Pediatric Constipation: Diagnosis and Management (Nursing)

00:01 Hi, I'm Dr. Jackie Calhoun.

00:03 And today we're going to talk about the diagnosis and management of pediatric constipation.

00:07 This is the second of these two constipation videos.

00:11 And in this video, we're going to talk about the diagnosis, prevention and treatment.

00:15 And the previous video, we talked about the definition, epidemiology, causes, and signs and symptoms or the cues.

00:22 So, let's start with, how is pediatric constipation diagnosed.

00:27 This diagnosis is based on a detailed patient history that includes a discussion of the patient's diet and stooling pattern.

00:34 So we want to know what they're eating, how often they're eating, and then what they're drinking, and how often they're drinking? We want to talk about the patient's symptoms, and this is how often they're stooling, how much they're stooling? When they're stooling, do they feel like they're completely stooling? Or do they feel like they need to go more.

00:54 And then lastly, we're going to do a very thorough physical exam, particularly focusing on the patient's abdomen.

01:00 So we want to see is it distended? Does it look like there could be stool in there, are they bloated? When we listen to them, do they have normal bowel sounds? When we listen to them, do they have normal bowel sounds? Do they have hyperactive, or very fast bowel sounds, or are their bowel sounds slow or hypoactive? And then when we palpate or feel their abdomen, we might actually be able to feel stool in their intestines.

01:22 So moving on, the next thing we might do after the history, and the symptom review, after the history, and the symptom review, and the physical exam is imaging.

01:29 and the physical exam is imaging.

01:29 and the physical exam is imaging.

01:31 And the imaging we usually start with ore abdominal and spine x-rays or radiographs.

01:38 The abdominal x-ray is a way to quickly see the patient's intestines and how much stool might be in them.

01:45 And to see, that they're all kind of looking, like located in the right spots, and then the spine radiographs give us an idea of whether a patient has a normal spine or not.

01:55 And if they did not have a normal spine, that could be one reason the patient is constipated.

02:01 The next type of imaging is an abdominal ultrasound.

02:04 And this is an imaging modality that doesn't have radiation, which is a nice advantage.

02:10 And it can also show us where patients organs are located.

02:14 We can see the patient's intestine and how much stool might be in them.

02:19 And then lastly, the patient might need an abdominal CAT scan, which is the most detailed way to see the patient's organs and their stool burden.

02:28 So, how can pediatric constipation be prevented? We're going to talk about this by age.

02:35 It's different in infants and then in older kids.

02:38 Let's start with the babies.

02:40 In babies, they can be formula fed.

02:41 In babies, they can be formula fed.

02:42 And if the iron supplementation on top of that, And if they need an iron supplementation on top of that, there's two ways to give it: It's either with a little bottle of iron and dropper fulls.

02:50 So you get a lot of iron all at one time, which can cause constipation, or you can put the iron in the formula.

02:57 And so they're drinking a little bit of iron at one time.

03:00 So the formula contains iron is definitely preferred to the iron drops.

03:04 In toddlers and children, we want to make sure they're taking enough water and fiber in as part of their diet.

03:12 So water should be the first beverage or drink that's offered to a child when they're thirsty.

03:17 And then we want to make sure that our diet includes lots of fresh fruits, vegetables, and whole grains.

03:24 We also in this age group, especially in the children that are becoming potty trained especially in the children that are becoming potty trained that we're promoting good toileting habits.

03:31 So we want to make going to the bathroom a normal part of people's day and have a positive association with it.

03:38 So now we're going to talk about the treatment of pediatric constipation.

03:42 Let's start with the treatment in infants who as a reminder our babies from about 30 days or one month up to one year of age.

03:52 So some types of fruit juice such as Apple or prune can be given to treat constipation and babies who are more than four months old.

04:00 We can also use high fiber foods in this age group.

04:03 So either fresh fruits and vegetables that are pureed, or oatmeal cereals as opposed to rice cereal.

04:07 or oatmeal cereals as opposed to rice cereal.

04:10 As we talked about, you can use formula that contains iron instead of an individual iron supplement.

04:16 And then continue to promote breastfeeding if the mother is able And then continue to promote breastfeeding if the mother is able which promotes consistent stooling patterns.

04:23 Now, let's talk about the treatment of constipation in children.

04:27 Like in babies apple and prune juice can be used.

04:30 We want to make sure that they're drinking enough water.

04:33 Make this the first beverage of choice for kids.

04:36 Make sure they're eating a balanced diet that contains fruits, vegetables, and whole grains, and then have a positive approach to toilet training.

04:46 Make it a normal part of kid's days, make it non-punitive, so no negativity associated with it at all.

04:54 So the next part of treatment are the medical treatments.

04:57 So we did all the things that don't involve a medicine, but maybe they didn't work, and we need to move on to something a little more serious.

05:04 and we need to move on to something a little more serious.

05:05 So medical treatments consists of three different steps.

05:09 There's the clean out, the maintenance, and the rescue therapies.

05:14 So we'll talk about the cleanup first.

05:16 This is when a patient comes with pretty significant constipation that wasn't relieved by adding more water to their diet or fruits and vegetables or fruit juices.

05:27 And so this is where we give the patient one of two medicines, usually polyethylene glycol or magnesium hydroxide, and they take it with their mouth, so they drink it.

05:39 And the goal of these treatments is to flush all of that stool out of their intestines.

05:44 So they drink these solutions until they're pooping the solution.

05:47 So they drink these solutions until they're pooping the solution.

05:48 So they start out by drinking and then the solution gets more brown.

05:52 and then the solution gets more brown.

05:52 They start to pass like regular looking stool, and then they pass more watery stool and then they are just passing the solution out.

06:00 And that means that all those tools out of their intestines and you're starting with a clean slate.

06:05 But sometimes we need to kind of jumpstart that process.

06:09 The oral solutions aren't enough so they get an enema or rectal suppository, and we use them in combination.

06:16 So after a patient has been cleaned out, we're going to move on to maintenance therapy.

06:21 So something that patient can do every day to help prevent the constipation from coming back.

06:26 And we do this with an oral laxative medication.

06:29 And that's usually we start with polyethylene glycol.

06:32 And then we may need to move to a rescue stage.

06:36 If for some reason the patient gets to clean out.

06:39 They start on a maintenance regimen with the medication, and then they become constipated again.

06:46 This is where a large amount of stool is retained in the colon despite those laxatives.

06:50 So we're going to move to like a super clean out.

06:54 This is where it's a combination of that clean out.

06:56 Where we're going to give them that oral solution until they're cleaned out.

06:59 And then we're going to increase the dose of that maintenance medication once they start back on it to hopefully prevent that constipation from happening again in the future.

07:07 So now let's put all of that into the clinical judgment model.

07:11 As always, we're going to start with layers two and three.

07:15 And let's start by recognizing the cues.

07:21 So remember, in an infant who has not passed that muconium in the first 24 hours, this is a cute like one time constipation.

07:29 These patients may develop severe abdominal distension.

07:33 They may have fever, vomiting, or diarrhea.

07:36 And if they don't pass it for a long enough period of time, they may develop rectal bleeding.

07:43 In chronic constipation, a child can have constipation that has started very early in their life.

07:51 They may have stools that don't look normal.

07:53 They may be ribbon like that are very narrow in diameter.

07:57 They may show either weight loss or poor growth or delayed growth They may show either weight loss or poor growth or delayed growth where they really just don't start growing.

08:05 As with, you know almost all types of constipation, they may have strain with bowel movements.

08:10 And then if this continues long enough, they may have urinary incontinence or bladder disease because of that routine stool in their rectum and colon.

08:20 So let's take all of cues or signs and symptoms and analyze them.

08:26 We talked with the patients and their families about how their spelling patterns are.

08:31 We did a physical exam, we talked about their symptoms, and now we're going to use some imaging to see what their stool burdened looks like.

08:39 to see what their stool burdened looks like.

08:40 So we're going to use abdominal and spine radiographs to get a sense of what the patient's intestines look like, and then how much stool is in them.

08:48 We're going to potentially use an ultrasound next for the same reasons but without radiation.

08:54 And then if we need to, we might do an abdominal CT scan, which will give us the best and most detailed images of the patient's anatomy, their intestines, their stool burden.

09:05 So now we can develop an action plan.

09:08 This action plan is going to be different based on age.

09:11 And then in the infants we're going to start with fruit juice if they're older than four months old.

09:16 We're going to encourage infants eat high fiber foods such as oatmeal cereal and fresh fruits and vegetables.

09:22 And then we will make sure if they're taking formula that it has iron in it instead of taking in separate iron supplement.

09:28 And then if they're breastfeeding, we want them to continue breastfeeding to promote that normal stooling pattern.

09:34 In children, so kids who are greater than one year old, we're also going to use fruit juice, or especially apple and prune.

09:42 And then we're going to ensure that they're drinking enough water, that they're eating a balanced diet with fruits, vegetables, and whole grains.

09:49 And that they have a positive approach toilet training.

09:51 So it's a normal part of their day that using the bathroom is something that has no negativity associated with it.

09:59 And then if they need to have a medical therapy, we're going to start with a clean out, which is where they take those oral solutions until they pass all of the routine stool.

10:10 Then they're going to be started on a maintenance medication, which is a daily laxative.

10:14 And then if that's not enough, and they need a rescue therapy.

10:17 We're going to do that clean out again, and then increase their daily laxative dose.

10:21 and then increase their daily laxative dose.

10:22 So finally, let's evaluate our outcomes.

10:27 First, we want to make sure those patients have achieved a normal stooling pattern for age.

10:32 So like we reviewed earlier, the younger a child is the more often they're expected to stool so babies can stool up to three times per day.

10:43 Toddlers can stool about two times per day and then older children can still about one time per day.

10:49 And then we want to continue to promote positive toileting behaviors, even when the constipation is resolved, so that the patients don't develop constipation again because of that.

10:59 So that's the end of the judgment model.

11:01 And that's the end of the video.

11:03 Thank you for watching. We'll see you next time.