Pediatric Primary Care (82 page)

4.  Repeat stool studies after treatment for
C. difficile
, giardia if symptoms persist.

J.  Complications.

1.  Dehydration, malnutrition.

2.  Chronic diarrhea may develop, especially if restricted diet/inappropriate fluids.

3.  Hemolytic uremic syndrome
(E. coli)
, bacteremia (shigella).

K.  Education.

1.  Reassure: most cases viral, self-limited.

2.  Review proper hygiene, handwashing techniques, handling of soiled objects. Alcohol-based hand sanitizers are not effective for
C. difficile.

3.  Review dehydration signs/symptoms: Instruct parent when to call.

4.  Review dietary instructions: Explain restricting diet may prolong diarrhea. Appropriate beverage selection essential.

5.  Skin care: Prevent diaper rash with effective barrier ointment.

VI. ENCOPRESIS

A.  Fecal incontinence in clothing usually after toilet training completed. Vast majority caused by chronic, functional constipation (retentive encopresis).

B.  Etiology.

1.  Chronic, functional constipation. Stool accumulates in rectum, which subsequently leaks out through anus. Soiling is not volitional/intentional.

2.  Underlying pathology is rare: tethered spinal cord (secondary to occult spinal dysraphism), prior anal-rectal surgery, Hirschsprung's disease, ectopic anus.

C.  Occurrence.

1.  Stool incontinence, usually during day, of varying quantities.

2.  Soiling often has soft consistency and parents misinterpret this as diarrhea, child “can't make it to the bathroom in time.”

3.  Parents commonly believe this is volitional or result of laziness.

4.  Important questions to ask:

a.  Age of toilet training? Was process difficult?

b.  Frequency, consistency, size/amount of BM on toilet. Any blood? What time of day does it usually occur?

c.  Does child hide soiled clothing?

d.  How has family dealt with problem?

5.  Associated symptoms may include abdominal pain, abdominal distention, poor appetite, school avoidance.

6.  Ask about history of UTI and enuresis.

7.  Any possibility of sexual abuse?

D.  Clinical manifestations.

1.  Common pediatric problem: boys affected more than girls.

E.  Physical findings.

1.  Abdomen may appear distended or full. Dull on percussion. Stool may be palpable in lower quadrants (smooth, movable mass).

2.  Anus may appear erythematous with stool around exterior. Observe for fissures. Digital exam may reveal decreased tone, copious stool in vault of varying consistency. Check for position of anus, anal wink.

3.  Assess back for signs of occult spinal dysraphism: sacral dimple or hair tuft above gluteal crease, deviated gluteal crease.

4.  Assess muscle tone throughout, DTRs.

F.  Diagnostic tests.

1.  Rarely necessary.

2.  Abdominal flat-plate X-ray can be useful to assess fecal load, tailor disimpaction. However, good physical exam and history often eliminates need for X-ray.

3.  MRI of lumbosacral spine if concern for tethered spinal cord.

G.  Differential diagnosis.

1.  Majority of cases are from functional constipation.

2.  Tethered spinal cord: can result in fecal/urinary incontinence.

H.  Treatment.

1.  All children with encopresis must first start with disimpaction (“clean out”). Soiling will not resolve without this. Depending on amount of stool on X-ray exam, can give oral cathartics at bedtime for 1-3 nights in row and up to 1 Fleet enema bid for 1-3 days in row.

2.  After clean out, child immediately starts daily stool softening.

3.  Keep track of BMs, soiling episodes on calendar.

4.  High-fiber diet.

5.  Toilet retraining: child to sit on toilet after meals 2-3 times/day, work up to 5-10 minutes. Provide footstool. Ask child to “try” to have BM, to “practice,” not expected to produce BM each time.

6.  Positive reinforcement only. No punishment for soiling. Soiling should be cleaned up swiftly with child's assistance and little attention paid to it.

I.  Follow up.

1.  Encourage telephone contact. If continues to soil, may need further clean out.

2.  Follow up in clinic about 1 month after diagnosis.

3.  May need follow-up abdominal X-ray if results of clean out are in doubt.

4.  Referral if patient not responding to treatment once compliance has been assured.

J.  Complications.

1.  Low self-esteem/shame.

2.  Child abuse.

3.  School avoidance.

4.  UTI (due to proximity of stool in clothing to urinary tract).

5.  Enuresis.

K. Education.

1.  Stress to parents that child has not had control over soiling episodes.

2.  Relieve parental guilt over prior negative reinforcement.

3.  Explain to parent and child why soiling occurs, discuss normal defecation.

4.  Treatment will take at least 6 months. Parents are advised to be diligent about daily stool softening, toilet training during this time.

5.  Reassure about functional nature of chronic constipation.

6.  Advise parent to speak with school about problem so child will have better access to restroom at school, may need to provide written request.

VII. GASTROESOPHAGEAL REFLUX DISEASE (GERD)

A.  Passage of stomach contents into esophagus. Gastroesophageal reflux (GER) is normal, physiologic process, can occur in healthy individuals. GERD refers to pathologic degree of GER, causing symptoms.

B.  Etiology.

1.  Infants (up to 18 months).

a.  Very common in infants, may be result of immaturity of lower esophageal sphincter (LES).

b.  Position of LES and feeding techniques may induce GER.

c.  GERD probably multifactorial.

2. Children/adolescents.

a.  Probably multifactorial, exact cause not known.

b.  May be malfunctioning LES: inappropriate relaxation.

c.  Environmental/dietary influences may induce GER.

C.  Occurrence.

1.  About 50% of infants have recurrent vomiting in first 3 months, 67% of 4-month olds, 5% of 10- to 12-month olds.

2.  Increased incidence among premature babies, neurologically impaired children.

D.  Clinical manifestations.

1.  Infants: recurrent vomiting, regurgitation (“spit up”); usually effortless.

2.  Important questions to ask for affected infants:

a.  Type, quantity, frequency of feedings? How positioned during, after feeding?

b.  Quality, quantity, timing of emesis? Does baby cry/grimace with emesis?

c.  History of apnea?

3.  Children: regurgitation (reswallowed/spit up), possible vomiting, nausea, epigastric abdominal pain. Pain may be poorly localized. Can have any/all of these symptoms.

4.  Important questions to ask for affected children:

a.  Frequency, timing of symptoms including regurgitation with/without emesis.

b.  Abdominal pain: location, timing, frequency, quality.

c.  Any specific foods that provoke symptoms?

d.  Complete diet history including type and amount of beverages.

e.  Any dysphagia, food lodging, chronic throat clearing, dental decay?