John T. Stutts, MD, MPH University of Louisville Department of Pediatrics Division of Pediatric Gastroenterology.

THE SCOOP ON POOP

MANAGEMENT OF THECONSTIPATED PATIENT IN THE PEDIATRIC SETTINGJohn T. Stutts, MD, MPHUniversity of Louisville Department of Pediatrics

Division of Pediatric Gastroenterology

L O U I S V I L L E . E D U

• The speaker has been a part of the

speaker bureau for Abbott Nutrition

in the past.

DISCLOSURE

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• Constipation is the #1 cause of

abdominal pain.

• If the chief complaint is abdominal

pain …. think constipation until

proven otherwise.

IN YOUR CLINIC …..

L O U I S V I L L E . E D U

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?

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• 3 critical time periods- Introduction of cereals/solids

- Toilet training

- Start of school

FUNCTIONAL: ETIOLOGY

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• 2 phases to treatment- Phase 1: The Cleanout

- Phase 2: Maintenance

Phase 1 is arguably the most important!

FUNCTIONAL: TREATMENT

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• Osmotic- Milk of Magnesia

≤ 1 year 1-2 tsp BID2 – 6 years 2 tsp BID7-8 years 1 T BID≥ 9 years 2 T BID

- Lactulose1 – 3 mL/kg/day

FUNCTIONAL: MAINTENANCE OPTIONS

L O U I S V I L L E . E D U

• Lubricant- Mineral Oil

• Not recommended• Lipoid pneumonia if aspirated

• Stimulant- Senna

≤ 2 yrs ¼ - 1 tsp BID2 – 4 yrs ½ - 1 tsp BID5 – 6 yrs 1 tsp BID7 – 9 yrs 1 tablet BID≥ 10 yrs 2 tablets BID

FUNCTIONAL: MAINTENANCE OPTIONS

L O U I S V I L L E . E D U

• Fiber is the KEY!

• Wean the laxative slowly!!

HOW DO WE COME OFF THE LAXATIVE?

AGE DOSE

1 – 3 years 15 grams/day

4 – 8 years 20 grams/day

9 – 12 years 25 grams/day

≥ 13 years 30 grams/day

L O U I S V I L L E . E D U

• The question of Organic

etiology…

SO WHEN IS IT MORE THAN JUST CFC?

L O U I S V I L L E . E D U

•Organic causes are

responsible for fewer than 5%

of cases of constipation in

children.

ORGANIC CONSTIPATION

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• Medications- Opiates- Antacids- Phenobarbital

• Miscellaneous- Cow’s milk protein intolerance- Lead ingestion- Botulism10,11

ORGANIC CONSTIPATION

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• 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.

L O U I S V I L L E . E D U

• Rectal exam – The “Wine Goblet” Explosion…

HIRSCHSPRUNG'S DISEASE: DIAGNOSIS

VS

H.D. CFC

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• Rectal suction or full-thickness biopsy

═ The definitive test- absence of ganglion cells

- high acetylcholinesterase accumulation on staining

HIRSCHSPRUNG'S DISEASE: DIAGNOSIS

L O U I S V I L L E . E D U

• Constipation is common

• DIOS = Distal Ilial Obstruction

Syndrome

CYSTIC FIBROSIS

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• Associated signs/symptoms- constipation- bladder dysfunction- weak lower extremity reflexes

• Diagnosis- MRI of the lumbosacral spine

• Treatment- Neurosurgical release

TETHERED CORD SYNDROME

L O U I S V I L L E . E D U

• If since the neonatal period,

there has been constipation

(especially with delayed

passage of meconium)…. do an

unprepped contrast enema.

ORGANIC PEARLS

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• If the patient has FTT, RAP and

constipation (+/- anemia),

consider celiac disease.

ORGANIC PEARLS

L O U I S V I L L E . E D U

• 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

L O U I S V I L L E . E D U

• If there is impaired linear

growth and depressed

reflexes…. consider

hypothyroidism.

ORGANIC PEARLS

L O U I S V I L L E . E D U

• If at risk of electrolyte

disturbances (metabolic

abnormalities or unable to

tolerate adequate fluids)…..

check a serum Calcium.

ORGANIC PEARLS

L O U I S V I L L E . E D U

• If at risk for lead toxicity…. test

for it.

ORGANIC PEARLS

L O U I S V I L L E . E D U

• 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

THE SCOOP ON POOPThank you!

REFERENCES1. Baker SS, Liptak GS, Colletti RB, et.al. Constipation in infants and children: evaluation and

treatment. J Ped Gastro Nutr 1999;29(5):612-626.2. 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):679-682.3. Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary school

children. Amb Child Health 1998;4:277-282.4. 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):190-193.5. Zaslavsky C, Ávila EL, Araújo MA, et. al. Constipaҫão intestinal da infância – um estudo de

prevalência. Rev AMRIGS 1988;32:100-102.6. Maffei HVL, Moreira FL, Oliveira WM, et. al. Constipaҫão intestinal em escolare. J Pediatr

1997;73:340-344.7. Thompson WG, Longstreth GF, Drossman DA, et. al. Functional bowel disorders and

functional abdominal pain. Gut 1999;45:1143.8. Hyman PE, Milla PJ, Benninga MA, et. al. Childhood functional gastrointestinal disorders:

neonate/toddler. Gastroenterology 2006;130:1519.9. Benninga MA, Bϋller HA, Heymans HS, et. al. Is encopresis always the result of

constipation? Arch Dis Child 1994;71:186.10. DiLorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am 2001;30:269.11. Thiessen PN. Recurrent abdominal pain. Pediatr Rev 2002;23:39.12. Magazzu G, Scoglio R. Gastrointestinal manifestations of cow’s milk allergy. Ann Allergy

Asthma Immunol 2002;89:65.13. Turunen, et al. Lymphoid hyperplasia and cow’s milk hypersensitivity in children with

chronic constipation. J Pediatr 2004;145:606.14. Lewis NA, et. al. Diagnosing Hirschsprung’s disease: increasing the odds of a positive

rectal biopsy result. J Pediatr Surg 2003;38:412.