Constipation and Colic
5/4/15 Cons*pa*on and Colic: Tips and Tools for the PCP when Management is Not Straigh@orward CO AAP 2015 Annual Mee*ng Jasper Hillhouse, MD FAAP David Brumbaugh, MD MSCS FAAP Disclosures • No financial conflicts of interest • Off label use of medica*ons will be discussed Learning Objec*ves • We will follow a single tortured family to learn strategies for management of chronic stooling disorders. • Recognize ‘red flag’ signs and symptoms that indicate an organic e*ology for cons*pa*on. • Dis*nguish infant colic from diges*ve causes of fussiness in the first months of life. 1 5/4/15 A New Mother is Distraught… • 6 week old male infant presents with a chief complaint of screaming and writhing just before defeca*on. • Term infant, passed meconium at 12 hours of life. Mainly breas@ed, a li]le formula, gaining weight. • Stools are so^. Infant calms down soon a^er passage of stool. • Mother: “Something must be wrong. I have never seen a baby scream like this.” With this history, what are you thinking? • Audience response ques*on – Anal Stenosis – Hirschsprung Disease – Milk protein intolerance/Allergic Coli*s – Infant Dyschezia – Infant Botulism Key Features of the Physical Exam • Overall appearance/Tone • Abdominal Exam – Flat or distended? • Perineal/Anal inspec*on!! – Bu]ock musculature – Placement of Anus – Digital Exam 2 5/4/15 Ensure the Anatomy is Normal • Low Anorectal Malforma*ons – Anal stenosis • Anal opening is normal on physical exam • Presents with straining with defeca*on – may not be symptoma*c un*l a^er first few weeks of life • DRE is performed and an internal membrane prohibits passage of your finger (typically past first knuckle) • Treated with serial dila*ons with Hagar dilators • Typically resolves in 2-‐3 months and no surgery required Ensure the Anatomy is Normal • Perineal fistula – Can be difficult for parents to recognize – Surgical correc*on (anoplasty) Perineal Fistula Anal Sphincter Complex Hirschsprung Disease • Incidence 1 in 5,000 • Congenital absence of ganglion cells – Most commonly short segment, rectosigmoid; rarely total colonic aganglionosis • Most underrecognized presenta*on: Neonatal enterocoli*s – diarrhea/ hematochezia • Abdominal disten*on/obstruc*on • >90% present/diagnosed in neonatal period 3 5/4/15 Hirschsprung Disease • Delayed passage of meconium a^er birth – 94% fail to pass meconium in the first 24 hours of life – 57% fail to pass meconium in the first 48 hours of life • • • • • Cons*pa*on (93%) Abdominal disten*on (83%) Vomi*ng (64%) Diarrhea (26%) Failure to thrive Infant Dyschezia • Crying/straining/reddening of face for 10 minutes before passage of a so^ stool. • Incidence: – 17% at 1 month – 6% at 3 months • Self-‐limited and does not predict development of cons0pa0on Coordina*on of Defeca*on 4 5/4/15 He Returns with Pellet Stools • Screaming fits resolved and he was doing “great” for 8 weeks. Now 3 months old. • Mother just weaned baby from breastmilk to standard formula when she returned to work • Now passage of small, hard pellet-‐like stools • Cries with defeca*on What is Your First Move? • Audience response ques*on – Karo Syrup – Prune juice – Glycerin Suppositories – Lactulose – Miralax Infant Cons*pa*on • Rare in BF infants (1%). Common in formula-‐ fed infants (9%). • Limited high quality evidence demonstra*ng efficacy of one laxa*ve versus another. – Family preferences – Goal-‐directed therapy 5 5/4/15 Treatment Op*ons During Early Infancy – <6 months of age • Non-‐absorbed or Poorly Absorbed Carbohydrates – Osmo*c agents – keep stool so^ – Prune/pear/apple juice -‐ sorbitol – Lactulose – Corn Syrup (Karo syrup) – Avoid s*mulant laxa*ves, phosphate enemas, frequent suppository use 9 month old Well Child Check • He is thriving and developing well • Mom brings up stooling again • Stools were be]er un*l introduc*on of solids 2 months ago • Hard stools every 3 days. Mom has seen blood in diaper twice • Physical exam normal except for some palpable stool in LLQ • Mom wants to know – is this stooling pa]ern just normal for Junior? What Do You Tell Mom? • Audience Response Ques*on – It’s OK. He will grow out of it – I’m a li]le worried. Let’s discuss op*ons – Real Worried. I think we should get Gastroenterology involved. 6 5/4/15 How Aggressively to Manage? • We know unfortunately li]le about the prognosis of cons*pa*on in primary prac*ce • In referral popula*on, 50% recover at 1 year follow-‐up, 50% at 5 year follow-‐up – High likelihood of relapse • Up to 40% of children with chronic cons*pa*on have symptoms <1yo • Delay in ini*a*on of treatment > 3 months predicts a longer dura*on of cons*pa*on 9 month old WCC • Mom really dislikes the idea of laxa*ves in her infant – now she wants to try a dairy free diet for her infant’s cons*pa*on because it has worked for her. Do You Endorse a Dairy Free Diet? • Audience response ques*on – Yes – No ? 7 5/4/15 Cow’s Milk Protein and Cons*pa*on • Controversial topic with conflic*ng results of pediatric studies – What defines a proper test of “milk allergy” – Challenges of blinding study par*cipants • Proposed mechanism? • Trial of non-‐cow’s milk protein based formula for 2-‐4 weeks is OK • Cau*on – Dairy free diet is associated with early osteoporosis Nachshon et al. JACI 2014 Probio*cs and Cons*pa*on • Limited data • Randomized, double blinded study in small # of cons*pated infants given Lactobacillus strain resulted in improvement • Larger randomized, blinded study in older children with cons*pa*on showed no improvement with Bifidobacterium strain • No known adverse effects, but cost? Tabbers et al. Pediatrics 2011. Coccorullo et al. J Pediatr 2010 He Never Really Got Be]er… • Now a 3yo who has not learned to toilet train for defeca*on • Mom started toilet training at 18 months and he has always urinated on toilet • Every 2 days he goes to his corner of the playroom and takes 15 minutes to pass a hard, formed stool • Mom has a friend whose child is on Miralax but has heard that it is “an*freeze” 8 5/4/15 How Do You Feel About Miralax? • Audience Response Ques*on – Not comfortable using – Used to be OK prescribing but now I’m nervous – Miralax is OK for short term use – Miralax is OK for long term use Miralax – Should We Be Concerned? Scru0ny for Laxa0ves as a Childhood Remedy NY Times Jan 2015 • Described FDA-‐sponsored grant award for study of PEG 3350 metabolism and behavioral effects – Study yet to be performed • Many trials and meta-‐analyses have demonstrated efficacy and long term safety of PEG compounds • So what’s the fuss? Miralax (PEG 3350) • There have been isolated reports of neuropsychiatric symptoms a^er taking Miralax • Polyethylene glycol (PEG) 3350 is absorbed in trace amounts from the intes*ne – and PEG may theore*cally degrade to diethylene glycol and ethylene glycol, which are components of an*freeze – however, this has not been demonstrated a^er oral inges*on in animals • PEG used in toothpaste/lips*ck/ointments/ creams/etc. 9 5/4/15 Func*onal Cons*pa*on -‐ Risks • Early toilet training leads to conflict – Child “controls” the parents • Fear of using toilet outside of home • Behavioral disorders • Au*sm spectrum disorders Func*onal Cons*pa*on -‐Dietary milestone -‐Illness -‐Toilet training -‐Anal fissure Painful defecation Withholding Behavior Untreated Func*onal Cons*pa*on • Vicious cycle of stool reten*on, further stool desicca*on, development of a hard stool impac*on • Prolonged stretching of intes*nal wall leads to an atonic, poorly sensi*zed rectum • Inability of external anal sphincter to func*on adequately 10 5/4/15 How Long Would You Treat this 3yo with Miralax? • Audience Response Ques*on – 2 weeks – 2 months – 6 months or longer Key Principle of Cons*pa*on Management “Improvement in bowel pa]ern must be measured in months, not days or weeks” Weaning Laxa*ves • Wean off over 2-‐3 months • Ini*ate fiber supplement when weaning • Fiber absorbs large amounts of water, resul*ng in bulkier and so^er stools. • Fiber promotes frequency of high amplitude peristal*c contrac*ons decrease the *me necessary to move fecal material through the colon Daily fiber goal in grams = Age in years + 5 11 5/4/15 6yo Returns with Soiling • • • • Developmentally normal. Growing well Mul*ple soiling events every day He clogs toilet once every 2 weeks. Has used Miralax for short s*nts over the last 2 years – it “doesn’t work” • Exam: Mild abdominal disten*on. Fullness in LLQ but no discrete stool palpated. Soiling present. Anal tone slightly diminished. Very dilated rectal vault with copious stool present. What is Next Step? • Audience response ques*on – This has been going on too long. Check labs for underlying disorder – Abdominal x-‐ray to assess fecal burden – MRI to assess for spinal cord problem – Ini*ate home bowel cleanout Value of Laboratory Evalua*on for Cons*pa*on • Cons*pa*on is unlikely to be sole presen*ng feature of celiac disease, hypothyroidism, or hypercalcemia – Consider if abdominal pain out of propor*on to cons*pa*on, poor growth, other s*gmata celiac, strong FMHx thyroid dz, other autoimmune dz. Chogle A, Saps M. Can J Gastro, 2013 12 5/4/15 X-‐rays for Cons*pa*on • Mul*ple studies have shown poor ability of abdominal radiographs to discriminate between cons*pated and non-‐cons*pated individuals – Cons0pa0on is a clinical, not radiographic, diagnosis – Colonic stool is a normal, physiologic finding Encopresis • • • • “Overflow” incon*nence Rarely occurs before 3 yo Mean age is 7-‐8 yo Boys more likely to experience • Great source of embarrassment for child and frustra*on for parents • Denial is common Principles of Therapy • Fecal impac*on must be cleared before successful management can take place – We use Miralax one capful every 2 hours! • Daily laxa*ve use – plan on at least 9 months of therapy • A]en*on to behavior and toile*ng rou*ne is as important as pharmacologic therapy 13 5/4/15 6yo Returns To Clinic in 2 months • Family successfully completed cleanout • 2 weeks without soiling, then gradual return of soiling, but s*ll less frequent than before • Abdomen no*ceably less full on exam than at previous visit • Family admits they have slacked off the toile*ng rou*ne in the last few weeks How Do You Respond? • Audience Response Ques*on – This is a lost cause. Refer to GI – Increase maintenance Miralax dose – Repeat cleanout – Add s*mulant laxa*ve Don’t Give Up! • The dilated rectum takes months to return to a normal caliber • A s*mulant laxa*ve may be needed for the atonic rectum • Repeat cleanouts are commonly needed • Lots of posi*ve reinforcement – this kid is be]er! • You are a cheerleader for the kid and the family – stay with the rou*ne 14 5/4/15 Soiling and MRI Changes • 6yo twin brother presents with intermi]ent fecal incon*nence and nigh~me urinary incon*nence over the last year • No history of cons*pa*on/hard stools • With toile*ng rou*ne and low-‐dose Miralax, he has big decrease in soiling. • With nightly waking reminders, he stays dry. • No other neurologic symptoms • Normal exam • KUB shows concern for occult spinal dysraphism – f/u MRI spine shows fa]y filum terminale. Neurosurgery wants to operate!! Family Asks For Your Opinion. • Audience Response Ques*on – Get the surgery – Hold on! Let’s watch this for a while – Keep the scalpels away – Order addi*onal tes*ng NonReten*ve Fecal Incon*nence • Minority of children with fecal incon*nence (most have encopresis – fecal incon*nence) • More common in boys (3-‐6 *mes more likely than in girls) • High rates of associated urinary incon*nence • Pathophys: Ina]en*on to cues from rectum/ bladder • Toilet training and posi*ve mo*va*on are cornerstones of therapy • Laxa*ves typically are ineffec*ve Burgers R, Benninga MA. JPGN 2009. 15 5/4/15 Spinal Cord Lesions and Bowel Disorders in Children • Retrospec*ve associa*ons of cons*pa*on and incon*nence with spinal cord dysraphism. • Only one prospec*ve study: – >150 children with refractory cons*pa*on or nonreten*ve fecal incon*nence – Abnormal MRI findings in 3% – No rela*onship between abnormal MRI and neurologic examina*on – All children with abnormal MRIs improved with conserva*ve management Bekkali NL et al. J Pediatr 2010. Fussy 5 Week Old Infant • Full term infant on Enfamil. Uncomplicated pregnancy/birth • Gaining weight • Arches back, turns head with ini*a*on feeds • Spits up 4-‐5 *mes per day. Nonbilious. • Needs to be held all the *me • Stooling regularly • Baby looks great • Mother doesn’t look so great What Would You Do Next? • Audience response ques*on – Start lansoprazole for probable reflux – Upper GI series to look for reflux – Change to hypoallergenic formula – Start probio*c – Reassurance 16 5/4/15 Fussy Babies and GERD • GERD is an uncommon cause of unexplained crying in otherwise fussy infants • In otherwise normal infants with unexplained crying, irritability, or distressed behavior, there is no evidence to support acid suppression [Quality of Evidence: A] Empiric Acid Suppression for Irritability/ Suspected GERD? • 50% of PPI prescrip*ons are wri]en by pediatricians • < 10% undergo tes*ng • Poten*al side effects: – Infec*ons • GI: C Diff • Pulm: CAP – Bone demineraliza*on – Cost # publica*ons on PPI safety or side effects Yang and Metz. Gastroenterology. 2010 Oct;139(4):1115-‐27. Epub 2010 Aug 19 Barron. JPGN. 2007 (45). Addi*onal Tes*ng in Fussy Infants • Value of Upper GI Series is exclusion of anatomic problems (malrota*on, duodenal stenosis). Likely to see reflux event in a neonate, as reflux occurs up to 100 *mes per 24 hours in a normal infant. • No prospec*ve studies evalua*ng role for fecal hemoccult tes*ng in fussy infants 17 5/4/15 Colic and Milk Protein Allergy • Mixed evidence. Possibility of benefit in some, but not all infants. – In breas@ed infants, maternal hypoallergenic diet (esp. avoiding dairy) – In formula-‐fed infants, extensively hydrolyzed formula – Guidelines suggest trial of 2 weeks of formula to see if there is benefit Probio*cs and Colic • Studies suggest beneficial effect of Lactobacillus reuteri on crying *me in infants – Significant study limita*ons include heterogeneity of study par*cipants (age, feeding status), quality of blinding and outcome measures – At least one well conducted study (Canada) showed no benefit to probio*cs – Mechanism of benefit is not understood – Probably limited risk with treatment, but long-‐term effects of probio*cs in infants have not been studied. – Insufficient evidence to support probio*c use generally for treatment/preven*on of colic Chau K et al. J Pediatr 2015. Sung V et al. BMJ 2014. Indrio F et al. JAMA Pediatr 2014. Sung V et al. JAMA Pediatr 2013. Clinical Pearls • Don’t forget the anal inspec*on and rectal exam – every cons*pated kid deserves at least one DRE • Why do we fail at trea*ng cons*pa*on? – Laxa*ve dose insufficient (therapy not goal-‐ directed.) – Dura*on of therapy insufficient – Lack of focus on toile*ng rou*ne • Proton pump inhibitors are great drugs…but very rarely indicated in infants 18 5/4/15 Thanks! 19
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