Peds Laxatives, Enemas and Clean Outs. Oh My!
Transcript of Peds Laxatives, Enemas and Clean Outs. Oh My!
7/12/2021
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Peds Laxatives, Enemas and Clean Outs. Oh My!Katherine Battisti, MD FAAP
Pediatric Emergency Medicine
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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.
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• 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
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You can’t identify abnormal if you don’t know normal…so… what is normal?
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• 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?
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Normal Infant Stool
Formula fed infantBreast fed infant Iron fortified
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• 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?
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Doctor, my baby is constipated!Ask yourself… is it true?
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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?
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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?
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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…
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• ≥ 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
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• 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
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• 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
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A life-saving tangent…
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***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.
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- 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
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Back to ConstipationConstipation in Toddlers and School Age Children
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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.
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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.
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Dr Battisti’s Version(How to ask kids so they understand)
Little Balls
A Bumpy Log
A Snake
Mashed Potatoes
Mud
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But they poop every day…
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• 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
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Common Times for Onset of Constipation
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• 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?
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• 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
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— 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
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• 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
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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
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• 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
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• 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…
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Questions?
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• 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
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