A 7-week-old boy is brought to clinic by his mother due to trouble stooling. The patient passed meconium in the first 24 hours of life and stooled easily for the first 2 weeks. To pass a stool now, he has to strain for approximately 10 minutes, during which he often cries, his body gets stiff, and his face turns bright red. This behavior is even more pronounced in the early morning, when the patient appears to be asleep but is found to be grunting and straining to pass stool. He stools 2 or 3 times daily, and the stools are soft, yellow, and seedy. The patient is exclusively breastfed without issues. Temperature is 36.8 C (98.2 F) and pulse is 135/min. Physical examination reveals a soft, nontender abdomen with mild distension and no palpable masses. Rectal tone is normal, and there is no anal fissure. Which of the following is the best next step in management of this patient?

Question

A 7-week-old boy is brought to clinic by his mother due to trouble stooling.  The patient passed meconium in the first 24 hours of life and stooled easily for the first 2 weeks.  To pass a stool now, he has to strain for approximately 10 minutes, during which he often cries, his body gets stiff, and his face turns bright red.  This behavior is even more pronounced in the early morning, when the patient appears to be asleep but is found to be grunting and straining to pass stool.  He stools 2 or 3 times daily, and the stools are soft, yellow, and seedy.  The patient is exclusively breastfed without issues.  Temperature is 36.8 C (98.2 F) and pulse is 135/min.  Physical examination reveals a soft, nontender abdomen with mild distension and no palpable masses.  Rectal tone is normal, and there is no anal fissure.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5f8_01e6_bc81_49e0de930370_MD0003_00 Straining in infants can be a sign of a serious organic disorder. Features warranting further evaluation include severe abdominal distension, abnormal rectal tone or sacral findings, a history of delayed passage of meconium, or failure to thrive. This otherwise healthy infant with straining and crying prior to passing normal soft stool most likely has infant dyschezia, a common, benign functional stooling disorder. Pathogenesis of infant dyschezia involves the following: Failure to coordinate increased intraabdominal pressure with relaxation of the pelvic floor muscles Inadequate abdominal muscle tone to produce an effective Valsalva maneuver These mechanisms result in characteristic findings of crying, turning red in the face, and straining for greater than 10 minutes, followed by passage of a soft, nonbloody stool. Infants are otherwise well-appearing with no abnormalities on physical examination. As the infant's gut nervous system matures, defecation becomes more coordinated, and infant dyschezia resolves spontaneously, typically by age 9 months. Episodes may be concerning to parents, but management includes providing education and reassurance alone. (Choice A) Hirschsprung disease, caused by an aganglionic colonic segment and diagnosed by barium enema, can cause straining in infants due to lack of internal sphincter relaxation. Typical findings include severe abdominal distension, increased rectal tone, and a history of delayed passage of meconium. (Choice B) Switching to soy formula can be considered for straining from food protein-induced proctocolitis due to milk. Unlike this infant, these patients have loose stools containing mucus and blood. (Choice C) Lactulose can be used to treat functional constipation, an uncommon diagnosis in an exclusively breastfed young infant. This patient's soft stools are inconsistent with this diagnosis. (Choice E) A sweat chloride test evaluates for cystic fibrosis, which can cause straining and constipation due to improper intestinal development (ie, microcolon) in the setting of meconium ileus. Delayed passage of meconium in the newborn period is typical in cystic fibrosis. Educational objective: Infant dyschezia is a common, benign, and self-resolving functional disorder characterized by crying and straining prior to passing normal, soft stools. Alternative diagnoses of straining (eg, functional constipation, Hirschsprung disease) should be considered in an infant with hard stools, poor growth, delayed passage of meconium, or abnormal physical examination. References: Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. (http://www.ncbi.nlm.nih.gov/pubmed/27144631)

A 7-Week-Old Boy Is Brought to Clinic by His Mother