Pediatrics
Cases
I. Obstipation in Paediatrics
1. Definition and Pathology
- Definition: near complete constipation often with no underlying medical condition
- Constipation: a delay or difficulty in defecation present for >2 weeks sufficient to
cause significant distress to the patient
- In children the caregiver is often more distressed
- Causes
- Physiological (functional)
- Transition to solid diet (infants)
- Toilet training (toddlers): withholding
- Starting school (young children)
- Stress: at home, at school, abuse …
- Non-Physiological
- Pain: bowel movements can be painful in children so the child can
become constipated from avoiding going to the bathroom
- Stress
- Medications
- Medical condition (occurs in <5% of children)
- Infants
- Neurological: Hirschsprung disease, spinal cord abnormality,
encephalopathy
- Congenital: abnormal anal development, cystic fibrosis
- Metabolic: hypothyroidism, hypercalcemia, hypokalemia, diabetes
1
- Children (>1 yo)
- Neurological: Hirschsprung’s disease
- Metabolic: hypothyroidism, hypercalcemia, hypokalemia, diabetes
- Trauma: spinal cord trauma/abnormality, heavy metal poisoning
sexual abuse
- Congenital: cystic fibrosis
- Autoimmune: gluten enteropathy
- Other: neurofibromatosis, development delay
2. Clinical Features
- Epidemiology
- ⅓ of children between 6-12 yos report constipation during any given year
- Encopresis
- Toddlers: no gender difference
- School age (5yo): 3x more common in boys
,- Normal bowel habits
- 1st week of life: 4 liquid-soft bowel movements per day
- 1st 3 months of life:
- Breastfed: between 1-3 soft bowel movements per day and 1 per week
- Formula-fed: 2-3 bowel movements per day depending on the formula
- By 2 yrs old: 1-2 formed bowel movements per day
- Symptoms
- Abnormal bowel habits: hard, pellet-like feces, infrequent (relatively)
- Possible: pain, encopresis
- Indication of a functional cause (most common cause)
- History: stool passed within 48 hours of birth, hard large-caliber stools,
encopresis, pain/discomfort, blood on stools, decreased appetite diet low in
fiber/fluids or high in dairy products, avoidance of the toilet
- Physical examination: mild abdominal distension, palpable stool in LLQ, normal
anal placement and anal sphincter tone, rectum packed with stool, presence of
anal wink and cremasteric reflex
- Indication of an organic cause
- Hirschsprung’s: meconium >48hrs after delivery, small-caliber stools, failure to
grow, fever, bloody diarrhea, bilious vomiting, tight anal sphincter, empty rectum
with palpable abdominal fecal mass
- Pseudo-obstruction: abdominal distension, bilious vomiting, ileus
- Spinal cord abnormalities: decrease in lower extremity reflexes/muscular tone
absence of anal wink, presence of pilonidal dimple/hair tuft
- Hypothyroidism: fatigue, cold intolerance, bradycardia, poor growth
- Diabetes: polyuria, polydipsia
- Cystic fibrosis: diarrhea, rash, poor growth, fever, recurrent pneumonia
- Gluten enteropathy: diarrhea after gluten consumption
- Congenital anorectal malformation: abnormal position or appearance of anus on
P.E
3. Treatment and Prognosis
- Treatment
- Non-pharmacological -> if no underlying medical condition
- Increase fibre intake: increases weight of the stool, speeds its passage
through intestines
- A sudden increase can cause bloating and gas → gradually
increase intake
- Over-the-counter fibre supplements can be a solution, but a child
needs to drink a lot of water for them to work
- Adequate fluids
, - Give the child adequate time for bowel movement: encourage them to sit
on the toilet for 5-10 minutes within an hour after a meal
- Physical activity (adults)
- Pharmacological -> if there is a medical condition or if the non-
pharmacological therapy was insufficient
- Laxatives: if an accumulation of fecal material is the cause of the
blockage, this can help
- Prevention
- Eat foods high in fibre
- Drink enough (water)
- Create a toilet route for the child
- Encourage the child to go when nature calls
- Exercise enough (adults)
Cases
I. Obstipation in Paediatrics
1. Definition and Pathology
- Definition: near complete constipation often with no underlying medical condition
- Constipation: a delay or difficulty in defecation present for >2 weeks sufficient to
cause significant distress to the patient
- In children the caregiver is often more distressed
- Causes
- Physiological (functional)
- Transition to solid diet (infants)
- Toilet training (toddlers): withholding
- Starting school (young children)
- Stress: at home, at school, abuse …
- Non-Physiological
- Pain: bowel movements can be painful in children so the child can
become constipated from avoiding going to the bathroom
- Stress
- Medications
- Medical condition (occurs in <5% of children)
- Infants
- Neurological: Hirschsprung disease, spinal cord abnormality,
encephalopathy
- Congenital: abnormal anal development, cystic fibrosis
- Metabolic: hypothyroidism, hypercalcemia, hypokalemia, diabetes
1
- Children (>1 yo)
- Neurological: Hirschsprung’s disease
- Metabolic: hypothyroidism, hypercalcemia, hypokalemia, diabetes
- Trauma: spinal cord trauma/abnormality, heavy metal poisoning
sexual abuse
- Congenital: cystic fibrosis
- Autoimmune: gluten enteropathy
- Other: neurofibromatosis, development delay
2. Clinical Features
- Epidemiology
- ⅓ of children between 6-12 yos report constipation during any given year
- Encopresis
- Toddlers: no gender difference
- School age (5yo): 3x more common in boys
,- Normal bowel habits
- 1st week of life: 4 liquid-soft bowel movements per day
- 1st 3 months of life:
- Breastfed: between 1-3 soft bowel movements per day and 1 per week
- Formula-fed: 2-3 bowel movements per day depending on the formula
- By 2 yrs old: 1-2 formed bowel movements per day
- Symptoms
- Abnormal bowel habits: hard, pellet-like feces, infrequent (relatively)
- Possible: pain, encopresis
- Indication of a functional cause (most common cause)
- History: stool passed within 48 hours of birth, hard large-caliber stools,
encopresis, pain/discomfort, blood on stools, decreased appetite diet low in
fiber/fluids or high in dairy products, avoidance of the toilet
- Physical examination: mild abdominal distension, palpable stool in LLQ, normal
anal placement and anal sphincter tone, rectum packed with stool, presence of
anal wink and cremasteric reflex
- Indication of an organic cause
- Hirschsprung’s: meconium >48hrs after delivery, small-caliber stools, failure to
grow, fever, bloody diarrhea, bilious vomiting, tight anal sphincter, empty rectum
with palpable abdominal fecal mass
- Pseudo-obstruction: abdominal distension, bilious vomiting, ileus
- Spinal cord abnormalities: decrease in lower extremity reflexes/muscular tone
absence of anal wink, presence of pilonidal dimple/hair tuft
- Hypothyroidism: fatigue, cold intolerance, bradycardia, poor growth
- Diabetes: polyuria, polydipsia
- Cystic fibrosis: diarrhea, rash, poor growth, fever, recurrent pneumonia
- Gluten enteropathy: diarrhea after gluten consumption
- Congenital anorectal malformation: abnormal position or appearance of anus on
P.E
3. Treatment and Prognosis
- Treatment
- Non-pharmacological -> if no underlying medical condition
- Increase fibre intake: increases weight of the stool, speeds its passage
through intestines
- A sudden increase can cause bloating and gas → gradually
increase intake
- Over-the-counter fibre supplements can be a solution, but a child
needs to drink a lot of water for them to work
- Adequate fluids
, - Give the child adequate time for bowel movement: encourage them to sit
on the toilet for 5-10 minutes within an hour after a meal
- Physical activity (adults)
- Pharmacological -> if there is a medical condition or if the non-
pharmacological therapy was insufficient
- Laxatives: if an accumulation of fecal material is the cause of the
blockage, this can help
- Prevention
- Eat foods high in fibre
- Drink enough (water)
- Create a toilet route for the child
- Encourage the child to go when nature calls
- Exercise enough (adults)
