THE SCOOP ON POOP Management of the Constipated Patient in the Pediatric Setting

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

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

3. 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 • Definition

4. 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 • Constipation: Prevalence

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

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 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 • Functional vs. Organic

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

9. 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 • Functional

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

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

12. 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” • Functional: Cleanout Options

13. 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 • Functional: Maintenance Options

14. Osmotic • Milk of Magnesia ≤ 1 year 1-2 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 • Functional: Maintenance Options

15. 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 • Functional: Maintenance Options

16. Fiber is the KEY! • Wean the laxative slowly!! • How do we come off the Laxative?

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

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

19. Anatomic • Anal stenosis • Imperforate anus • Anteriorly displaced anus • Pelvic mass (sacral teratoma) • Metabolic • Hypothyroidism • Hypercalcemia • Hypokalemia • Cystic Fibrosis • Diabetes Mellitus • Celiac disease • MEN type 2B • Organic Constipation • 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. Medications • Opiates • Antacids • Phenobarbital • Miscellaneous • Cow’s milk protein intolerance • Lead ingestion • Botulism10,11 • Organic Constipation

21. 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 • Cow’s Milk Protein Allergy/Intolerance

22. 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 • Hirschsprung's disease

23. 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 • Hirschsprung's disease

24. 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 • Hirschsprung's disease The “classic triad” present in 82% of cases.

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

26. 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. • Hirschsprung's disease: Diagnosis

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

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

29. 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. • Tethered Cord Syndrome

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

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

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

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

34. 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. • Organic Pearls

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

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

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

38. 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. • Organic Pearls

39. THE SCOOP ON POOP Thank you!

40. Baker SS, Liptak GS, Colletti RB, et.al. Constipation in infants and children: evaluation and treatment. J Ped Gastro Nutr 1999;29(5):612-626. 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):679-682. Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary school children. Amb Child Health 1998;4:277-282. 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):190-193. Zaslavsky C, Ávila EL, Araújo MA, et. al. Constipaҫão intestinal da infância – um estudo de prevalência. Rev AMRIGS 1988;32:100-102. Maffei HVL, Moreira FL, Oliveira WM, et. al. Constipaҫão intestinal em escolare. J Pediatr 1997;73:340-344. 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. References