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Abbey Rupe, MD 2.7.12.  “Rome III” diagnostic categories of functional disorders of defecation in children: ◦ Functional constipation  In infants and.

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Presentation on theme: "Abbey Rupe, MD 2.7.12.  “Rome III” diagnostic categories of functional disorders of defecation in children: ◦ Functional constipation  In infants and."— Presentation transcript:

1 Abbey Rupe, MD

2  “Rome III” diagnostic categories of functional disorders of defecation in children: ◦ Functional constipation  In infants and preschool children  In children 4-18 years of age ◦ Infant dyschezia ◦ Nonretentive fecal incontinence

3  Infants and toddlers: 2 or more of the following present for at least 1 month: ◦ 2 or fewer defecations/week ◦ At least 1 episode of incontinence after being toilet trained ◦ Hx of excessive stool retention ◦ Hx of painful or hard bowel movements ◦ Presence of large fecal mass in the rectum ◦ Hx of large-diameter stools that may obstruct the toilet

4  Children w/ developmental age 4-18 yrs; at least 2 of the following present for at least 2 months: ◦ 2 or fewer defecations/week ◦ At least 1 episode of fecal incontinence/week ◦ Hx of retentive posturing or excessive volitional stool retention ◦ Hx of painful or hard bowel movements ◦ Presence of a large fecal mass in the rectum ◦ Hx of large-diameter stools that may obstruct the toilet

5  Organic causes: < 5% of cases ◦ Anatomic: anal stenosis, imperforate anus ◦ Metabolic/GI: hypothyroidism, CF, diabetes mellitus, celiac disease ◦ Neuropathic: spinal cord abnormalities, tethered cord ◦ Intestinal nerve/muscle disorders: Hirschsprung disease, neuropathies ◦ Misc: cow’s milk protein intolerance, lead ingestion, vit D intoxication, botulism

6  3 periods when kids prone to develop constipation: ◦ Introduction of cereals and solid food to infant’s diet ◦ Toilet training ◦ Starting school

7  Painful defecation ◦ Can start a vicious cycle  Toilet training ◦ Stool is held for longer periods between BMs ◦ Power struggles can develop  Diet ◦ Highly processed foods consumed at the expense of fruit, veggies, and fiber  Cow’s milk and constipation???? controversial

8  History ◦ Delayed passage of meconium ◦ Painful defecation ◦ Blood on stool ◦ Toilet training issues ◦ Voiding dysfunction and enuresis ◦ Diet ◦ Changes at home/school ◦ Family hx

9  Hx: signs suggesting possible organic cause: ◦ Weight loss or poor weight gain ◦ Anorexia ◦ Delayed growth ◦ Delayed passage of meconium (after 48 hours) ◦ Urinary incontinence ◦ Passage of blood (unless due to anal fissure) ◦ Constipation present since birth/early infancy ◦ Acute constipation ◦ Fever, vomiting, diarrhea ◦ Extraintestinalsx

10  Physical exam ◦ Abdominal distention ◦ Mass in suprapubic area ◦ Anal fissure ◦ Soiled underwear ◦ Anal sphincter tone ◦ Size of rectal vault ◦ Impacted stool ◦ Lower back skin defects

11  PE findings suggestive of organic cause: ◦ FTT ◦ Abdominal distention ◦ Lower spine abnormalities ◦ Anteriorly displaced anus ◦ Tight, empty rectum in presence of palpable fecal mass ◦ Absent anal wink ◦ Absent cremasteric reflex ◦ Decreased lower extremity tone or strength

12  Laboratory (if indicated) ◦ KUB ◦ CBC ◦ Thyroid ◦ Celiac disease panel ◦ Barium enema ◦ Anorectalmanometry ◦ Rectal biopsy ◦ Motility studies ◦ Sweat chloride

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14  Findings supportive of functional etiology: ◦ Onset coincides with dietary changes, toilet training, or painful bowel movements ◦ Stool withholding behavior ◦ Good response to conventional treatment

15  Breast-fed infants: average 3 stools/day ◦ Range: BM with every feed to BM every 7-10 days  Formula-fed infants: ◦ Average 2/day ◦ Can vary with formula  Soy-based—tend to produce harder stools; hydrolyzed casein formulas tend to produce looser stools

16  Grunting, apparent straining, turning red in the face, etc does not necessarily mean an infant is constipated ◦ More appropriate measure is consistency of the stool ◦ Efforts >10 minutes to produce soft stool: “infant dyschezia” – failure to relax pelvic floor during defecation effort; resolves spontaneously with time

17  “normal” stools ◦ Reassure, reassure, reassure ◦ Press on feet, press knees to belly, raise vertical, etc  Constipated: ◦ 1 tsp dark Karo syrup bid ◦ Miralax ◦ Glycerin suppository ◦ Juice—pear, apple, prune ◦ If on solids:  increase pear, prune, plums, beans, peas, peaches  Decrease rice cereal, applesauce, bananas

18  Goal: 1 soft, easily passed stool daily  Education ◦ “cycle” of constipation ◦ Length of treatment ◦ Safety of medication used  3 phases: 1.Disimpaction 2.Maintenance 3.Follow-up

19  Options: oral or NG medications, rectal medications, or combination ◦ Inpatient vs outpatient  Oral: ◦ Polyethylene glycol (Miralax) ◦ Polyethylene glycol-electrolyte solution ◦ Mineral oil (don’t use if at risk for GER) ◦ Other: magnesium hydroxide, magnesium citrate, lactulose, sorbitol, senna, bisacodyl

20  Rectal ◦ Phosphate sodium enema (2 yrs and older) ◦ Mineral oil enema ◦ Bisacodyl suppository (older children) ◦ Glycerin suppository (infants)

21  Polyethylene glycol  Magnesium hydroxide  Lactulose  Mineral oil

22  Polyethylene glycol (PEG 3350, Miralax) ◦ Osmotic laxative ◦ OTC ◦ grams/kg/day  Mix in 4-8 ounces liquid  Increase or decrease by ½ to 1 tsp every other day until stools soft and daily

23  Mineral oil ◦ Lubricant laxative  ? Interfere with absorption of fat soluble vitamins  Administer in mid-afternoon and bedtime  +/- give multivitamin  More palatable if chilled and served with a fat- containing food the child likes (pudding, yogurt, ice cream, chocolate syrup)  Avoid in kids < 1 yr of age and those at risk for GER (aspiration pneumonitis)

24  Other osmotic laxatives: ◦ Milk of magnesia ◦ Lactulose  Stimulant laxatives ◦ Senna, bisacodyl

25  Behavior modification: ◦ “scheduled sitting” on the toilet for 5-10 minutes at same time each day (preferable within 30 minutes after a meal)  Provide footstool for support if needed ◦ Reward system  “Poop Journal”

26 lax.com/constipation- education

27  Dietary changes ◦ Increase intake of fruit, raw veggies, bran, whole- grain breads, cereals, and fluids other than milk ◦ Cow’s milk  Consider 1-2 week trial of elimination in atopic children whose constipation is unresponsive to other measures ◦ ?probiotics

28  When to discontinue medications? ◦ Depends on child and severity of constipation ◦ Taper gradually, resume if constipation returns

29  Constipation with fecal incontinence—80- 95%  Nonretentive fecal incontinence—5-20% ◦ Rome III criteria:  Children with developmental age of >4 yrs, with all the following present for at least 2 months:  Defecation into places inappropriate to the social context at least once/month  No underlying disease process to explain the symptoms  No evidence of constipation

30  Manage as you would for severe constipation

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32  Causes: unclear ◦ Some association w/ behavioral and attention problems as well as anxiety and depressive symptoms ◦ Soiling episodes often linked to certain persons or situations ◦ Up to 40% have never been fully toilet trained

33  Treatment: ◦ No widely effect treatments  ◦ Behavior modification  Highly structured toilet training protocol aimed at frequent efforts at defecation  Reward system ◦ Psychosocial diagnosis and support  Outcome: ◦ one study found 29% resolution at 2 yrs, 65% after 5 yrs, and 90% after 10 years

34  Consider when oral and/or rectal medications are ineffective for disimpaction or when dietary and laxative therapy are ineffective ◦ Complete laboratory data prior to consultation (thyroid, calcium, celiac disease, lead)  Referral options: ◦ Wichita: 2 peds gastroenterologists ◦ Children’s Mercy: peds GI, BRICK clinic

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36  Acute ◦ Passage of loose or watery stools at least 3x/day in a 24-hour period ◦ Lasts <14 days  Chronic ◦ Stool volume of >10 gm/kg/day (infants/toddlers) or >200gm/day (older children) x14 or more days  Typically means: loose or watery stools occurring at least 3x/day

37  Etiology ◦ Infectious gastroenteritis  Acute watery diarrhea  Rotavirus (infants/young children)  E. coli (older children)  Invasive (bloody) diarrhea—frank blood in stool + fever  Shigela  Salmonella  Campylobacter  EHEC  EIEC ◦ Other: influenza, HIV, pneumonia, UTI, meningitis, sepsis

38  Assessment: ◦ Type of diarrheal illness (watery, invasive, chronic) ◦ Assess hydration ◦ Assess comorbid conditions

39 Clinical feature< 5 % dehydrated 5-10 % dehydration >10% dehydration Gen. appearanceWell, alertRestless, irritable Lethargic or unconscious EyesNormalSunken ThirstDrinks normally, not thirsty Thirsty, drinks eagerly Drinks poorly or unable to drink Skin pinchGoes back quickly Goes back slowly Goes back very slowly Estimated fluid deficit < 50 ml/kg ml/kg>100 ml/kg

40  Not indicated in most cases  Dehydration requiring IVF  Stool studies: ◦ Viral antigen (rota) ◦ Culture (bloody diarrhea) ◦ O and P (recent travel) ◦ C. diff (recent abx)

41  Fluid and electrolytes ◦ Replacement ◦ Maintenance  < 2 yrs: ml ORS/episode of V/D  > 2 yrs: ml ORS/episode of V/D  Oral Rehydration Solution ◦ Mixture of water, salts, and glucose ◦ Pedialyte, etc  IVF ◦ Rehydrate with NS boluses (20 ml/kg), followed by dextrose-containing IVF

42  Refeeding ◦ Feeding can be resumed as soon as rehydration is complete  Feed age-appropriate diet  BRAT is unnecessarily restrictive

43  Pharmacotherapy ◦ Antibiotics—not indicated ◦ Antidiarrheal—not recommended  Antimotility (i.e. loperamide)—not recommended due to side effects (lethargy, CNS depression, etc)  Antisecretory (i.e. bismuth)—contain salicylates (EVEN Children’s PeptoBismol) ◦ Probiotics  Reduce stool output and diarrhea duration ◦ Antiemetics--controversial

44  Post-enteritis syndrome ◦ Most acute enteric infections resolve within 14 days ◦ Occasionally, acute GE can cause mucosal damage to small intestine and trigger chronic diarrhea  ? Secondary to transient lactase deficiency  Probiotics may speed recovery

45  DDx list is HUGE! ◦ Functional  Excessive juice/osmotically active carb intake  Idiopathic ◦ Enteric infection  Postentereitis syndrome  Parasites  Bacteria  Viruses  CMV, rota, HIV

46  DDx, cont’d ◦ CF ◦ Immune deficiency ◦ Abnormal immune response  Celiac disease  Food allergic enteropathy ◦ IBD ◦ Protein losing gastroenteropathy ◦ Factitious diarrhea

47  Lab ◦ Celiac serology (anti-tTG) ◦ Stool pH, electrolytes, reducing substances ◦ Occult blood and leukocytes ◦ Stool fat ◦ Concern for IBD: CBC, albumin, ESR ◦ Sweat chloride ◦ Fecal elastase

48  Aka Functional Diarrhea or Chronic nonspecific diarrhea of childhood: ◦ Painless passage of 3 or more large, unformed stools during waking hours for 4 or more weeks ◦ Onset in infancy or preschool years ◦ Without FTT or specific definable cause

49  Early morning stools: large and semi-formed  Stools become progressively looser as day progresses  Nearly all will develop normal bowel patterns by 4 yrs of age

50  Sometimes due to excessive intake of fruit juice ◦ Improves if intake is decreased  No other dietary modification needed

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