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Khaled Hussein Kamel Bahaaeldin
Professor of Pediatric Surgery,
Cairo University
1/16/2015 Khaled H.K. Bahaaeeldin
Functional constipation, accounts for 3% of visits to general pediatric clinics and as many as 30% of visits to pediatric gastroenterologists.
1/16/2015 K. H Bahaaeeldin
The most common literature definition of chronicconstipation in pediatric patients is:
Stooling <3 times a week
or
Hard stools with painful passage (even with normalfrequency) during the last 2 months.
1/16/2015 K. H Bahaaeeldin
Paris Consensus on Childhood Constipation Terminology (PACCT) Group
Chronic constipation is defined as
The occurrence of two or more of the following characteristics, during the last 8 weeks:
Frequency of bowel movements less than three per week
More than one episode of fecal incontinence per week
Large stools in the rectum or palpable on abdominal examination
Passing of stools so large that they obstruct the toilet
Retentive posturing and withholding behavior
Painful defecation
1/16/2015 K. H Bahaaeeldin
Pathophysiological mechanisms that underlie childhood functional constipation are multi factorial, and not understood well.
1/16/2015 K. H Bahaaeeldin
Different factors such as
Genes, Early toilet training of children and/or difficulty in learning it Changing diet from breast feed to formula and/or liquid to
solid food, Having painful and difficult defecation, Early commencement of school, Infrequent defecation as necessity, Poor fibre dietary regime, Inadequate liquid intake, Immobilization, Psychological problems and anxiety
All can cause constipation during childhood.
1/16/2015 K. H Bahaaeeldin
Despite the fact that childhood constipation is the most common complaint in childhood gastrointestinal disease, no large, placebo controlled, randomised trials are available.
1/16/2015 K. H Bahaaeeldin
Onset of constipation frequently occurs during one of three periods:
When the infant switched from breast milk to either formula milk or introduction of solids,
When the toddler is acquiring toileting skills and finds defecation painful,
When the child starts school (they tend to avoid defecation throughout the school day).
Approximately 40% of children with functional constipation develop symptoms during the first year of life, with peak incidence during the time of toilet training, often between 2 and 4 years of age
1/16/2015 K. H Bahaaeeldin
Most children with functional faecal retention will benefit from a precise, well-organized plan. The treatment is comprehensive and has four phases including
1. Education
2. Disimpaction; removal of the faecal retention
3. Maintenance (PLAN);prevention of re-accumulation of stools through reconditioning to normal bowel habits and laxative use
4. Withdrawal of treatment.
1/16/2015 K. H Bahaaeeldin
1/16/2015 K. H Bahaaeeldin
Education Education is the start of successful management.
The child and parent are told that many children are troubled with this condition
Explain normal defecation to the child and parents.
Discuss realistic expectations for response to therapy.
Stress that months to years of treatment will be necessary.
A detailed plan eliminates the parents’ and child’s frustration and improves compliance with the prolonged treatment necessary.
1/16/2015 K. H Bahaaeeldin
Disimpaction; Isotonic enema regimen Hardened fecal matter in the colon and rectum needs to be
evacuated completely. The parents can prepare a roughly isotonic saline solution. One
teaspoon of table salt is added to every 1.5 Liters of tap water. The wash out enemas administered via a gravity assisted enema
bag and nozzle roughly one meter above the child. The parents are instructed to infuse the isotonic solution till the
child indicates discomfort, and then allowed to expel the fluid. The process is repeated using around 1-1.5 liters of fluid per session.
The regimen schedules an enema daily for one week followed by once every other day for another week. After the initial two weeks, if the child fails to pass stools for two consecutive days the parents are told to administer a rectal washout and record the episode.
1/16/2015 K. H Bahaaeeldin
Maintenance; Elements of treatment
Isotonic enema regimen
Osmotic laxatives
Dietary and bowel habits readjustments.
Fibers
Water intake
Treatment of Anal conditions
1/16/2015 K. H Bahaaeeldin
Osmotic laxatives The need to maintain adequate water intake and its
importance for the functioning of these laxatives.
Lactulose (initially starting at 1-3 ml/kg/d)
Commercial magnesium sulfate/phosphate (1-3 ml/kg/d (as 400 mg/5 ml suspension) mixture.
Two concerns ; cost & flatulence of Lactulose and palatability of the Magnesium salts.
PEG Poly Ethylene Glycol, still not available in Egypt despite having none of the disadvantages
1/16/2015 K. H Bahaaeeldin
Dietary and bowel habits readjustments. Balanced diet especially carbohydrates
The healthy diet should be balanced to incorporate vegetables, fruits, more whole grain cereals and less highly processed wheat.
Whole grain bread should be substituted for other types.
The snacks and sweets should be moderated, and are used as reward for eating healthy diets.
1/16/2015 K. H Bahaaeeldin
Fibers Children older than 2 years of age should increase
dietary fiber intake to an amount equal to or greater than their age + 5 g/day.
According to the “age + 5” rule dietary fiber intake would increase from 8 g/day at age 3 years to 25 g/day by age 20 years.
Can add bran to the child’s food (1 tbsp of wheat bran meal = 2 grams of fiber) in addition to green leafy vegetables, homemade unfiltered juices and fruits to ensure adequate dietary fiber intake.
1/16/2015 K. H Bahaaeeldin
Water intake
Age (years) Water intake
1-3 0.8-1 liter/day(roughly 4-5 cups)
4-8 1.2-1.4 liter/day(5-7 cups)
9-13 1.5-2 liter/day (6-8 cups)
1/16/2015 K. H Bahaaeeldin
Treatment of Anal conditions Perianal abscesses; incision and drainage under
general anesthesia and short course of antibiotics (ampicillin/clavulanate for 5 days).
Fistula in ano cases; fistulotomy under general anesthesia and antibiotics (ampicillin/clavulanate for one week)
Anal fissures; conservatively with local anesthetic cream prior to enema administration and defecation in toilet trained children.
1/16/2015 K. H Bahaaeeldin
SurgerySurgery, in absence of organic causes, is not easily
justifiable particularly to parents, for treatment of functional constipation in children.
However there exists a sizeable minority of cases who fail to respond to even aggressive conservative regimens.
Many modalities of surgery have been proposed; Colectomies, myectomies and colostomies. Ante grade continence enemas provide a compromise between extensive surgery and the failed conservative means
1/16/2015 K. H Bahaaeeldin
1/16/2015 K. H Bahaaeeldin
Prognosis Long-term follow-up studies revealed that 65% up to
88% of functional constipation resolve within one to four years of treatment
These wide ranges of differences are because;
No single protocol for management of Functional Constipation
and
Management necessitates a strict medical and behavioral continuous regimen that should be followed accurately and promptly by the parents.
1/16/2015 K. H Bahaaeeldin
Thank you
1/16/2015 K. H Bahaaeeldin
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