peds laxatives, enemas and clean outs. oh my!

7/12/2021

1

• Edit Master text styles

— Second level

• Third level

– Fourth level

» Fifth level

Peds Laxatives, Enemas and Clean Outs. Oh My!Katherine Battisti, MD FAAP

Pediatric Emergency Medicine


— Second level

• Third level

– Fourth level

» Fifth level

MCEP –Michigan Emergency Medicine Assembly

Peds Laxatives, Enemas and Clean Outs, Oh My!

Dr. Katherine Battisti, MD

July 21, 2021

DISCLOSURE

The planner(s) and speaker(s) for this session disclose no relevant financial relationships with commercial interests.

1

2

7/12/2021

2


— Second level

• Third level

– Fourth level

» Fifth level

• Recognize pediatric constipation and identify red flags that indicate the need for further evaluation.

• Become familiar with age appropriate medications for bowel clean out and maintenance regimens for pediatric patients.

Objectives


— Second level

• Third level

– Fourth level

» Fifth level

You can’t identify abnormal if you don’t know normal…so… what is normal?

3

4

7/12/2021

3


— Second level

• Third level

– Fourth level

» Fifth level

• Infants should stool in the first 24 hours of life

• Meconium

— sticky, tarry, but almost odorless

• Over the next 1-4 days it should transition to infant stool

What is normal?


— Second level

• Third level

– Fourth level

» Fifth level

Normal Infant Stool

Formula fed infantBreast fed infant Iron fortified

5

6

7/12/2021

4


— Second level

• Third level

– Fourth level

» Fifth level

• It is not always pathologic.

— Hirschsprung's Disease

— Cystic Fibrosis

— anatomic abnormality (ex. imperforate anus, anal stenosis)

— premature infants

— delayed enteral feeding

— maternal magnesium during labor/delivery

— maternal drug use

— Normal variant

What if meconium is delayed?


— Second level

• Third level

– Fourth level

» Fifth level

Doctor, my baby is constipated!Ask yourself… is it true?

7

8

7/12/2021

5


— Second level

• Third level

– Fourth level

» Fifth level

A) 10 times a day

B) 1-2 times a day

C) Every other day

D) Once a week

E) Once every 10 days

How often should a baby poop?


— Second level

• Third level

– Fourth level

» Fifth level

A) 10 times a day

B) 1-2 times a day

C) Every other day

D) Once a week

E) Once every 10 days

How often should a baby poop?

9

10

7/12/2021

6


— Second level

• Third level

– Fourth level

» Fifth level

My Baby is Constipated!

https://www.bellybelly.com.au/baby/baby-constipation-remedies-and-causes/

Parents tell you…• My baby is gassy…• My baby acts like they need to poop and cry like they are in pain

but nothing comes out…• My baby doesn’t poop every day…


— Second level

• Third level

– Fourth level

» Fifth level

• ≥ 10 min of straining and crying before successful or

unsuccessful passage of soft stools in patient <9 months

• THIS IS DEVELOPMENTAL – NOT PATHOLOGIC

— Successful stooling requires coordination of

• Pelvic floor movement

• Abdominal muscular contractions

• Relaxation of the anal sphincter

Infant Dyschezia

11

12

7/12/2021

7


— Second level

• Third level

– Fourth level

» Fifth level

• Reassurance

• Efforts to comfort/console infant during periods of distress

• AVOID the following

— Changing formulas or discontinuing breast feeding in favor of formula

— Laxatives

— Rectal Stimulation

Treatment for Infant Dyschezia


— Second level

• Third level

– Fourth level

» Fifth level

• Simethicone – (Gas drops) 0.3ml QID PRN

— Literature is equivocal regarding efficacy

— No safety concerns unless patient is taking levothyroxine

• Gripe water

— Water and herbs – commercially available

— Can contain alcohol, sugar and potentially dangerous supplements

— Encourage parents to review ingredients and buy products that are regulated or at least manufactured in the US.

Gas Drops and Gripe Water

13

14

7/12/2021

8


— Second level

• Third level

– Fourth level

» Fifth level

A life-saving tangent…


— Second level

• Third level

– Fourth level

» Fifth level

***Check urinalysis, Total and Direct Bilirubin, and LFTs***If these are abnormal, get an ultrasound!

https://pedemmorsels.com/acholic-stool/

Neonatal acholic stools. Red flag. Always confirm that it is not real.

15

16

7/12/2021

9


— Second level

• Third level

– Fourth level

» Fifth level

- Conjugated hyperbilirubinemia in newborns

- Inflammatory destruction of intrahepatic and extrahepatic bile ducts

- Leading cause of liver transplants in children

- Early diagnosis is important!!!

- Diagnosis and surgical intervention in the first 60 days of life has significantly improved outcomes. Diagnosis >100 days of life = universally poor outcomes.

Biliary Atresia


— Second level

• Third level

– Fourth level

» Fifth level

Back to ConstipationConstipation in Toddlers and School Age Children

17

18

7/12/2021

10


— Second level

• Third level

– Fourth level

» Fifth level

A 2yo female presents to the ED with “something coming out of her bottom.” Her mother noticed it after finding some blood in her underwear. She has had no recent illnesses and takes no medications. On examination the following is noted:

Which of the following is most likely associated with this finding?

A) Frequent urinary tract infections

B) Premature birth at 33 weeks

C) Functional Constipation

D) GERD

E) Autism Spectrum Disorder

Wang VJ, Flood RG, Godambe SA. “Pediatric Emergency Medicine Question Review Book 2017”, PEMQBook, Atlanta, 2017.


— Second level

• Third level

– Fourth level

» Fifth level

A 2yo female presents to the ED with “something coming out of her bottom.” Her mother noticed it after finding some blood in her underwear. She has had no recent illnesses and takes no medications. On examination the following is noted:

Which of the following is most likely associated with this finding?

A) Frequent urinary tract infections

B) Premature birth at 33 weeks

C) Functional Constipation

D) GERD

E) Autism Spectrum Disorder

Wang VJ, Flood RG, Godambe SA. “Pediatric Emergency Medicine Question Review Book 2017”, PEMQBook, Atlanta, 2017.

19

20

7/12/2021

11


— Second level

• Third level

– Fourth level

» Fifth level

Dr Battisti’s Version(How to ask kids so they understand)

Little Balls

A Bumpy Log

A Snake

Mashed Potatoes

Mud


— Second level

• Third level

– Fourth level

» Fifth level

But they poop every day…

21

22

7/12/2021

12


— Second level

• Third level

– Fourth level

» Fifth level

• Most common causes

— Functional

— Anal fissure

— Ileus s/p viral illness

— dietary

• Other causes

— Sexual abuse

— Mechanical obstruction

• Abdominal/pelvic mass

• Pregnancy

• Stenosis

— Decreased sensation/motility

• Drug related

• Neuromuscular disease

• Metabolic abnormalities

• Infant botulism

— Stool abnormalities

Causes of Constipation


— Second level

• Third level

– Fourth level

» Fifth level

Common Times for Onset of Constipation

23

24

7/12/2021

13


— Second level

• Third level

– Fourth level

» Fifth level

• History and Physical

• Red flags?

— urinary retention, bleeding, vomiting, weight loss, localized abdominal pain, neurologic symptoms

• Rectal Exam?

— NOT recommend a digital rectal exam on most children with constipation. Visual inspection is appropriate.

• Xrays are rarely indicated but…

— Sometimes it helps families buy into treatment regimens

— Can help determine if enema is even worth while if family is requesting it but situation is unclear

— Looks for alternative pathology like ileus/sbo/mass

How do I evaluate constipation in the ED?


— Second level

• Third level

– Fourth level

» Fifth level

• Counselling Families:

— More water, fiber, exercise

— Less fat, processed food

— Scheduled bathroom time

• If children require a clean out, don’t forget maintenance

— It takes 4-6 months for the bowel to regain shape and function after being stretched out from constipation

Everyone Poops… or should

25

26

7/12/2021

14


— Second level

• Third level

– Fourth level

» Fifth level

— For neonates and children under 12 months

— Glycerin Suppositories • for use in infants since enemas are not truly an option

• Use sparingly as frequent use can increase irritation and result in functional constipation

Meds in the ED - Suppositories


— Second level

• Third level

– Fourth level

» Fifth level

• Mineral Oil Enema – often given before saline enema to make things slippery

o 66ml for children 2-12, 133ml for >12yo

• Fleet Enema (Sodium Phosphate)

o Max 1-2 doses in 24 hours due to risk of phosphate absorption

o 33ml for ages 2-5, 66ml for 5-12, 133ml for >12 yo

o Avoid in renal patients

• Saline Enema

o 10ml/kg

• Soap Suds Enema –risk of perforation and water intoxication

o 5-10ml/kg

• Milk of Molasses Enema

o 1:1 ratio of milk to molasses

o Volumes vary widely

Meds in the ED - Enemas

27

28

7/12/2021

15


— Second level

• Third level

– Fourth level

» Fifth level

Meds at home – Clean Out • For 2-5 years old

— 1 chocolate laxative (15mg Senna) in the AM

— 4 capfuls Polyethylene Glycol in 20 ounces fluids (drink over 4-8 hours)

— 1 chocolate laxative (15mg senna) before bed

• For 5-10 years old

— 1.5 chocolate laxative (20-25mg senna) in AM

— 7 capfuls of Polyethylene Glycol in 32 ounces of liquid (drink in 4-8 hours)

— 1.5 chocolate laxatives (20-25mg senna) before bed

• For older than 10

— 2 chocolate laxatives (30mg senna) in AM

— 14 capfuls of Polyethylene Glycol in 64 ounces of liquid in 4-8 hours

— 2 more chocolate laxatives (30mg senna) before bed


— Second level

• Third level

– Fourth level

» Fifth level

• Maintenance

— For infants

• 1 ounce of prune juice daily

• lactulose (1-2g/kg/dose 1-2 times per day) (osmotic laxative)

— For Older Children

• Lactulose (1-2g/kg/dose 1-2x/day)

• Polyethylene Glycol 17g in 8 ounces fluid titrate for soft daily stools (osmotic)

• Senna (stimulant laxative)

– comes in solution 8.8mg/5ml, chocolate squares 15mg and tablets 25mg

Meds at home - Maintenance

29

30

7/12/2021

16


— Second level

• Third level

– Fourth level

» Fifth level

• A lot of GI complaints especially in infants are normal…

— Know your normals so you don’t work up something you don’t have to

— Be able to confidently educate parents about normal behaviors

• Constipation is REALLY common

— Good counseling on clean out, maintenance and dietary changes can help prevent repeat customers

Take Aways…


— Second level

• Third level

– Fourth level

» Fifth level

Questions?

31

32

7/12/2021

17


— Second level

• Third level

– Fourth level

» Fifth level

• Biagioli E, Tarasco V, Lingua C, Moha L, Savino F. Pain-relieving agents for infantile colic. Cochrane Database Syst Rev. 2016 Sept;9:CD009999.

• DesJarlais J. “Baby Poop: A visual Guide” Baby Center. https://www.babycenter.com/baby-poop-photos

• Hansen SE et al. Safety and efficacy of milk and moilasses enemas compared with sodium phosphate enemas for the treatment of constipation in a pediatric emergency department. Pediatr Emerg Care. 2011 Dec;27(12)1118-20.

• LeLeiko N, Mayer-Brown S, Cerezo C, Plante W. Constipation. Pediatr Rev. 2020 Aug;41(8):379-392.

• Harb T, Matsuyama M, David M, Hill RJ. Infant Colic-What Works: A systematic Review of Interventions for Breast-fed Infants. J Pediatr Gastroenterol Nutr. 2016 May;62(5):668-86.

• Ho JMD, et al. Chronic constipation in infants and children. Singapore Med J. 2020 Feb;61(2):63-68. Doi:10.11622/smedj.2020014

• https://pedemmorsels.com

• Shaw, Kathy N, and Richard G Bachur, editors. Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine. 7th ed., Wolters Kluwer, 2016.

• Tabbers MM, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58(2):258-74.

• Wang VJ, Flood RG, Godambe SA. “Pediatric Emergency Medicine Question Review Book 2017”, PEMQBook, Atlanta, 2017.

Resources

33

https://www.babycenter.com/baby-poop-photos

peds laxatives, enemas and clean outs. oh my!

Documents