Transcript Chronic Constipation in Children

New Consultants in Paediatrics at the
Royal Surrey from 1st April 2014






Dr Paula McQueen
Dr Ruth Mew
Dr Ozan Hanci
Dr Joanne Bartley
Dr Rick Fulton
Dr Archana Kshirsagar
Allergy
Allergy
Gastroenterology
Oncology
Diabetes (Locum)
Diabetes (from Sept 14)
Common paediatric conditions which
seldom require hospital referral








Constipation
Recurrent abdominal pain
Gastro-oesophageal reflux
Cow’s milk protein allergy
Eczema
Immunisations
Urinary tract infections
Nocturnal enuresis
NICE Guidelines for Children







Antisocial behaviour and conduct disorders
Atopic Eczema
Bedwetting (nocturnal enuresis)
Constipation
Diarrhoea & vomiting
Feverish illnesses
Food allergy
NICE Guidelines for Children








Immunisations
Looked-after babies & children
Reducing substance misuse
Social & emotional wellbeing
Spasticity in children
Surgical management of CSOM
Urinary tract infection
When to suspect child maltreatment
Chronic Constipation in Children
Dr Mark Evans
Consultant Paediatrician
Royal Surrey County Hospital
Chronic Constipation








Common problem in children (5-30%)
Usually functional, rarely due to an organic cause
Can usually be managed in General Practice
NICE Guidelines available (QS62)
Use oral macrogols as first line treatment
May need disimpaction followed by maintenance Rx
Treat for 3 months before specialist referral
Watch out for Red Flag signs needing referral
Chronic Constipation
Which children require referral for specialist advice ?







Delayed passage of meconium (> 48 hours)
Symptoms starting in the first 4 weeks of life
Ribbon-like stools (more likely in infants)
Abdominal distension with vomiting or FTT
New onset of weakness in lower limbs
Disclosure suggesting Child Abuse
Poor response to Rx for > than 3 months
Chronic Constipation
Unusual organic causes







Coeliac Disease
Cow’s Milk Protein Allergy
Hypothyroidism
Hypokalaemia
Hypercalcaemia
Neurological problems
Peri-anal Streptococcal Infection
Chronic Constipation
Investigations that can be done in General Practice







FBC & Film
U&E’s
TFT’s
Bone profile
Coeliac serology
IgE and RAST to food mix
Peri-anal Swab
Recurrent Abdominal Pain
Dr Mark Evans
Consultant Paediatrician
Royal Surrey County Hospital
Recurrent Abdominal Pain







Common problem in children (25%)
Usually functional, rarely due to an organic cause
Can usually be managed in General Practice
NICE Guidelines not yet available
Reassurance is the main management
May need to exclude an underlying organic cause
Watch out for Red Flag signs needing referral
Recurrent Abdominal Pain
Which children require referral for specialist advice ?






Pain associated with weight loss or chronic diarrhoea
Pain associated with significant rectal bleeding
Pain associated with bile-stained vomiting
Abnormal investigation results
Chronic symptoms lasting for > 3 months
Children who are missing a lot of school
Recurrent Abdominal Pain
Investigations that can be done in General Practice







FBC & Film
ESR & CRP
U&E’s, LFT’s, bone profile, amylase
Coeliac serology, IgE & RAST to mixed foods
MSU & Stool for m/c/s, H pylori Ag & faecal calprotectin
Plain abdominal x-ray
Abdominal / pelvic ultrasound scan
Recurrent Abdominal Pain
Treatment of RAP in General Practice







Reassurance +++ (if no Red Flags)
Basic investigations as discussed previously
Movicol if constipation suspected or proven on AXR
Pizotifen 1 – 1.5 mg OD if abdominal migraine suspected
Omeprazole 10 – 20 mg OD if acid reflux suspected
CAMHS referral if psychological factors suspected
Paediatric referral if symptoms > 3 months
Cow’s Milk Protein Allergy
Dr Mark Evans
Consultant Paediatrician
Royal Surrey County Hospital
Cow’s Milk Protein Allergy






Common problem in infants & children
Can usually be managed in General Practice
Often a self-limiting condition resolving by 4 yrs
Prescribing guidelines for milks widely available
May need to exclude an alternative organic cause
Watch out for Red Flag signs needing referral
Cow’s Milk Protein Allergy







CMP Allergy affects 2 – 8 % of all babies
Gastro-intestinal symptoms occur in 60 – 80 %
Can also present with skin & respiratory symptoms
Sometimes presents with pr bleeding in infants
Often resolves spontaneously by 3 – 4 years of age
Hydrolysates should be used as 1st line treatment
Amino-acid formulas should reserved for severe cases
Cow’s Milk Protein Allergy
Treatment of CMPA







Many different types of ‘special milks’
Note new prescribing guidelines on the G & W web-site
Start with a hydrolysate such as Aptamil Pepti 1 or 2
Only use amino-acid based formulas if above ineffective
Do not use soya / goat’s milk / sheep’s milk, etc
Coconut milk or oat milk can be used > 12 months
Do not use rice milk < 4 years (contains arsenic)
Cow’s Milk Protein Allergy
Which children need referral for specialist advice ?







Babies with ‘failure-to-thrive’ (weight loss > 2 centiles)
All infants on a CMP-free diet should have dietetic input
Rectal bleeding in infants unresponsive to 1st line Rx
Any children not responding to Rx with hydrolysates
Children with CMPA as part of multiple food allergies
CMP complicating Coeliac disease in older children
Children requiring a CMP challenge under supervision
Cow’s Milk Protein Allergy
Useful References




Guildford & Waverley Prescribing Web-Site
NICE Guidelines on Food Allergy in Children (2011)
MAP Guidelines for Rx CMPA in General Practice (2013)
Venter et al - Clinical & Transitional Allergy 2013 3:23
GO Reflux in Children
Dr Mark Evans
Consultant Paediatrician
Royal Surrey County Hospital
GO Reflux in Children







Common problem in infants & children
Usually functional, rarely due to an organic cause
Can usually be managed in General Practice
NICE Guidelines not yet available (Jan 2015)
Reassurance is the main management
May need to exclude an underlying organic cause
Watch out for Red Flag signs needing referral
GO Reflux in Children
Which children need referral for specialist advice ?





Projectile vomiting in the early weeks of life
Vomiting associated with ‘failure-to-thrive’
Vomiting associated with significant haematemesis
Symptoms unresponsive to conventional anti-reflux Rx
Symptoms persisting beyond 12 months of age
GO Reflux in Children
Treatment of GO Reflux in Infants






Infant Gaviscon or feed thickening agent
Ranitidine at a dosage of 2 mg / kg / TDS
Domperidone at a dosage of 0.2 – 0.3 mg / kg / QDS or
Erythromycin at a dosage of 3 mg / kg QDS
Omeprazole at a dosage of 1 – 2 mg / kg OD
Consider a hydrolysate in case of CMP allergy
Any Questions ?