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December 9, 2009 Francine Jolton, MD. Constipation Different Approaches for Different Ages **Infants **Toddlers in Diapers **Children who are toilet.

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Presentation on theme: "December 9, 2009 Francine Jolton, MD. Constipation Different Approaches for Different Ages **Infants **Toddlers in Diapers **Children who are toilet."— Presentation transcript:

1 December 9, 2009 Francine Jolton, MD



4 Constipation Different Approaches for Different Ages **Infants **Toddlers in Diapers **Children who are toilet trained

5 Infants Typical story A 1 ½ month old comes in and mother is concerned that he is constipated. He only stools on his own 1X/week. He strains and cries but the stool is of normal consistency. Mom gives a suppository every 2 days which produces a stool

6 Question Is this Constipation ???? What is the normal stooling pattern for a 1 ½ month old?

7 Things to Consider Could this be Hirschsprung’s, Hypothyroidism, Tethered spinal cord, etc? Is the baby anatomically normal or is there anal stenosis or an anterior anus?

8 Is it Infant Dyschezia? At least 10 minutes of straining and crying before successful passage of soft stools No other health issues Seen in infants < 6 months old Begins spontaneously Resolves after a few weeks

9 Treatment ???? If it ain’t broke, don’t fix it Don’t use mineral oil (risk of aspiration) Don’t do rectal stimulation and suppositories Don’t use low-iron formula Could consider prune/apple juice (if old enough), lactulose, dark karo syrup

10 The Toddler A 2 year old only stools once/week after hours of straining, crying and parental distress. The stools are large caliber, hard, can have blood on the outside and are painful to pass. This has been going on for 6 months

11 Things to Remember Examine for structural anomalies, fissures Usually starts with toilet training conflict and/or anal fissure The “dance”, trying to stool or not???

12 Treatment Parental Education Postpone Toilet Training unless child drives it Miralax, Mineral Oil Treat fissure (sitz baths, vaseline) Avoid Enemas Fiber is an adjunct

13 Miralax Disimpaction at 1.5 – 2 g/kg/d ½ the dose for maintenance Titrate to achieve a soft stool daily Tasteless, can mix in any liquid OTC Don’t wean while toilet training, do wean after 2 – 3 months of normal stools

14 Mineral Oil 1 tablespoon (1 oz)/yr of age BID Keep it cold and mix in thick juice Titrate as needed Failures caused by too small of dose, prn usage instead of qd, child refuses (keep cold), large intake of whole milk Taper after 2 good months

15 The Toilet Trained Child Child sits on toilet when he feels like going (about once/week) Soils his underwear daily Stools are large caliber Problem is long standing (months to years) RX with water, juice, occassional enemas Tries to avoid going Can have encoporesis Many social aspects

16 Treatment if Mild High fiber diet – grams/day = age + 5 Increase fiber gradually Can use fiber supplement (benfiber, metamucil, citrucel, etc) Fluids Toileting schedule

17 Treatment for Moderate to Severe Will likely need initial clean out Then can use: Miralax, Mineral Oil, MOM Dose titration for all Can use a stimulant (Senna, Ex-Lax) Must have a routine for toilet time Reward System Avoid Toilet Posture

18 Why Treatment Fails Family doesn’t understand the problem Incomplete initial clean out Inconsistent or inadequate maintenance Stop meds too soon No schedule Lots of attention for the wrong behavior

19 Special Consideration Sexually abused child Autism Neurologically impaired

20 Resources Toilet Learning by Alison Mack – gastroenterology issue

21 On to Dermatology Molluscum Contagiosum seen in 5% of children 2 – 8 years old The only lesion that needs to be treated is the one on the eyelid causing corneal irritation Untreated will resolve in 6 months – 3 years Curettage most efficacious with lowest side effects but requires time and anesthesia

22 Warts Seen in 4 – 5% of children Common, flat, plantar and genital Untreated warts resolve in 6 months – 3 years Most patients have already decided to have their warts treated Some are painful (plantar), some are socially awkward (common) Best evidence is topical treatments with salicylic acid for about 3 months

23 Scabies Treat all in the home Permetherin 5% cream (Elimite) for > 6hours Treat clothing and bedding Repeat Therapy in 7 – 10 days 30 – 60 grams/person

24 Lice Permethrin 1% (NIX) applies for > 6 hours Wash or heat clothing All contacts should be treated -------OR----- Cetaphil Cleanser – apply 8 – 12 oz of lotion thoroughly in hair, wait 2 minutes Comb out excess lotion Dry hair with hand held drier Shampoo with usual shampoo in 8 hours

25 A little more on Lice Dry-on suffocation based treatment is effective without neurotoxins, nit removal of extensive house cleaning Newly approved, Benzyl Alcohol Lotion 5% Used in two 10 minute treatments a week a part Still need to treat contacts, bedding, clothing, etc. Nit removal +/-, use nit comb toward scalp




29 Now, on to Orthopedics Developmental Dysplasia of the Hip Spectrum of Pathology Dysplastic Subluxated Dislocated Can be present at birth (congenital) Can occur later (developmental)

30 Possible Outcomes of DDH The hip can become normal The hip begins to subluxate The hip completely dislocates The hip remains located but dysplastic ( leads to hip pain and arthritis in adults)

31 Interesting Facts about the Hip Fully formed by 11 weeks gestation Requires normal movement for development Normal hip anatomy with a ossific nucleus doesn’t appear on x-ray until 4 – 7 months of age Normal hip development and growth accounts for 30% of the adult femur length (abnormalities lead to short leg length)

32 Hip Dysplasia Can be progressive The Anatomy can change secondary to changes in the surrounding muscles and ligaments Any treatment must limit damage to the medial circumflex artery to prevent AVN

33 Diagnosis When should the hip be examined? ***at every well child check until age 2 ***must document Who remembers the names of the tests used to examine the hip for DDH? There are 3 ……………………………………………………..

34 Ortolani Test CLICK OF ENTRY Hip is flexed 90 degrees, sl. abducted Trochanter is elevated (use middle finger) Lift and abduct Head slides into acetabulum


36 Barlow Test CLICK OF EXIT Hip is flexed, adducted Gentle posterior pressure


38 Abduction Most reliable after 3 months Other signs disappear with muscle changes Used for late diagnosis Skin fold asymmetry and leg length discrepancy are unreliable.

39 What to X-Ray Ultrasound Not accurate in first 6 weeks, overly sensitive Best between 6 weeks and 6 months Radiography High false negative early on Can be used after 6 months (ossific nuclei present)

40 When and How to Treat Want to treat early If untreated leads to limp, short leg, back pain and arthritis in adults Pavlik Harness Birth – 6 months Allows for motion that fosters normal joint formation Time in harness depends on age of diagnosis NO DOUBLE/TRIPLE DIAPERS !!!!!! All therapy after 6 months requires surgery, the later it occurs, less likelihood of normal joint


42 Rotational and Angular Conditions Why Bother ? THE MOST COMMON MUSCULOSKELETAL COMPLAINTS ENCOUNTERED BY PEDIATRICIANS Need to know the difference between normal and pathology Understand torsional profiles Know when to Refer

43 Helpful Definitions Deformity: > 3 SD from the norm Variation: < 3 SD from the norm Angular Conditions: deviations from neutrality in the frontal plane Rotational Conditions: deviation from neutrality in the axial plane Rotation = Torsion = Version

44 Conditions by Anatomical Area The Feet (birth to six months) Metatarsus adductus The Legs (6 months to 3 years) Tibial Torsion The Knees (6 months to 3 years) Bow legs & Knock knees The Hip (> 3 years) Femoral Anteversion

45 Metatarsus Adductus

46 Evaluate Three Things Heel Bisector Rigid vs. Supple Ankle Range of Motion – is dorsiflexion limited? ***Double check hip exam


48 When to Refer If Rigid – may need casting or surgery if a skewfoot Limited Dorsiflexion – could be clubfoot or other problem that could need surgery Exasperated MD or parent

49 Tibial Torsion Parents and Grandparents – very concerned Child completely unconcerned Large standard deviations Usually internal rotation Can evaluate the thigh foot axis and follow


51 Treatment Denis Browne Bar – no evidence it helps Derotation Osteotomies – dangerous surgery OP – Orthopedic Psychotherapy


53 Genu Varum and Valgum Becomes a concern when child begins to walk Angular History of the Knees Birth – Varus Neutral by 1.5 – 2 years Valgus at 3 years Normal at 5 years Look for difference between tibial torsion and genu varum

54 Cover-Up Test Child sitting or supine with legs in extension May look bowed at knees Place patella in neutral Cover up lower leg and foot, look at Tib-Fem Angle (knee is straight, tib-fem = 0) Uncover the foot If turned in approx 70 degrees from distal leg dx is tibial torsion

55 When to Refer Genu Varum If unilateral Rapid Progression If angled, not bowed at the knee Gait has a limp (lateral thrust) Asymmetry of legs (check hips) Think Blount’s diseases or Rickets Can get an x-ray

56 Femoral Anteversion Place child prone Flex knees to 90 degrees Legs go out = internal rotation Legs to in = external rotation Internal rotation estimates anteversion

57 Intoeing Gait This is the main complaint (and they fall) Determine if it comes from the hip, leg or foot Torsional Profile ***Foot Progression Angle (watch them walk) ***Hip Rotation ***Thigh Foot Axis ***Heel Bisector

58 Is Any of This Really a Problem? Wide Variation of Normal No evidence of musculoskeletal impairment, no arthritis Associated with Athletic Ability (Sprinting) ????Associated with Political Power (Have you looked at the governator’s gait !!)

59 Return to Play Guidelines After a Concussion Common Sports Injury – football, hockey, gymnastics, wrestling, boxing 1.5 million kids play high school football It has the highest injury rate, 4 – 5 % Underreported Most common symptoms are headache, dizziness, confusion Greatest Risk of a second injury is 7 – 10 days after the first concussion

60 Removal from game for all concussions, regardless of severity of symptoms No participation in contact sports until all cerebral symptoms have resolved Asymptomatic at rest and exertion for at least one week. Begin activity gradually with light workouts, and progressing to sport specific exercises, then full contact training (after medical clearance)then game play Step back in sequence if symptoms develop




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