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

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

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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

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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

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APRIL 24, 2019

Constipation in the Premature and Fragile Infant

Puji Jonnalagadda, MD Jill Permeswaran, DNP , CPNP-PC

4

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
  • f life in 17% to 40% of children
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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
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Anatomy & Physiology

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Skeletal muscle Smooth 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  relaxes external sphincter  increases intra-abdominal pressure  stool evacuation Maintaining external sphincter and gluteal muscles to contract  forces stool back  urge to pass stool disappears

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Common Causes

Functional Constipation

  • Constipation in the absence of evidence of pathological condition
  • Most common cause, also called idiopathic

12 Stools increase in size and consistency Reabsorption

  • f fluids

Prolonged fecal stasis in the colon Resultant voluntary withholding of feces to avoid unpleasant defecation. Painful bowel movements

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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
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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

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History

  • Fever or vomiting
  • Age of onset of symptoms
  • Passage of first meconium
  • Frequency and consistency of stools
  • Prior and current treatments
  • ral 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
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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

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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

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Medications

  • Maternal/Infant exposures
  • Opioid Narcotics*
  • Anticholinergic Agents
  • Tricyclic Antidepressants
  • Iron supplementation
  • Formula Fortification

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Dietary/Allergy Causes of Constipation

  • Cow Milk Protein Allergy
  • Celiac Disease
  • Low Fiber Diet
  • Decreased Fluid Intake for Age

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Other Causes of Constipation

  • Sexual Abuse
  • Chronic Intestinal Pseudo-obstruction

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Managing Constipation

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Treating Constipation

  • Prevention and treatment are both important
  • Education should be paired with medical treatment
  • Treat the cause not just the constipation

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Infants 1-6 months old

Nonpharmacological

  • Proper mixing of formula
  • No evidence that one formula

is better that another

  • Exercises
  • Bicycles
  • Tummy massage

Pharmacological

  • Small amount of juice (1/2 ounce)
  • Apple, pear, prune juices
  • Should NOT replace formula/breastmilk

intake

  • Can substitute juice for water when

mixing formula

  • Sometimes Karo syrup (1-2 tsps.) is

also recommended

  • Glycerin Suppository
  • Talk to your PCP for recommendations
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Infants 6-12 months old

Nonpharmacological

  • Once solids are introduced, include

foods high in fiber into purees

  • Small amount of 100% fruit juice

(limit to 4 ounces)

  • Small amount of water intake is safe

at this age but in moderation

  • Proper mixing of formula and

Exercises still apply

Pharmacological

  • Fiber supplements
  • Miralax (osmotic laxative)
  • Lactulose
  • Glycerin Suppository
  • Talk to your PCP for recommendations

Children >1 year old

Nonpharmacological

  • Foods high in fiber
  • Small amount of 100% fruit

juice (limit to 4 ounces)

  • Optimal water intake (32 to

64 ounces)

  • Increase physical activity
  • Well rounded diet
  • Limit dairy
  • AAP recommends “limiting

the intake of cow's milk to 24 fluid ounces (720 mL) per day”

Pharmacological

  • Osmotic laxatives
  • Miralax
  • Lactulose
  • Glycerin Suppository

Talk to your PCP for recommendations

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Example of High-Fiber Foods

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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

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References:

  • Blackmer, A.B., & Farrington, E.A. (2010). Constipation in the pediatric patient: An overview and

pharmacologic considerations. Journal of Pediatric Health Care 23(6) 385-399.

  • Bladder and Bowel UK, Disabled Living (2017) Understanding Constipation in Infants and Toddlers.
  • Colombo, J.M., Wassom, M.C., & Rosen, J.M. (2015). Constipation and ecopresis in childhood. Pediatrics in

Review 36(9), 392-402. doi: 10.1542/pir.36-9-392. 10.1016/j.pedhc.2010.09.003

  • Hyams, J.S., Lorenzo, C., Saps, M., Shulman, R.J., Staiano, A., & van Tilburg, M. (2016). Childhood functional

gastrointestinal disorders: Child/adolescent. Gastroenterology 150. 1456-1468. doi:10.1053/j.gastro.2016.02.015

  • Madani, S., Tsang, L., & Kamat, D. (2016). Constipation in children: A practical review. Pediatric Annals,

45(5). E189-196. doi: 10.3928/00904481-20160323-01

  • Maupin, J. Constipation and abdominal pain. [powerpoint presentation]
  • Nash, M. Nutrition management of the premature infant [powerpoint presentation]

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References Continued:

  • North American Society of Pediatric Gastroenterology, Hepatology and Nutrition [NASPGHAN] (2016).

Clinic practice guideline evaluation and treatment of constipation in infants and children: Recommendations of North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Journal of Pediatric Gastroenterology and Nutrition 43 1-13.

  • NASPGHAN (n.d.) Constipation. Retrieved from https://www.gikids.org/content/129/en/constipation
  • Navidi, T. (2015) Gastroenterology. In Engorn, B. & Flerlage, J. (Eds.), The Johns Hopkins Hospital: The

Harriet Lane Handbook 12th Edition 272-273 Philadelphia, PA: Elsevier Sanders .

  • Nurko, S., & Zimmerman, L.A., (2014). Evaluation and treatment of constipation in children and
  • adolescents. American Family Physician, 90(2), 82-90.
  • Philichi, L. (2018). Management of childhood functional constipation. Journal of Pediatric Health 32(1)

103-111. doi: 10.1016/j.pedhc.2017.08.008.

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References Continued:

  • Sood, M. (2019). Chronic functional constipation and fecal incontinence in infants and children:
  • Treatment. Retrieved from https://www.uptodate.com/contents/chronic-functional-constipation-and-

fecal-incontinence-in-infants-and-children-treatment

  • Tabbers, M.M., DiLorenzo, C., Berger, M.Y., Faure, C., Langendam, M.W., Nurko, S., Staiano, A.,

Vandenplas, Y., & Benninga, M.A. (2014). Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NAPSGHAN. JPGN, 58(2) 258-274. doi:10.1097/MPG.0000000000000266

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Thank you!

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Break

Join us from 11:35 am to noon for updates from the NICU Consortium Partnership

CONSTIPATION IN BABIES AND TODDLERS

Darja Pisorn, RD CNSC Kristin Frank, OTR

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The gastrointestinal tract is one big long TUBE!

Type to enter a caption.

RED FLAGS: WHEN TO ASK QUESTIONS

*By the time a doctor or dietitian is involved, constipation has been identified

  • Parents may need help identifying that their child is constipated
  • When a therapist should ask probing questions:

– If the child is vomiting – If the child has low appetite or is disinterested in food – If the child’s growth is faltering (not following along growth curve) – If parents are having a hard time with potty training – If you notice the child has a hard, distended abdomen – If you identify that the child has low muscle tone

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DISTENDED BELLY

WHAT QUESTIONS TO ASK

  • How often is your child having a bowel movement? (per day or per week)
  • Describe the size and consistency of bowel movements to me (can use Bristol stool

chart)

  • What color are your child’s stools?
  • Does your child cry, strain, or exhibit any other signs of pain during bowel

movements?

  • Does your child ever go several days without a bowel movement followed by a lot of

loose stool?

  • Do you ever observe streaking in the diaper with no formed stool?
  • Does your child ever vomit after several days of no bowel movements?

* If constipation is identified: When did these symptoms start?

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WHAT IS “NORMAL?”

  • Newborns - 4 bowel movements per day
  • First year of life - 2-3 bowel movements per day
  • Toddlers- at least 1 bowel movement per day
  • Large, soft formed stools

Not normal: bleeding, crying, rabbit pellets, dry hard stools, a hard distended abdomen, vomiting

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POTENTIAL CAUSES

  • Abnormal muscle tone (high or low)
  • Lack of movement, motor delays
  • Not chewing food adequately
  • Lack of fiber or fluid in diet
  • Related to medical or genetic diagnosis

(structural abnormalities or changes, i.e. G- tube, nissen, NEC)

  • Medications/supplements (iron, painkillers)
  • Impaction
  • Food allergies (celiac disease, cow’s milk

PREVENTION & TREATMENT: < 6 months

  • Look at the whole child: ensure appropriate medical & therapeutic supports

are in place

  • Infant bowel massage
  • Ensure proper mixing of formula if baby is formula fed
  • MD may prescribe a very small amount of juice or a suppository

If constipation persists:

  • Consider changes in mother’s diet in breastfed babies (trialing removal of

dairy or gluten)

  • Consider changing formulas in formula fed babies
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PREVENTION & TREATMENT: 6-12 months

  • Look at the whole child: ensure appropriate medical & therapeutic supports are in

place

  • Introduce new foods slowly (wait 3 days between each new food)
  • Be aware that stools will change as solid foods are introduced; there may be an

“adjustment period.”

  • Ensure adequate fiber intake: 5 g per day by 1st birthday; up to 19 g once fully

transitioned to solids.

  • Ensure adequate fluid intake: about 27 oz (800 ml) per day
  • “P” fruits (and some non “P” fruits) and their juices: up to 4 oz juice per day

–Prunes, Peaches, Pears, Plums, Apples, Cherries, Apricots, Figs, Dates, Raisins *These fruits are higher in sorbitol and fructose, which are fermented in the colon and subsequently draw water into the large intestine

PREVENTION & TREATMENT: 1 year+

  • Look at the whole child: ensure appropriate medical & therapeutic supports are in

place

  • Fiber intake up to 19 g per day once fully transitioned to solids

*Be careful to increase fiber gradually and provide enough fluid

  • Fluid intake- about 40 oz (1200 ml) per day
  • Encourage movement & physical activity
  • Limit cow’s milk to 16 oz per day when possible
  • Warm epsom salt bath
  • “P” fruits (and non “P” fruits too!) and their juices (up to 8 oz/day)
  • Probiotics (yogurt, kefir, fermented foods), or probiotic supplements

containing lactobacillus and bifidobacterium

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Constipation in Babies and Children; Alberta Health Services 2015; https://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-constipation-in-babies-and-children.pdf

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Review & Key Points to Remember:

  • Always consider the whole child (and family)
  • Make sure all necessary team members are in

place and collaborate with them!

  • Ask specific, detailed questions and investigate

the WHY

  • GI tract is one big tube
  • Consult a dietitian if constipation is suspected
  • Don’t forget that feeding difficulties can often

be constipation and GI related

  • Consistency and long-term management is key

QUESTIONS?

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NICU Consortium Partnership

Please join us at 11:35 am for updates from the NICU Consortium Partnership Committees and community partners

Future NICU Consortium Education Programs

Last Wednesday of the month - 9:00-11:30am

  • July 31, 2019
  • October 30, 2019

NICU Consortium Partnership

Leadership Council

Leadership

Chair Petora Manetto-Spratt Co-chair Lisa Hymes Secretary Carolyn Kwerneland Treasurer Beth Cole

Community Representatives

Parents - Amber Minogue JFK Partners - Renee Charlifue-Smith Physicians - Sharon Langendoerfer

Committee Chairs/Co-chairs Mental Health - Emily McNeil NICU Consortium Planning Committee - Kristin Frank Family Support Programs - Natalie Gates Safe Sleep Going Home – Mekida Wilson NICU Outreach - Open 2019 Once Day Conference – Barbara Deloian 2020 Interdisciplinary Institute - Open

Please contact Barbara Deloian at specialcare@sk-sc.org if you would like to participate on one of the Committees

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Special Kids, Special Care Sign Up

Please use our website: www.specialkids-specialcare.org

  • Announcements about our education programs, the NICU

Consortium Meetings and our newsletter

  • Our Family Support Programs

 NICU Outreach: Safe Sleep Going Home Program: Wearable Sleep Sac Blanket and safe sleep parent education materials  Family Support Grant - Applications for newborn cribs, respite care, lactation consultation, or other health support services needed by families