- What comprehensive physical, social, emotional, information will you gather from parents of a three-year-old who is straining to stool, complaining of abdominal pain, but refusing to use the toilet for bowel movements? What treatment recommendations will you detail in your plan of care? What time frame for a follow-up visit will you expect to establish? What information will you obtain from the parents?
Constipation is one of the most common chronic disorders of childhood, affecting 1% to 30% of children worldwide (Nurko, & Zimmerman, 2014). Constipation is responsible for 3% of all primary care visits for children and 10% to 25% of pediatric gastroenterology visits (Nurko, & Zimmerman, 2014). Stool toileting refusal is present when a child demonstrates a pattern of successfully using the toilet to urinate, but refuses to use the toilet for bowel movements, this is a commo yet not well documented causative agent for constipation in the pediatric population (Burns, et al., 2017). It will be important to identify this from other causes of primary encopresis.
When obtaining the it is important to assess the current condition and possible associated factors including social and psychological (AAP, 2017). Key points of history taking include, reports of stained underwear, must differentiate between leakage and hygiene issue, report of fewer than three bowel movements per week, difficult or painful defecation, large-caliber or hard stool, child suddenly becoming still during play, attempting to hide when urge to defecate is felt, child attempting to retain, reports of a bloated sensation, abdominal pain, or both, odor of stool from leakage into underwear, streaks of bright blood on toilet paper or underwear, child attempting to retain urine, enuresis, nocturnal or diurnal, UTIs, anorexia, avoiding using the toilet at school or other public places (Burns, et al., 2017). Key findings associated with stool toilet refusal include bladder control but refusal to defecate on the toilet, a regular or irregular pattern of bowel movements, consistent signs from child that a bowel movement is imminent, may have a history of hiding when defecating, either before or after toilet training begins (Burns, et al., 2017). Additionally, the medical history should include the family’s definition of constipation and a careful review of the frequency, consistency, and size of stools; age at onset of symptoms; timing of meconium passage after birth; recent stressors; previous and active therapies; presence of withholding behaviors, and systemic symptoms (Nurko, & Zimmerman, 2014). The presence of withholding behaviors supports the diagnosis of functional constipation (Nurko, & Zimmerman, 2014). Further evaluation may be warranted in children with red flags that might suggest an organic etiology (Nurko, & Zimmerman, 2014).
The physical examination should include an assessment for overflow soiling, abdominal distention, abdominal tenderness on palpation, a mass felt at the midline in the suprapubic area, anal fissures, sacral dimple or hair tuft, and neurologic signs including absent or diminished abdominal, cremasteric, anal wink reflexes, and deep tendon reflexes in lower extremities may indicate a neurologic cause (Burns, et al., 2017). Additionally, the physical examination should include a review of growth parameters, an abdominal examination, an external examination of the perineum and perianal area, and an evaluation of the thyroid and spine (Nurko, & Zimmerman, 2014). A digital examination of the anorectum is recommended to assess for perianal sensation, anal tone, rectum size, anal wink, and amount and consistency of stool in the rectum (Nurko, & Zimmerman, 2014). However, in children with normal neonatal courses or clear withholding behaviors, or in whom trauma is suspected, the rectal examination may be deferred (Nurko, & Zimmerman, 2014). A test for occult blood in the stool should be performed in all infants with constipation and in any child with constipation who has pain, failure to thrive, diarrhea, or a family history of colon cancer or polyps (Nurko, & Zimmerman, 2014). The presence of a hard mass in the lower abdomen combined with a dilated rectum filled with hard stool indicates fecal impaction (Nurko, & Zimmerman, 2014).
The treatment of functional constipation requires parental education, behavior interventions, measures to ensure that bowel movements occur at normal intervals with good evacuation, close follow-up, and adjustment of medication and evaluation as necessary (Nurko, & Zimmerman, 2014). The main goal is to establish a healthy bowel movement routine. If the patient is experiencing fecal impaction this may require decompaction either manually or pharmacologically (Nurko, & Zimmerman, 2014). Initial treatment includes education, dietary changes, behavior modification, and oral medication. The practitioner may not need to implement oral medication if impaction is not noted. PEG 3350: 1-1.5 g/kg/day in two to four divided doses, home treatment is preferred, should take 3 to 5 days or until stool output is runny diarrhea (Burns, et al., 2017). PEG can be premixed and stored in refrigerator for 48 hours. Once the patient has been cleared the medication should be adjusted to achieve one to three soft, mushy stools per day (Burns, et al., 2017). Follow up after initial evaluation should be 2 weeks (Nurko, & Zimmerman, 2014). If treatment is unsuccessful consultation may be recommended to either psychiatry or GI, depending on the causative factors (AAP, 2017).
As a follow up visit of an infant that was delivered premature, the information that should be gathered during nutritional assessment are the signs of infant’s progress as well as how the mother’s nutritional health and the activity of breastfeeding and supplementing with expressed breast milk. The mother should be asked about the milk supply where milk should be in the breast, activity of the infant during feeding, if able to tolerate it, the sucking and swallowing reflex if good with no frequent aspiration and after the baby should be satisfied, feeding routine, urine output and the stool. The following are the indicators of successful breastfeeding, active and alert state of the infant, developmentally appropriate progress, age-appropriate height and head circumference, good skin turgor and color, sufficient output of at least six wet diapers and several stool per day and contented and satisfied behavior after feeding. The mother should be asked also about her health, the expressed breastmilk preparation to check if the mother is doing and storing it correctly to prevent gastrointestinal problem of the infant, medications that she’s taking because this will affect the maternal milk supply as well as effects neurological on the infant and may inhibit prolactin release, such as estrogen, antihistamines, and ergot compounds. Amount of caffeine on her diet because large amounts of caffeine from coffee, sodas, or chocolate should be discouraged, because caffeine is transmitted via breast milk to the infant, can be associated with jitteriness in the infant, and may have a negative effect on the iron content of the breast milk. However, the equivalent of one to two cups of coffee per day does not pose a problem. The mother should be encouraged to eat well for her own sake to keep herself healthy and to meet the energy demands of nursing ( Burns et al., 2017).
In addition to these, it is clear that the goal of nutritional management of preterm infants should be to optimize quantitative and qualitative rates of growth to limit long-term morbidity and enhance long-term outcomes. The adequacy of nutrient intakes among infants is currently monitored by changes in weight gain, length and head circumference. Serial measurements of length and head circumference are important as they are better indicators of true growth, rather than weight alone, which may ﬂuctuate due to changes in ﬂuid balance rather than adipose or lean tissue mass. Whilst these measurements provide an important tool for assessing growth of infants, they do not provide information on the quality of growth achieved. The accurate and non-invasive measurement of infant body composition has been shown to be useful in assessing the quality of growth. To ensure optimal growth and body composition is achieved in preterm infants, their nutritional management should be personalized to meet their individual needs according to their gestational age, body weight and their need for catch-up growth. The development and implementation of responsive, personalized nutritional support in preterm infants is required. This should utilized real time nutrient intake data collection, with ongoing nutritional assessments that includes the measurement of the body composition (Brennan et al., 2016).