Abbey Rupe, MD2.7.12

“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

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

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

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

3 periods when kids prone to develop constipation:◦ Introduction of cereals and solid food to infant’s

diet◦ Toilet training◦ Starting school

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

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

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

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

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

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

Findings supportive of functional etiology:◦ Onset coincides with dietary changes, toilet

training, or painful bowel movements◦ Stool withholding behavior◦ Good response to conventional treatment

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

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

“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

Goal: 1 soft, easily passed stool daily Education

◦ “cycle” of constipation◦ Length of treatment◦ Safety of medication used

3 phases:1.Disimpaction2.Maintenance3.Follow-up

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

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

Polyethylene glycol Magnesium hydroxide Lactulose Mineral oil

Polyethylene glycol (PEG 3350, Miralax)◦ Osmotic laxative◦ OTC◦ 0.4-0.8 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

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)

Other osmotic laxatives:◦ Milk of magnesia◦ Lactulose

Stimulant laxatives◦ Senna, bisacodyl

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”

http://pedia-lax.com/constipation-education

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

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

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

Manage as you would for severe constipation

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

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

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

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

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

Assessment:◦ Type of diarrheal illness (watery, invasive,

chronic)◦ Assess hydration◦ Assess comorbid conditions

Clinical feature

< 5 % dehydrated

5-10 % dehydration

>10% dehydration

Gen. appearance

Well, alert Restless, irritable

Lethargic or unconscious

Eyes Normal Sunken Sunken

Thirst Drinks normally, not thirsty

Thirsty, drinks eagerly

Drinks poorly or unable to drink

Skin pinch Goes back quickly

Goes back slowly

Goes back very slowly

Estimated fluid deficit

< 50 ml/kg 50-100 ml/kg >100 ml/kg

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)

Fluid and electrolytes◦ Replacement◦ Maintenance

< 2 yrs: 50-100 ml ORS/episode of V/D > 2 yrs: 100-200 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

Refeeding◦ Feeding can be resumed as soon as rehydration is

complete Feed age-appropriate diet BRAT is unnecessarily restrictive

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

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

DDx list is HUGE!◦ Functional

Excessive juice/osmotically active carb intake Idiopathic

◦ Enteric infection Postentereitis syndrome Parasites Bacteria Viruses

CMV, rota, HIV

DDx, cont’d◦ CF◦ Immune deficiency◦ Abnormal immune response

Celiac disease Food allergic enteropathy

◦ IBD◦ Protein losing gastroenteropathy◦ Factitious diarrhea

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

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

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

Sometimes due to excessive intake of fruit juice◦ Improves if intake is decreased

No other dietary modification needed