Constipation is a common complaint.
Simple constipation is identified by timing and/or the substance of the stool. When a child fails to defecate for several days or when the child's stool is hard, large, or painful upon defecation, the diagnosis of constipation can be made. Another accepted definition of constipation is fewer than three stools per week and/or hard, dry, pebbly fecal material for more than 2 weeks

Parents are conscious of their child's stool patterns. Occasionally the lack of a daily bowel movement or misinterpretation of various physical signs (such as facial flushing and grunting in a normal infant) can be confused with constipation.
The child's age and diet will influence the frequency and consistency of stools.
The younger the infant, the more frequent the stools; for example, a typical newborn will have four to six stools per day, while an older child may defecate once every several days.

A breast-fed infant will defecate more frequently and the stools will look different than those of an infant who is fed formula. Stools of breast-fed infants are yellow to golden in color and have a pasty consistency, whereas a formula-fed infant's stools tend to be yellow to light brown and firmer.

Constipation can result from a variety of organic etiologies ("Causes of Constipation"), one of the more common being Hirschsprung's disease. Hirschsprung's disease (congenital aganglionosis) is an abnormal bowel categorized by an aganglionic segment identified via radiologic studies, anorectal manometry, and ultimately by biopsy
The most common site affected is the rectosigmoid section. This condition is suspected in a newborn with delayed passing of meconium, abdominal distension, and enterocolitis or in a child in the first year of life with symptoms of intestinal obstruction such as bilious vomiting, abdominal distension, and refusal to eat.
It also can be found in approximately 1% of children older than 1 year presenting with constipation
Other symptoms include ribbon-like stools, abdominal distension, a history of chronic constipation that does not respond to medical treatment, and failure to thrive. This condition should be suspected if, on digital examination, the rectal vault is empty and the abdominal palpation suggests stool in the colon.
Hirschsprung's disease is managed surgically.
In a newborn the surgery usually is performed in the first 6 months of life; in the older child, it is usually completed 3 to 6 months after diagnosis. Surgery is planned based on the length of involvement (short, partial, or total).

Enterocolitis could develop in patients with Hirschsprung's disease on presentation or after surgical repair. This complication could have a mortality rate ranging from 6% to 30%.

In addition, other complications such as anal stricture and fecal incontinence may occur after surgery. The most severe complication of undiagnosed Hirschsprung's disease is the development of enterocolitis, which has a high mortality rate.

Identification of the cause of constipation begins with a thorough history and physical examination. Co-existing symptoms such as fever, nausea, vomiting, abdominal distention, and weight loss suggest an organic etiology.

History

• Stool pattern
  • Lack of a bowel movement for several days
  • Size, number, consistency, and frequency of stools
  • Associated history of rectal/abdominal pain or bleeding
  • Soiling in the underwear
  • Liquid stool ("diarrhea") and soiling, often alternating with hard stools (a sign of encopresis)
• Stool-holding behaviors
  • Infants: extend legs and clutch buttocks together
  • Toddlers: stand on tiptoes and rock while holding legs and buttocks stiffly
• Stomach aches or cramping
• Nausea and/or vomiting
• Bloating and anorexia
• Urinary tract symptoms
  • Frequent urination
  • Urinary tract infections
  • Incontinence or enuresis
• Recent loss of appetite
• Weight loss or poor weight gain
• Unexplained fever
• Dietary habits
• Over-the-counter medication or herbal use
• Psychosocial factors
  • Family structure and relationships
  • In the school-aged child, classroom behaviors and use of the bathroom while at school

Physical Examination

• Abdomen
  • Distention
  • Tenderness
  • Palpable mass (hard stool), usually supra-pubic
• Spine
  • Spina bifida
  • Tuft of hair, dimples
• Rectum (digital examination)
  • Presence of hard fecal material
  • Rectal dilatation
  • Anal fissures or hemorrhoids
  • Presence of anal wink
  • Rectal prolapse

Diagnostic Tests

• Stool guaiac
• Urinalysis, urine culture
• Thyroid function studies
• Radiologic studies if organic cause suspected
  • Kidneys, ureters, and bladder
  • Barium enema

Treatment must begin as early as possible to avoid complications. If fecal matter is impacted, removal is the first priority. Once the impaction is eliminated, management should focus on prevention.
Increasing hydration, changing dietary habits to include more fruits and vegetables, whole grains, and fiber, and discontinuing medications known to be associated with constipation may be enough to produce normal stooling behaviors.

With simple constipation, a laxative regimen should be instituted until one to two loose bowel movements per day are experienced. The laxatives should be given along with behavior modification. Toilet training in a toddler should be stopped temporarily until a normal pattern is established.


Behavior modification of bowel training begins with encouraging the child to defecate after meals, especially after breakfast. The parent should have the child sit on the toilet for approximately 5 to 10 minutes of uninterrupted time.

While the child is sitting on the toilet, his or her feet should be on a platform or be able to reach the floor comfortably. A relaxed atmosphere is essential; the parent should be instructed not to become anxious and insist that the child defecate. The child should be reminded to go to the bathroom throughout the day. Warm liquids will entice the movement of stool through the colon. A reward system enhances the learning process.
Treatment of Infants

• Glycerin suppositories to relieve impaction
• Juices that contain sorbitol (prune, pear, and apple)
• Stool softeners such as lactulose or sorbitol; corn syrup or barley malt extract are acceptable alternatives
• Enemas, mineral oil, and stimulant laxatives should be avoided

Вложения

	Treat Constipation.doc (31.5 Кб, 114 просмотров)
	Constipation.doc (48.0 Кб, 123 просмотров)