Welcome NICU Consortium Education Program/Webinar April 24, 2019 - PDF document

5/1/2019 Welcome NICU Consortium Education Program/Webinar April 24, 2019 NICU Consortium Education Program April 24, 2019 9:00 am Welcome and Announcements 9:15 am Constipation in the Premature and Fragile Infant Shanmuga “ Puji ” Jonnalagadda, MD Developmental Pediatric Fellow, Developmental Pediatrics Children’s Hospital Colorado Jill Permeswaran, DNP, CPNP-PC Pediatric Nurse Practitioner, Developmental Pediatrics Children’s Hospital Colorado 10:15 am Break 10:30 am Therapeutic and Nutritional Approach to Addressing Constipation in Fragile Newborns in the Home Kristin J. Frank OTR, LLC Darja Pisorn RD, CNSC EI Registered Dietician Tiny Tummies Nutrition 1

5/1/2019 APRIL 24, 2019 Constipation in the Premature and Fragile Infant Puji Jonnalagadda, MD Jill Permeswaran, DNP , CPNP-PC Did you know? • 25% of referrals to Pediatric GI are for of constipation • More than 90% of childhood constipation is functional • Constipation starts in the first year of life in 17% to 40% of children 4 2

5/1/2019 Definitions • Constipation*: infrequent and uncomfortable passage of stool, present for 2 or more weeks. • Intractable Constipation: Constipation not responding to optimal (and consistent) conventional treatment for at least 3 months. • Fecal Impaction: A hard mass in the lower abdomen identified on physical examination or a dilated rectum filled with a large amount of stool on rectal examination or excessive stool in the distal colon on abdominal radiography Objectives 1. Anatomy and Physiology 2. Common Causes of Constipation 3. Differential Diagnosis 4. Managing constipation 3

5/1/2019 Anatomy & Physiology 7 4

5/1/2019 Smooth muscle Skeletal muscle Image credit: https://bilderbeste.com/foto/puborectalis-muscle-d6.html Rectal wall distention Internal sphincter relaxes and external contracts Squatting relaxes the puborectalis muscle  straighter angle  Maintaining external sphincter and gluteal muscles to contract  relaxes external sphincter  forces stool back  urge to pass increases intra-abdominal pressure  stool evacuation stool disappears 5

5/1/2019 Common Causes Functional Constipation • Constipation in the absence of evidence of pathological condition • Most common cause, also called idiopathic Resultant voluntary Prolonged Stools Painful bowel Reabsorption withholding of increase in fecal stasis in movements feces to avoid of fluids the colon size and unpleasant consistency defecation . 12 6

5/1/2019 Normal stool patterns • Transit time increases with age, leading to less frequent bowel movements. • First week of life: 4 BMs/day • Decreases to 1.7 BMs/day around 2 years • Some breast-fed babies may not stool for several days • Frequency of bowel movements do not change Dietary Causes • Breast fed infant: • Breast milk contains proteins and oligosaccharides that are not absorbed  larger and softer stool • Breast fed babies are fed on demand  more stimulation of the gastro colic reflex initially • With maturation of the gut, normal physiological changes causes less frequent stools 7

5/1/2019 Dietary Causes Continued • Formula feeding • Formula contains higher levels of lipids and minerals, particularly calcium fat acid soaps which contributes to stool hardness • Formula feed made up incorrectly (too concentrated, with not enough water) • Introduction of solid food • Not enough fiber (fruit and vegetables) • Decreased fluid intake • High dairy food intake (cows milk etc.) can affect some babies • Illness resulting in dehydration History and Exam 8

5/1/2019 History • Fever or vomiting • Age of onset of symptoms • Passage of first meconium • Frequency and consistency of stools • Prior and current treatments • oral laxatives, enemas, suppositories, herbal treatments • Fluid and dietary intake • General development • Success or failure of toilet training • Family history • gastrointestinal diseases including food allergies, thyroid and other systemic diseases such as cystic fibrosis . • Psychosocial history 9

5/1/2019 Physical • Growth parameters • Abdominal examination • muscle tone, distension, fecal mass • Inspect perianal region • anal position, stool present around the anus or on the undergarments, erythema, skin tags, anal fissures • Examine lumbosacral region • dimple, tuft of hair, gluteal cleft deviation, sacral agenesis, flat buttocks • Anal and cremasteric reflex and lower limb neuromuscular examination • Digital rectal examination • anal stenosis or fecal mass, explosive stool on digital exam Differential Diagnosis 20 10

5/1/2019 Differential Diagnosis Categories 1. Functional 2. Obstructive 3. Medications 4. Neurologic 5. Dietary/Allergy 6. Other 21 Obstructive/Anatomical Causes • Anatomical • Anal Stenosis • Anterior Displacement of the Anus • Colonic Stricture • Obstructive • Small left Colon Syndrome • Meconium Ileus 22 11

5/1/2019 Medications • Maternal/Infant exposures • Opioid Narcotics* • Anticholinergic Agents • Tricyclic Antidepressants • Iron supplementation • Formula Fortification 23 Dietary/Allergy Causes of Constipation • Cow Milk Protein Allergy • Celiac Disease • Low Fiber Diet • Decreased Fluid Intake for Age 24 12

5/1/2019 Other Causes of Constipation • Sexual Abuse • Chronic Intestinal Pseudo-obstruction 25 Managing Constipation 26 13

5/1/2019 Treating Constipation • Prevention and treatment are both important • Education should be paired with medical treatment • Treat the cause not just the constipation 27 Infants 1-6 months old Nonpharmacological Pharmacological • Small amount of juice (1/2 ounce) Proper mixing of formula • • Apple, pear, prune juices • No evidence that one formula • Should NOT replace formula/breastmilk intake is better that another • Can substitute juice for water when Exercises • mixing formula • Sometimes Karo syrup (1-2 tsps.) is • Bicycles also recommended Tummy massage • • Glycerin Suppository • Talk to your PCP for recommendations 14

5/1/2019 Infants 6-12 months old Nonpharmacological Pharmacological • • Once solids are introduced, include Fiber supplements foods high in fiber into purees • Miralax (osmotic laxative) • Small amount of 100% fruit juice • Lactulose (limit to 4 ounces) • Glycerin Suppository • Small amount of water intake is safe at this age but in moderation • Talk to your PCP for recommendations • Proper mixing of formula and Exercises still apply Children >1 year old Nonpharmacological Pharmacological Foods high in fiber Osmotic laxatives • • • Miralax • Small amount of 100% fruit Lactulose • juice (limit to 4 ounces) • Glycerin Suppository Optimal water intake (32 to • 64 ounces) Talk to your PCP for Increase physical activity • recommendations • Well rounded diet Limit dairy • • AAP recommends “limiting the intake of cow's milk to 24 fluid ounces (720 mL) per day” 15

5/1/2019 Example of High-Fiber Foods 16

5/1/2019 Resources • Bicycle Example: https://www.youtube.com/watch?v=ZmQWjJRFWLE • Tummy Massage Example: https://www.youtube.com/watch?v=RINGqYMmnkY • The Poo In You Video: https://youtu.be/SgBj7Mc_4sc • Squatty Potty Video: https://www.youtube.com/watch?v=YbYWhdLO43Q • GI Kids Website: https://www.gikids.org/content/129/en/constipation • Healthy Kids Website: https://www.healthychildren.org/English/health- issues/conditions/abdominal/Pages/Constipation.aspx 17