A 3-year-old otherwise healthy boy is brought to the office due to difficulty with bowel movements. Two months ago, the patient began toilet training. Although he has been able to urinate in the toilet, he has struggled with bowel movements. Prior to toilet training, the patient had a soft bowel movement every day. In the past 6 weeks, he has had hard stools every 3 or 4 days. He often cries while having a bowel movement and screams "ouch!" The patient drinks 24 oz of milk and 8 oz of water per day and eats vegetables, meats, and grains. He refuses to eat fruits. Height and weight have been tracking along the 75th percentiles. Examination shows a cooperative, well-nourished boy. The abdomen is firm, mildly distended, and nontender. An anal fissure is present. The remainder of the examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 3-year-old otherwise healthy boy is brought to the office due to difficulty with bowel movements.  Two months ago, the patient began toilet training.  Although he has been able to urinate in the toilet, he has struggled with bowel movements.  Prior to toilet training, the patient had a soft bowel movement every day.  In the past 6 weeks, he has had hard stools every 3 or 4 days.  He often cries while having a bowel movement and screams "ouch!"  The patient drinks 24 oz of milk and 8 oz of water per day and eats vegetables, meats, and grains.  He refuses to eat fruits.  Height and weight have been tracking along the 75th percentiles.  Examination shows a cooperative, well-nourished boy.  The abdomen is firm, mildly distended, and nontender.  An anal fissure is present.  The remainder of the examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d677_6b04_bc81_ed9c07bcbd9e_MD0003_00 This patient's straining, hard stools (pain with defecation), and anal fissure are characteristic of constipation. All pediatric patients with constipation are evaluated for alarm signs (eg, poor weight gain or linear growth, vomiting, severe abdominal distension), which may indicate an underlying anatomic or serious organic cause. This patient with normal growth and physical examination and an onset of constipation related to toilet training likely has functional constipation (ie, not associated with an anatomic or biochemical etiology), the most common cause of constipation in children. Toddlers are at risk for functional constipation due to multiple transitional events, including changes in diet (eg, solid food, cow's milk introduction), initiation of toilet training, and day care/school entry (causing stool-withholding behavior). In young children, initial treatment is with dietary changes (eg, increasing water and fiber) and laxatives (eg, polyethylene glycol), which softens stool and helps decrease the cycle of painful defecation and stool withholding. If symptoms become chronic, the rectum can progressively dilate and fecal impaction (eg, stool ball on examination) can occur. In these patients, disimpaction with an enema is recommended, followed by long-term laxative use to allow the rectum to return to normal size (Choice A). However, in children with anal fissures (such as this one), enemas can cause more rectal trauma and should be limited. (Choice B) Excessive intake of cow's milk can worsen constipation because it provides fat and protein without fiber, leading to slow transit time and causing satiety without room in the diet for higher fiber foods. However, this child's consumption of cow's milk is appropriate (16-24 oz daily); discontinuing it would deprive the child of an important source of calcium and vitamin D. (Choice D) Abdominal x-rays can be considered for patients with signs of severe constipation (eg, abdominal pain, vomiting) because severe fecal impaction can mimic intestinal obstruction. This patient with a benign abdominal examination has no signs of severe impaction. (Choice E) Hirschsprung disease usually presents in the neonatal period with delayed meconium passage and abdominal distension. However, mild disease may manifest later in childhood with chronic constipation; typically alarm signs will be present. Anal fissures are uncommon. If this patient's constipation persists despite standard therapy, evaluation with anorectal manometry can be considered. Educational objective: Functional constipation is common in toddlers due to transition to solid food and cow's milk, toilet training, and school entry. Initial treatment is with dietary changes and laxatives (eg, polyethylene glycol) to soften stools. References: Polyethylene glycol: a game-changer laxative for children. (http://www.ncbi.nlm.nih.gov/pubmed/23591910) Managing functional constipation in children. (http://www.ncbi.nlm.nih.gov/pubmed/23204909)

A 3-Year-Old Otherwise Healthy Boy Is Brought to the Office