 hours of life) Abdominal distention Vomiting Onset of symptoms in the first week of life A transition zone on contrast enema14 The “classic triad” present in 82% of cases.

25 Hirschsprung's disease: Diagnosis
Rectal exam – The “Wine Goblet” Explosion… VS H.D CFC

26 Hirschsprung's disease: Diagnosis
Unprepped contrast enema If H.D. present, a transition zone will be seen ~ 70% of the time. Anorectal manometry When the rectal balloon is inflated, reflex relaxation of the internal anal sphincter fails to occur.

27 Hirschsprung's disease: Diagnosis
Rectal suction or full-thickness biopsy ═ The definitive test absence of ganglion cells high acetylcholinesterase accumulation on staining

28 Cystic Fibrosis Constipation is common
DIOS = Distal Ilial Obstruction Syndrome

29 Tethered Cord Syndrome
What is it exactly? Stretch-induced dysfunction of the caudal spinal cord and conus caused by attachment of the filum terminale to inelastic structures caudally.

30 Tethered Cord Syndrome
Associated signs/symptoms constipation bladder dysfunction weak lower extremity reflexes Diagnosis MRI of the lumbosacral spine Treatment Neurosurgical release

31 Organic Pearls If since the neonatal period, there has been constipation (especially with delayed passage of meconium)…. do an unprepped contrast enema.

32 Organic Pearls If a patient has recurrent UTIs, consider constipation as an etiology due to mechanical effects of the distended rectum pressing on the bladder.

33 Organic Pearls If the patient has FTT, RAP and constipation (+/- anemia), consider celiac disease.

34 Organic Pearls If there is spinal dysraphism or neurological impairment of the lower extremities and/or daytime wetting in association with constipation, obtain an MRI of the lumbosacral spine.

35 Organic Pearls If there is impaired linear growth and depressed reflexes…. consider hypothyroidism.

36 Organic Pearls If at risk of electrolyte disturbances (metabolic abnormalities or unable to tolerate adequate fluids)….. check a serum Calcium.

37 Organic Pearls If at risk for lead toxicity…. test for it.

38 Organic Pearls If the H & P remains equivocal for etiology, don’t be afraid to get a KUB …. but remember the readings can be inconsistently interpreted. So, don’t be afraid to look at the film yourself.

39 THE SCOOP ON POOP Thank you!

40 References Baker SS, Liptak GS, Colletti RB, Constipation in infants and children: evaluation and treatment. J Ped Gastro Nutr 1999;29(5): Issenman RM, Hewson S, Pirhonen D, et. al. Are chronic digestive complaints the result of abnormal dietary patterns? Am J Dis Child 1987;141(6): Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary school children. Amb Child Health 1998;4: de Araújo Sant’Anna AM, Calҫado AC. Constipation in school-aged children at public schools in Rio de Janeiro, Brazil. J Ped Gastroenterol Nutr 1999;29(2): Zaslavsky C, Ávila EL, Araújo MA, et. al. Constipaҫão intestinal da infância – um estudo de prevalência. Rev AMRIGS 1988;32: Maffei HVL, Moreira FL, Oliveira WM, et. al. Constipaҫão intestinal em escolare. J Pediatr 1997;73: Thompson WG, Longstreth GF, Drossman DA, et. al. Functional bowel disorders and functional abdominal pain. Gut 1999;45:1143. Hyman PE, Milla PJ, Benninga MA, et. al. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology 2006;130:1519. Benninga MA, Bϋller HA, Heymans HS, et. al. Is encopresis always the result of constipation? Arch Dis Child 1994;71:186. DiLorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am 2001;30:269. Thiessen PN. Recurrent abdominal pain. Pediatr Rev 2002;23:39. Magazzu G, Scoglio R. Gastrointestinal manifestations of cow’s milk allergy. Ann Allergy Asthma Immunol 2002;89:65. Turunen, et al. Lymphoid hyperplasia and cow’s milk hypersensitivity in children with chronic constipation. J Pediatr 2004;145:606. Lewis NA, et. al. Diagnosing Hirschsprung’s disease: increasing the odds of a positive rectal biopsy result. J Pediatr Surg 2003;38:412.

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