The Toddler/Preschool Child
Case 3.5 Abdominal Pain
78 The Toddler/Preschool Child
Medications: Jasmine is currently taking no over - the - counter, prescription, or herbal medications.
She has no known allergies to medications, food, or the environment. She is up to date on required immunizations.
OBJECTIVE
Jasmine ’ s vital signs are taken, and her weight in the offi ce today is 27 kg. Her temperature is 37 ° C (temporal). She is alert, cooperative, and interactive. She appears well hydrated and well nourished.
Skin: Her skin is clear of lesions. There is no cyanosis of her skin, lips, or nails. There is no diapho- resis noted. Jasmine has good skin turgor on examination.
HEENT : Jasmine ’ s head is normocephalic. Red refl exes are present bilaterally; and pupils are equal, round, and reactive to light. There is no ocular discharge noted. Julia ’ s external ear reveals that the pinnae are normal and that there is no tenderness to touch on the external ear. On otoscopic examina- tion, the tympanic membranes are gray bilaterally and in normal position with positive light refl exes.
Bony landmarks are visible, and there is no fl uid noted behind the tympanic membranes. Both nostrils are patent. There is scant nasal discharge, and there is no nasal fl aring. Jasmine ’ s mucous membranes are noted to be moist when examining her oropharynx. She has 20 teeth present without evidence of caries. There are no lesions present in the oral cavity.
Neck: Supple and able to move in all directions without resistance; no cervical lymphadenopathy.
Respiratory: Respiratory rate is 24 breaths per minute, and lungs are clear to auscultation in all lobes.
There is good air entry, and no retractions or grunting are noted on examination. No deformities of the thoracic cage are noted.
Cardiovascular: Heart rate is 104 beats per minute with a regular rhythm. There is no murmur noted upon auscultation.
Abdomen: Normoactive bowel sounds are present throughout; abdomen is soft and mildly tender in the lower left quadrant. There is no evidence of hepatosplenomegaly.
Genitourinary: Normal female genitalia.
Neuromusculoskeletal: Good tone in all extremities; full range of motion of all extremities.
Extremities are warm and well perfused. Capillary refi ll is < 2 seconds, and spine is straight.
CRITICAL THINKING
Are there laboratory tests or diagnostic imaging studies that should be ordered as part of a workup for abdominal pain?
___Stool test for occult blood ___Anorectal manometry ___Digital rectal exam ___Abdominal radiograph ___Blood test for celiac disease
___ Erythrocyte sedimentation rate ( ESR ) ___Barium enema
___Total colonic motility studies ___Thyroid function test
___Stool culture
___Endoscopy/Colonoscopy
Abdominal Pain 79
What is the most likely differential diagnosis and why?
___Functional dyspepsia ___Functional constipation ___Irritable bowel syndrome ___Cyclic vomiting syndrome ___Abdominal migraine
___Functional abdominal pain syndrome ___Gastrointestinal infection
___Hirschsprung disease ___Intussusception ___Celiac disease ___Crohn disease ___Dietary intolerances
What is your plan of treatment, referral, and follow - up care?
Does this patient ’ s psychosocial history affect how you might treat this case?
What if the patient lived in a rural setting?
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: An abdominal radiograph may be helpful if constipation is suspected. It may reveal a full rectal vault and fecal loading. There would be no signs of obstruction. A stool test for occult blood would reveal the presence of blood in the stool and may suggest rectal or anal tearing during stooling. Anorectal manometry evaluates internal sphincter relaxation with rectal distention. This test would be used if Hirschsprung disease is suspected. A digital rectal exam should reveal a full rectal vault in functional constipation, while Hirschsprung disease is more likely to present with an empty rectum on physical exam. Patients with constipation and failure to thrive should be evaluated with a celiac panel for celiac disease and a thyroid function test for hypothyroidism. While Jasmine ’ s history and physical are not consistent with Crohn disease, it would be important to consider this diagnosis if her abdominal pain were persistent and unrelieved by treatment, given the family history for this disease. In a patient with Crohn disease, ESR may be elevated. An endoscopy and colonoscopy would be warranted if this diagnosis was suspected.
What is the most likely differential diagnosis and why?
Constipation:
While the differential for abdominal pain is extensive, it is important to bear in mind that the majority of abdominal pain in children is functional and not the result of an underlying pathological process.
Included in the differential for functional abdominal pain are functional dyspepsia, functional con- stipation, irritable bowel syndrome, cyclic vomiting syndrome, abdominal migraine, and functional abdominal pain syndrome.
Organic etiologies of abdominal pain include gastrointestinal infection, anatomic abnormalities such as Hirschsprung or intussusception, infl ammatory diseases such as celiac disease, Crohn disease, and dietary intolerances. Red fl ags for organic etiologies of abdominal pain include pain that occurs at night and awakens the child; pain that is distant from the umbilicus; pain accompanied by fever, dysuria, or hematuria; joint pain or swelling; signifi cant vomiting; a change in bowel movement habits; weight loss; or slowed growth. Constipation, with or without abdominal pain, may also be the result of cystic fi brosis, neurological dysfunction, and hypothyroidism, which should be ruled out in cases of constipation that do not respond to standard interventions. Given Jasmine ’ s history of increased cow ’ s milk intake, her habit of having a bowel movement only 2 – 3 times per week, and mild tenderness in left lower quadrant, the mostly likely diagnosis is constipation.
80 The Toddler/Preschool Child
What is your plan of treatment, referral, and follow - up care?
Initial management of constipation requires a “ cleanout, ” which can be achieved using oral or rectal medications, including enemas, osmotic laxatives, stimulant laxatives, and polyethylene glycol.
Polyethylene glycol ( PEG ) and stool softeners are safe and effective for long - term treatment and should be considered in patients with recurrent functional constipation. PEG is especially useful in the pediatric population, as it is tasteless and can be dissolved easily in any beverage.
Because much of the management for constipation involves behavior modifi cation and lifestyle changes, it is important to take the time to educate families. Jasmine ’ s parents should be educated about constipation, including management guidelines and when to seek medical care. While there is limited support for dietary and exercise interventions for constipation, these lifestyle changes are healthy choices for all patients and may offer some relief for select patients. Jasmine ’ s parents should be encouraged to provide her with a low - fat, high - fi ber diet and ensure that she gets plenty of regular exercise. Jasmine ’ s mother should be told to decrease Jasmine ’ s cow ’ s milk intake to no more than 24 oz per day since excessive intake of cow ’ s milk has been associated with constipation. Adequate water intake may help prevent constipation as well.
In preschool - aged children with a history of constipation, toileting is often met with fear and frustration. Scheduled toileting can help to normalize toilet time as a relaxing and painless activity.
Jasmine ’ s parents should be instructed to have her sit on the toilet for 15 to 20 minutes at a time, 2 to 3 times a day, even if she does not have a bowel movement. Due to the gastrocolic refl ex, timing this toileting for 15 to 20 minutes after the completion of meals may prove helpful. During toilet time, Jasmine should sit with both feet fi rmly on the fl oor and should be encouraged to relax. A parent should be present with Jasmine during toilet time to provide reassurance and to observe bowel move- ments. Information obtained about the size and shape of Jasmine ’ s stools can provide both her parents and her health care provider information about the success or failure of her treatment. A reward system (such as a sticker chart) for successful toileting efforts and bowel movements may help to encourage future success, while failures should simply be ignored.
Based upon the history and physical exam, there is no indication for referral at this time. It is impor- tant that Jasmine and her parents follow up with her health care provider by telephone in 1 to 2 weeks to assess the effectiveness of the recommended interventions. This time will also allow Jasmine ’ s parents to express any questions, concerns, or frustrations that may have arisen regarding her symp- toms and treatment. The family should follow up in the offi ce in 1 month or sooner if necessary.
Prolonged constipation that does not respond to treatment or recurrent abdominal pain that appears to be unrelated to functional constipation, may require a referral to a pediatric gastroenterologist.
Does this patient ’ s psychosocial history affect how you might treat this case?
Treatment for constipation does not vary signifi cantly based on psychosocial history; but it is impor- tant to bear in mind a family ’ s access to fresh produce, as well as their dietary preferences, when offering nutritional recommendations. Furthermore, constipation may be more prevalent during periods of transition, such as starting school, the arrival of a new sibling, or moving to a new home.
When these transitions exist, interventions may require more time before they are successful. Parents should be encouraged in their efforts, allowed to air frustrations, and offered regular support from health care providers.
What if the patient lived in a rural setting?
Residence in a rural setting should not affect the treatment of Jasmine ’ s constipation. However, if a more serious etiology were suspected and access to health care were limited by location, more aggres- sive diagnostics at the time of presentation may be warranted.
Are there any demographic characteristics that might affect this case?
Constipation is a very common complaint in childhood. In fact, it is estimated that 3% – 5% of pediatric health care visits are the result of constipation. The prevalence of constipation is equal among girls and boys during childhood, but it occurs more frequently in females than in males following puberty.
While constipation occurs throughout infancy, childhood, and adulthood, it appears to be more prevalent during weaning and toilet training, and also in school - aged children. Many children with constipation have a family member who also has constipation.
Abdominal Pain 81
Are there any standardized guidelines that you should use to assess or treat this case?
The Rome III diagnostic criteria, created by the Rome Foundation offer guidelines for the diagnosis and treatment of functional abdominal pain, including functional constipation, in children (Rasquin et al., 2006 ). American Academy of Pediatrics — Medical Specialty Society ( 2005 ) has also developed guidelines for diagnosing and treating chronic abdominal pain in the pediatric population. The North American Society for Pediatric Gastroenterology and the University of Michigan also offer guidelines for managing pediatric constipation.
REFERENCES AND RESOURCES
American Academy of Pediatrics — Medical Specialty Society ( 2005 ). Chronic abdominal pain in children . Pediatrics , 115 ( 3 ), 812 – 815 .
Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology ( 2006 ).
Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition . Journal of Pediatric Gastroenterology and Nutrition , 43 ( 3 ), e1 – e13 .
Daher , S. , Tahan , S. , Sole , D. , Naspitz , C. , Da Silva - Patricio , R. , Neto , U. , & De Morais , M. ( 2001 ). Cow ’ s milk protein intolerance and chronic constipation in children . Pediatric Allergy & Immunology , 12 , 339 – 342 . Rasquin , A. , Di Lorenzo , C. , Forbes , D. , Guiraldes , E. , Hyams , J. S. , Staiano , A. , & Walker , L. S. ( 2006 ). Childhood
functional gastrointestinal disorders: Child/adolescent . Gastroenterology , 130 , 1527 – 1537 .
University of Michigan Health System ( 2008 ). Functional constipation and soiling in children , Ann Arbor, MI : University of Michigan Health System . Sep. 15.