A 6-week-old boy is brought to the office by his father due to concerns about constipation. His father states, "He used to pass 4 or 5 soft, yellow stools every day. About 2 weeks ago, this decreased to twice a day, and since last week it has gone down to only one large, soft, yellow bowel movement every 1-2 days. I've also noticed that he spits up after he eats. I had surgery for pyloric stenosis when I was 5 weeks old, and I'm concerned that my baby has the same problem." The patient is fed pumped breast milk every 2-3 hours and does not drink formula. He has 6-8 wet diapers a day. He was born at 39 weeks gestation by vaginal delivery and received deep suctioning for meconium-stained amniotic fluid. Hospital course was significant for jaundice at age 36 hours, which resolved after a day of phototherapy. Birth weight was 3 kg (6.6 lb, 25th percentile) and length was 50 cm (19.7 in, 50th percentile); he is at the 50th percentile for length and weight today. Physical examination shows an awake and alert infant. The anterior fontanelle is open and flat, and the oral mucosa is moist with no thrush. The abdomen is soft, nontender, and nondistended. Testes are descended bilaterally. The anus is located halfway between the posterior border of the scrotum and the tip of the coccyx. There are no anal fissures or tags. Skin shows no jaundice, and capillary refill is

Question

A 6-week-old boy is brought to the office by his father due to concerns about constipation.  His father states, "He used to pass 4 or 5 soft, yellow stools every day.  About 2 weeks ago, this decreased to twice a day, and since last week it has gone down to only one large, soft, yellow bowel movement every 1-2 days.  I've also noticed that he spits up after he eats.  I had surgery for pyloric stenosis when I was 5 weeks old, and I'm concerned that my baby has the same problem."  The patient is fed pumped breast milk every 2-3 hours and does not drink formula.  He has 6-8 wet diapers a day.  He was born at 39 weeks gestation by vaginal delivery and received deep suctioning for meconium-stained amniotic fluid.  Hospital course was significant for jaundice at age 36 hours, which resolved after a day of phototherapy.  Birth weight was 3 kg (6.6 lb, 25th percentile) and length was 50 cm (19.7 in, 50th percentile); he is at the 50th percentile for length and weight today.  Physical examination shows an awake and alert infant.  The anterior fontanelle is open and flat, and the oral mucosa is moist with no thrush.  The abdomen is soft, nontender, and nondistended.  Testes are descended bilaterally.  The anus is located halfway between the posterior border of the scrotum and the tip of the coccyx.  There are no anal fissures or tags.  Skin shows no jaundice, and capillary refill is <2 seconds.  Which of the following is the most appropriate course of action in management of this patient?

Quizplus · Accepted Answer

Explanation: A newborn's first bowel movement is meconium, the thick, black, tarry stool that occurs within the first 48 hours of life and sometimes during childbirth (eg, meconium-stained amniotic fluid). After this, the typical frequency of stool passage in an exclusively breastfed newborn is 6-10 times daily, or approximately one soft, yellow-green stool per episode of breastfeeding. After the first month, the stooling frequency in some infants decreases to 1 episode every 1-2 days or less, with some having only 1 or 2 bowel movements per week. This infant therefore has normal bowel habits for his age, and no treatment is necessary. soft, yellow-green stool Formula-fed infants tend to have relatively solid stool consistency compared to nursing babies, and generally have a frequency of 1 or 2 bowel movements per day. If warning signs of an organic etiology (eg, abdominal distension, emesis, poor feeding, failure to thrive) are absent, this will most likely resolve spontaneously or with increased fluid intake. Adding supplemental water to the diet (Choice A) or diluting the infant formula is not recommended and may result in dangerous hyponatremia or other electrolyte imbalances. (Choice B) Glycerin suppositories are stimulant laxatives that increase peristalsis to promote defecation. They can be used as short-term therapy for acute severe constipation. Side effects include rectal irritation, abdominal pain, and diarrhea. This patient's bowel habits are typical for his age, so medication is unnecessary. (Choice C) There is no evidence that increasing maternal fiber intake will increase the frequency of a nursing infant's bowel movements, and the patient's bowel habits are normal for his age. Therefore, there is no indication for the mother to change her diet. (Choice D) Ultrasound is recommended for suspected gastrointestinal obstruction such as pyloric stenosis, which usually presents at 3-6 weeks with postprandial, nonbilious, projectile vomiting rather than spitting up. Infrequent bowel movements are not a typical presentation, and weight loss would likely be present. Educational objective: Many breastfed infants have a decrease in the frequency of infant bowel movements after the first month of life. Parents should be reassured that this is normal and requires no treatment. References: Practical algorithms for managing common gastrointestinal symptoms in infants (http://www.ncbi.nlm.nih.gov/pubmed/23137717) Infrequent stools in exclusively breastfed infants (http://www.ncbi.nlm.nih.gov/pubmed/25243969)

A 6-Week-Old Boy Is Brought to the Office by His