Pediatric Primary Care Case Studies (31 page)

Hellings, P. (2009). Breastfeeding. In C. Burns, A. Dunn, M. Brady, N. Starr, & C. Blosser (Eds.),
Pediatric primary care
(4th ed., pp. 235–252). St. Louis, MO: Saunders Elsevier.

Lawrence, R. A., & Lawrence, R. M. (2005). Normal growth, failure to thrive, and obesity in the breastfed infant. In R. A. Lawrence, R. M. Lawrence (Eds.)
Breastfeeding: A guide for the medical profession
(pp. 436–447). Philadelphia: Elsevier Mosby.

Meier, P., Furman, L., & Degenhardt, M. (2007). Increased lactation risk for late preterm infants and mothers: Evidence and management strategies to protect breastfeeding.
Journal of Midwifery and Women’s Health, 52
, 579–587.

National Association of Pediatric Nurse Practitioners. (2007). NAPNAP position statement on breastfeeding.
Journal of Pediatric Health Care, 21
(2), A39–A40.

Schwartz, D., Arcy, H., Gillespie, B., Bobo, J., Longeway, M., & Foxman, B. (2002). Factors associated with weaning in the first 3 months postpartum.
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(5), 439–444.

Thilo, E. H. & Townsend, S. F. (1996). Early newborn discharge: Have we gone too far?
Contemporary Pediatrics, 13
, 29–46.

Chapter 9

The Constipated 8-Year-Old

Tamra D. Kehoe

Undoubtedly, the primary care provider will encounter patients with concerns related to constipation. Childhood constipation accounts for approximately 3% of general pediatric outpatient visits and 25% of pediatric gastroenterology consultations (Baker et al., 2006). Parents often worry that their child’s stools are too large, too infrequent, or too hard, or are painful to pass. Children presenting with encopresis may have fecal soiling without painful defecation, which is often perceived to be chronic diarrhea.

Families are often frustrated by multiple trials of ineffective strategies or believe their children are lazy or choose to have fecal accidents. The management of constipation and fecal soiling can be challenging for the child, family, and healthcare provider. To successfully treat these children, a well-organized plan utilizing medication as well as behavioral modification is paramount.

Educational Objectives

1.   Discuss the etiology of encopresis including predisposing mechanical and psychosocial factors.

2.   Apply the guidelines for management of encopresis to a school-age child.

3.   Identify barriers to successful treatment.

   Case Presentation and Discussion

Zachary Morris is an 8-year-old male who is brought to your office by his parents with concerns of fecal accidents that have been occurring since 6 years of age. Mrs. Morris reports Zach’s school has recommended a medical evaluation because Zach is now being teased by peers for his malodorous smell and because he often wears a pull-up diaper which is occasionally visible. Zachary has loose to peanut butter consistency stools in his underwear or pull-up approximately four to five times daily; he denies any sensation of these stools. He is frequently malodorous and will sit in his soiled underwear until mandated by his parents to clean up. They believe he is quite lazy and elects to stool in his pants rather than excuse himself to the bathroom. Soiling occurs more frequently when he is on the computer, watching TV, or engaged in active play.

Mom expresses great frustration. Soiling was initially infrequent but has escalated to a daily problem. Because of odor and frequent leakage, the family tends to withdraw from outings and social events.

What questions will you ask about strategies the parents have tried?

Zachary’s parents have utilized various strategies to correct his soiling including sticker charts and reward systems for putting stool in the potty, mandatory toilet sits every 2 hours, time-outs, and punishments. Medical treatment from their pediatrician has included polyethylene glycol 3350 powder (PEG 3350), 1 cap (17 g) orally every day for 2 weeks. This treatment resulted in more accidents, so his parents discontinued the stool softener after 1 week.

At this point, the problem sounds like encopresis so you consider what you know about this condition.

Pathophysiology of Constipation

Encopresis or fecal soiling refers to the repetitive voluntary or involuntary passage of stool in inappropriate places by children 4 years or older, at which time a child may reasonably be expected to have completed toilet training and exercise bowel control. Encopresis is usually associated with chronic constipation and functional fecal retention; however, it may occur in the absence of fecal retention, in which case, it is termed nonretentive encopresis. If a child is under 4 years old, it is termed fecal incontinence. Criteria for the diagnosis of functional constipation in children can be found in
Table 9-1
.

Encopresis can be termed retentive or nonretentive. Retentive encopresis is associated with constipation. The major difference between retentive and non-retentive encopresis is intent. In nonretentive soiling, the child is
voluntarily
stooling in inappropriate places, and it is usually associated with some degree of psychological disturbance.

Pathophysiology

Functional constipation, meaning constipation without evidence of a pathological condition, is most commonly caused by painful bowel movements with resultant voluntary withholding of feces. This withholding is done to avoid uncomfortable or painful defecation. In the majority of cases, encopresis is thought to occur as a consequence of chronic functional constipation with resulting overflow incontinence (Di Lorenzo & Benninga, 2004). The overflow stool can be pasty to watery, and is often confused with diarrhea.

There are time periods when a child is more vulnerable to developing acute constipation. In infancy, the change from breastmilk to formula or the addition of solids can cause constipation. Toddlers may exhibit magical thinking that results in fearful reactions or have conflict over toileting. School-age children may be too busy to stop play or there may be lack of privacy at school. Events common to all age groups that can lead to painful defecation include changes in diet, routines, stressful events, and/or illness (Baker et al., 2006).

Withholding feces can lead to prolonged fecal contact in the colon with reabsorption of fluids and an increase in the size and hardness of stool (Baker et al., 2006). The passage of these large, hard stools can be quite painful and difficult. The child may then consciously delay the passage of stool with subsequent defecation urges. These withholding behaviors can be subtle with children, especially toddlers, and can be mistaken for attempts to pass stool. Maintaining a rigid posture with clenched fists, hiding in a corner or other room, or excessive grunting and straining are often signs of voluntary fecal withholding. For other children, parents will recognize withholding behaviors as children rise up to their toes and rock back and forth. Many parents call this the “poopy dance.”

As the rectum is continually stretched with retained stool, defecation urges subside. Soft or watery stool eventually leaks around the retained fecal mass, resulting in fecal soiling.

Epidemiology

Although few prospective studies have been conducted to examine the prevalence of encopresis in childhood, an estimated 1–2% of children younger than
10 years have encopresis. The range of age at presentation is typically 4–12 years, with a peak at 7–9 years. Approximately 80% of affected children are boys (Borowitz, 2008).

Approximately 80–95% of children with encopresis have a history of constipation or painful bowel movements. The remaining 5–20% are said to have nonretentive encopresis; however, many of these children have a remote history of constipation or painful defecation or demonstrate incomplete evacuation during defecation (Partin, Hamill, Fischel, & Partin, 1992). Little or no evidence indicates that encopresis is primarily a behavioral disorder, and most available evidence suggests that behavioral difficulties associated with encopresis may be the result of the encopresis and not the cause (Joinson et al., 2007). Also, there is no scientific evidence to suggest that encopresis is an indicator of sexual abuse (Mellon, Whiteside, & Friedrich, 2006). Low self-esteem or parent–child conflict as a result of the disorder is not uncommon (Borowitz, 2008).

What information from the history do you need to make the correct diagnosis?

History Taking

As with all pediatric complaints, the assessment of a child with encopresis begins with a careful and detailed history.

Questions to be asked during evaluation include:

•   What are the frequency and consistency of the stools?

•   What are the frequency and timing of the fecal soiling?

•   Is there visible blood or mucous in the stool?

•   Are there complaints of pain with defecation?

•   When did potty training occur and was that a smooth or difficult transition?

•   What was the timing for the passage of meconium stool after birth?

•   Does the child exhibit any withholding behaviors?

•   Have there been any delays in motor milestones?

•   Is there a history of urinary dysfunction or recurrent urinary tract infections?