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Англоязычные статьи по Педиатрии

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 Буду сюда выкладывать статьи и ссылки на ресурсы  по Педиатрии на английском языке. Тема будет закрытой. Без комментариев. 

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Sex and Drinking Alcohol More Common in Children Who Dislike School

Susan Kreimer

November 10, 2010 — Children who dislike school are more likely to engage in sex and drink alcohol, according to a new British study.

The risk for involvement in a sexual relationship is 2.5 times higher for these students, who also have a strong inclination toward alcohol use. They tend to be unhappy with their home lives as well.

Results of the research were published online November 10 in Substance Abuse, Treatment, Prevention and Policy.

"This study paints a clear picture that the children we most need to support are often the hardest to reach through conventional educational and parental routes," lead author Mark Bellis, PhD, professor at Liverpool John Moores University's Centre for Public Health, United Kingdom, said in a journal press release.

They "risk progressing to sexually transmitted infections, teenage pregnancies or becoming an alcohol-related casualty at an accident and emergency unit."

Dr. Bellis and colleagues enrolled 3641 children, aged 11 to 14 years, from 15 schools in North West England. Withdrawal forms were received for 30 children, another 65 children declined to participate, and 255 returned surveys were flawed, resulting in a nonresponse rate of 10%. Nearly 52% of the respondents were girls.

The team assessed general well-being by asking how satisfied children were with their appearance and how well they got along with their parents. They also inquired about assertiveness and feelings of remorse. As for the children's impressions of school, the questions delved into how teachers treated them and how closely students followed the rules.

Sexual activity in 13- to 14-year-olds (n = 768) increased incrementally with more frequent alcohol use. Youth who imbibed once a week or more had a 12-fold higher risk for any sexual activity and a 10-fold higher probability of having sex. The risks were much greater for rare and occasional drinkers compared with for nondrinkers. In this age group, 49.4% of boys and 55.2% of girls reported some type of sexual activity ranging from kissing, deep kissing, and petting (>50% of responders), to oral sex (11%) and intercourse (10.2% of positive responders). Having any sexual activity was significantly associated with negative response to indicators of school well-being and with report of alcohol use.

Adolescent health is a heightened concern in many countries, particularly in the United Kingdom, where children have one of the lowest well-being scores among wealthy nations, the authors note.

"The rising prevalence of adolescent alcohol misuse and stubbornly high teenage pregnancy rates are recognised to be national public health priorities," they write. "Early alcohol use increases the risk of dependency and fuels the growing burden of alcohol-related disease. The teenage birth rate has been found to most closely relate to the overall index of well-being."

Overall, 45.5% of children reported ever drinking alcohol. The prevalence rose from 32% in 11-year-olds to 65.8% in 14-year-olds (P < .001). Many more 11-year-old boys than girls had consumed alcohol (39% vs 25%; P < .001). By age 14 years, the difference was insignificant (66.9% in girls vs 63.5% in boys).

The average age of the reported first drink for 11-year-old boys and girls was 9.4 years. Among drinkers, the frequency of alcohol consumption tended to increase dramatically with age.

In addition, the odds of reporting alcohol use were twice as high, per bivariate analysis, for those who responded negatively to indicators of school well-being, particularly in terms of relationships with teachers. Children who indicated that they were unable to talk with parents had the highest likelihood of reporting ever drinking alcohol.

Researchers note some limitations of the study. "The sample was not intended to be representative but opportunistic for both students and classroom participation," they state. "Survey participants may thus not be fully representative of all children in North West England."

"The association between alcohol use and sexual activity highlights the need for integrated public health programmes," the authors conclude. "Policies restricting alcohol use may help reduce sexual exposure among young teenagers."

Government Office North West and Cheshire and Merseyside Sexual Health Network provided support for this project. The authors have disclosed no relevant financial relationships.

Subst Abuse Treat Prev Policy. 2010;5:27.

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An Ounce of Prevention: Decreasing Painful Interventions in the NICU

Keitha Mountcastle, NNP-BC, EdD

Posted: 11/30/2010; Neonatal Network. 2010;29(6):353-358

Despite a proliferation of literature relative to pain physiology, assessment, and treatment, pain management in NICUs remains inconsistent—most often focused on assessment and treatment rather than prevention. The acceptance of pain as an inevitable part of NICU hospitalization is part of the culture in many NICUs. This article is intended to encourage discussion of pain prevention in the NICU, with a goal of creating a new "minimal-pain" NICU culture. The focus of NICU pain management programs should be on decreasing the number of painful events the NICU patient experiences. Areas for consideration include assessing the performance of procedures by novice versus experienced NICU personnel, reevaluating the role of pediatric residents in the treatment of NICU patients, evaluating the use of umbilical lines and peripherally inserted central catheters to reduce the frequency of peripheral punctures, and evaluating the admission process for ways to reduce neonatal pain and stress. This article discusses the physiology of pain in the neonate, identifies adverse outcomes related to repeated pain, and proposes practice changes that can prevent unnecessary pain in neonatal care.

Introduction

This clinical case occurred, not 20 or even 10 years ago, but in 2008. Despite greater knowledge about pain physiology and treatment, the development of numerous neonate-specific pain assessment tools, and the availability of a variety of pharmacologic and nonpharmacologic pain interventions, many neonates still must endure undertreated or untreated pain. Much has been written about pain assessment and pain treatment in the NICU; unfortunately, pain prevention in the neonatal population receives much less attention. Anand and colleagues, reporting on proceedings of the American Academy of Pediatrics' Neonatal Pain-Control Group, noted that intervention for pain is used infrequently, partly because of a lack of appreciation for the need for pain control and also because the long-term effects of pain in the neonatal population are not recognized.[1] In practice, pain relief measures are commonly provided after surgery, but are often not provided for the multiple minor interventions that are part of the neonate's daily life in the NICU.[2] Pain is often considered to be an inevitable component of NICU hospitalization.

Similar issues exist in the treatment of pediatric patients. In the late 1990s, several pediatric emergency rooms adopted the concept of the "ouchless" or "painless" emergency room.[3,4] Dr. William Zempsky suggested that with the implementation of cultural change, education, changes in policy, and new technology, a "painless" emergency department could be achieved.[4] More recently, Dr. Neil Schechter suggested that the complete elimination of pain is an unrealistic goal. He described a new emergency room designed using a model called "comfort central"; the goal of this program is to assure families that the hospital staff will provide the highest level of comfort possible.[5]

The purpose of this article is to encourage discussion about pain prevention in the NICU, with a goal of creating a "minimal-pain" culture in the NICU. Health care providers recognize that there are moral, ethical, and physiologic reasons for preventing, assessing, and adequately treating pain. The first-line approach of a successful pain management program should be to prevent pain whenever possible. A minimal-pain culture in the NICU hinges on establishing pain prevention as a top priority among NICU health care providers. Pain prevention must become a responsibility of all health care providers, with families as part of the team. Emphasis on pain prevention does not, however, minimize the need for pain assessment and treatment.

Pain and Noxious Stressors in the Neonate

Approximately 300,000 infants, or 8 percent of the newborn population, are admitted to NICUs annually. Neonates admitted to NICUs, especially preterm infants, are subjected to many procedures, each resulting in varying degrees of pain. Commonly recognized painful procedures include endotracheal intubation, suctioning, insertion of needles into peripheral veins to obtain laboratory samples and/or venous access, nasogastric or orogastric tube placements, tape removal, central vascular line placements, intramuscular or subcutaneous injections, lumbar puncture, eye exams, arterial blood draws, and chest tube placement.[6] Examples of common noxious stimuli in the NICU include bright lights, noise, and frequent handling by a variety of caregivers.[7]

Several studies have documented the frequency of painful procedures in the NICU. Simons and coworkers reported that in the first 14 days of an NICU admission, neonates were subjected to a mean of 14 painful procedures per - In this study, 39.7 percent of all neonatal subjects did not receive any analgesia during the 2-week study period.[8] Carbajal and associates reported that neonates at 33 weeks gestational age admitted to the NICU experienced an average of 10 painful procedures per day, and 79.2 percent of them were performed without any type of analgesia.[9]

In addition to procedural events that are easily recognized as painful, infants in the NICU are exposed to many other situational stressors that may increase their sensitivity to pain. As mentioned earlier, these include frequent handling by multiple caregivers, bright lights, and high noise levels. Although these stimuli are not normally considered sources of pain, research has shown that in ill or preterm infants, these stimuli may readily be processed along the same nerve pathways and perceived in the same manner as more obvious pain signals.[2,10] Researchers have recognized that preterm neonates have an increased sensitivity to pain and develop prolonged periods of hyperalgesia in response to acutely painful stimuli; stimuli that do not normally cause pain may, because of this hyperalgesia, expose the premature infant to prolonged periods of pain.[11] Differences in anatomic, physiologic, and biochemical structure and function may cause infants to feel pain more intensely than adults.[12]

Knowledge and Misconceptions about Neonatal Pain

Historically, many misconceptions existed regarding the ability of the neonate to experience pain and about the safety/efficacy of both pharmacologic and nonpharmacologic interventions to alleviate pain. As recently as the 1980s, it was uncommon for neonates undergoing surgical procedures to be anesthetized.[13] Misconceptions regarding pain in the neonate have traditionally included the following beliefs:

Neonates have an underdeveloped nervous system, resulting in inability to perceive and/or process pain signals.[7,13]

Unmyelinated nerve fibers, present in the fetus/neonate until approximately 37 weeks gestation, are incapable of transmitting pain signals.[7,14]

Neonates are unable to remember painful experiences and therefore lack the situational and emotional functions required to interpret/experience pain.[13]

Several important research articles published in the late 1980s and the 1990s challenged these beliefs about the neonate's ability to perceive and process painful experiences.[14,15] Anand and colleagues discussed the fact that neonatal physiologic responses to pain are reflected in biochemical and cardiorespiratory changes that are similar in character to, but more pronounced than, those in adults. Anand and colleagues further presented evidence that both anatomic and neurochemical systems begin to develop early in the fetal period and are capable of perceiving, transmitting, and processing even in the preterm newborn. Physical nerve and receptor cells are present and functional in even the tiniest preterm infants.[14]

Important differences exist between adult and fetal/neonatal pain structures and functions:

In the fetus, nerve fibers that transmit pain are nonmyelinated, resulting in somewhat slower transmission of pain than in adults. Contrary to earlier beliefs, however, these nonmyelinated fibers do transmit pain. Slower conduction times could potentially result in a prolonged pain experience in the premature infant.[14]

The fetus/neonate has a higher concentration of peripheral receptor cells than the adult.[16]

The neonate's central nervous system pain pathways and endocrine response systems are sufficiently anatomically and functionally developed to allow transmission of painful stimuli.[14]

Fetal/neonatal sensory nerve cells are more excitable than adult sensory nerve cells, resulting in a greater reflex response in newborns.[17]

Transmission of sensory input along the spinal cord is less specific in the fetus and neonate than in the adult, creating the potential for newborns to sense normally pleasurable sensory input (for example, touch) as painful or to sense normally noxious but nonpainful stimuli (lights, noise) as pain.[16]

Descending nerve tracts responsible for modulation or dampening of pain signals are immature and ineffective in the neonate, resulting in prolongation of pain.[16]

These differences raise the concern that newborns, and especially premature newborns, may perceive pain more intensely than adults and for a more prolonged period of time.

Researchers have demonstrated that preterm infants have a lower pain threshold than term infants. These studies support the contentions of neonatal experts that preterm infants experience a more intense transmission of pain signals and that these signals become more intensified with repeated painful experiences (hyperalgesia).[6,18]

Assessment of Neonatal Pain

In the past decade, much attention has been paid to assessment of pain in the neonate. Pain behaviors are easily identifiable, particularly in term and near-term infants. However, the most acutely ill or tiniest preterm infants may become lethargic and nonresponsive to painful stimuli. In 2001, the International Association for the Study of Pain acknowledged the inability of pediatric and neonatal patients to clearly communicate pain and revised its classic definition of pain to state that "the inability to communicate in no way negates the possibility that an individual is experiencing pain" (p. 2).[19]

The Joint Commission on the Accreditation of Healthcare Organizations requires pain assessment at regular intervals and in response to known painful interventions and pain relief measures, regardless of the time interval.[20] Professional organizations and consensus groups have also issued statements on management and treatment of neonatal pain.[2,21] Most NICUs have been successful in implementing the assessment of pain as the fifth vital sign.

Numerous neonate-specific pain scales have been developed and validated through appropriate research methodologies. However, pain assessment is only one part of a successful pain management program. A 2002 educational module published by the Association of Women's Health, Obstetric and Neonatal Nurses highlights several important points regarding the use of pain assessment tools, including the following:

Pain measurement is only one tool in a pain management program.

Lack of response to a painful intervention does not mean the infant is not experiencing pain.

Selected pain tools should be multidimensional (measure physiologic and behavioral elements) and should have established reliability and validity.

No pain assessment tool is perfectly suited to all circumstances.[22]

Merely assessing pain is of limited value; the value of assessment lies in the ability to then apply evidence-based intervention to decrease or eliminate the pain.

Research shows that assessment of pain is not consistent. A 2006 survey of 105 Australian neonatal units reported that only 6 percent of the units routinely used pain assessment tools, and 15 percent of the units identified that they had a pain management program in place.[23] Reporting on a study conducted in 12 U.S. NICUs, Dunbar and colleagues noted that pain assessments were done in less than 20 percent of painful interventions.[24] These studies suggest that although pain assessments might be completed as a routine part of vital sign assessments, pain inflicted during procedures and follow up of pain levels after intervention are not regularly assessed. Despite an increased understanding of the physiology of neonatal pain and the development and implementation of numerous pain assessment tools specific to the neonate, treatment of neonatal pain remains inconsistent.

Complications of Untreated Pain

Multiple studies report that untreated, frequent, and/or chronic pain in the neonate may be related to a variety of adverse outcomes in later life.[1,6,10] Frequent exposure of the neonate to pain, especially the preterm neonate, occurs at a time of neurologic development when it is "developmentally unexpected."[9] Puchalski and Hummel discussed the concept of "neural plasticity," which is defined as the potential for change in the normal structural development or formation of the neonatal brain as the result of exposure to unexpected stimuli; such stimuli include exposure to pain and stress.[25] The neonatal brain is in a period of rapid physical growth and development; the more premature the infant, the higher the risk that external stimuli can cause changes in that normal development.

Although it is difficult to extract specific mechanisms for adverse outcomes from the many other risk factors the NICU patient experiences, more and more researchers are focusing on links between untreated neonatal pain and both short- and long-term adverse outcomes. Short-term effects of pain for the preterm infant are related to the infant's clinical status and overall outcome.[26] The immediate pain response results in increased heart and respiratory rates, increased blood pressure, decreased oxygen saturation, and changes in cerebral blood flow.[6,10] Additionally, the infant secretes increased amounts of adrenal stress hormones. This increase in physiologic parameters can result in the expenditure of energy resources that are needed for healing and growth.[10]

Research has shown that continued secretion of stress hormones in response to untreated pain can result in increased infections, poor healing, prolonged hospitalization, and increased mortality.[27] Anand and colleagues demonstrated a relationship between repetitive and long-term pain in the neonatal period and changes in pain sensitivity and pain processing in later life.[1] McClain and Kain reported that exposure to poorly controlled pain may result in increased pain sensitivity (hyperalgesia) and potentially to chronic pain conditions in later life.[28] Other long-term adverse outcomes that have been suggested in the literature include anxiety disorders; hyperactivity/attention deficit disorders; impaired social skills; self-destructive behaviors; and other neurodevelopmental, cognitive, and behavioral disorders.[1,6,10]

Toward a "Minimal-pain" NICU: Creating an Expectation of Pain Prevention

There has been a dramatic increase in research and review articles directed at neonatal pain over the past decade, but most of these discussions focus on physiology, assessment, and treatment of pain. Treatment of pain in the neonate presents its own challenges and concerns. Analgesics may have short-term adverse effects such as hypotension or respiratory depression. Long-term effects of analgesic use in the neonate, and especially in the preterm infant, are not well known. Additionally, there remains the issue of how to wean infants effectively and safely from long-term opiate use.

These issues should not prevent treatment of pain, but they do highlight the importance of preventing pain whenever possible. Strategies to minimize the number of painful procedures are an essential piece—indeed, the most essential piece—of a comprehensive pain management program in the NICU.

Authors have addressed avoiding or eliminating unnecessary laboratory tests and other interventions. Dunbar and associates discussed reducing the number of painful procedures as one "potentially better practice" intervention in the NICU.[24] Urso emphasized prevention of pain whenever possible and the use of all available means of nonpharmocologic and pharmacologic interventions when prevention is not possible.[13] Reducing the frequency of neonatal pain experiences remains of paramount importance. While acknowledging their inability to completely eliminate painful experiences in the NICU, health care practitioners need to recognize that prevention is the most effective way to manage pain.

Decreasing Painful Experiences in Neonatal Care

The most difficult step in decreasing painful interventions may well be changing the NICU culture as it relates to pain prevention. Despite health care professionals' increased awareness of the importance of pain prevention, NICU patients continue to be exposed to numerous routine painful procedures every -[2,24] Establishing pain prevention as an expectation requires a multidisciplinary team approach, as well as extensive education for all groups of health care providers.[29] Preventing and/or reducing the incidence of painful interventions in the NICU is an interdisciplinary process that requires input and cooperation from every health care provider who directly or indirectly cares for the neonate, including medical directors and medical resident supervisors; nursing administrators; and educators and clinical specialists responsible for policies, education, and process improvement/patient outcome programs.

Eliminating Unnecessary Procedures

The literature contains many discussions of eliminating unnecessary procedures and grouping procedures whenever possible.[1,2,9,10] For example, infants newly admitted to the NICU may require blood to be drawn to monitor glucose levels every four hours; infants who have been stable on a given glucose infusion for two to three days may not need them. Too often NICU policies fail to acknowledge differences between patients; these same detailed policies also often fail to allow for independent nursing judgment in assessing patient needs. Chronic feeding-growing infants who are stable rarely require weekly complete blood counts and/or hematocrits or routine metabolic panels. It is important to identify when an order for a laboratory test is merely routine or customary rather than necessary. This distinction reinforces the need for an NICU culture in which the expectation of pain prevention is key.

Other methods of reducing the frequency of pain events in the NICU are less obvious—and in some cases are controversial. These include drawing blood from a vein rather than doing a heelstick, reviewing the risk/benefit assessment of central line placement, assessing procedures (both medical and nursing) performed by novice versus skilled personnel, and assessing the number of interventions (particularly assessments) performed by novice practitioners for "learning" purposes.

Research has demonstrated that drawing venous specimens may be less painful than heel lancing in term infants. In less acutely ill infants, where preservation of peripheral veins may not be as critical, drawing blood for "sepsis workup" laboratory tests and for glucose blood levels from a vein can result in fewer and/or less painful punctures than the customary heel lances.[30,31] In more acutely ill infants, short-term use of umbilical lines and early placement of peripherally inserted central catheter (PICC) lines, may allow nurses to feel more comfortable drawing venous blood for laboratory tests. Early placement of an umbilical line can reduce the number of venous and peripheral blood samples needed. Early placement of PICC lines can also reduce the number of times intravenous (IV) access is needed over the course of a neonate's hospitalization.[2] Central lines have associated risk factors, the most common being infection, thrombus formation, and arterial spasm; these are clinically significant in less than 10 percent of patients.[32] Taking this into consideration may lead us to revisit the risk/benefit of central lines, factoring in the risks of frequent, painful needle insertions for peripheral IVs and heel lancing for glucose screens and lab draws.

Novice versus Experienced Providers and NICU Procedures

Although new nurses and resident physician staff need opportunities for learning, the primary focus should always be on the well-being of the neonate. This statement seems straightforward, but too often the number of procedure attempts or the number of physical exams an infant is subjected to is overlooked in the quest to provide educational experiences for practitioners. The number of disciplines seeking teaching experiences in the NICU (e.g., medical residents, staff nurses, nurse practitioner staff, respiratory therapists) may exacerbate an already difficult situation.

The question has been raised in the literature as to the appropriateness of allowing less-experienced health care providers to perform procedures on neonates, especially unstable ones. For example, when an extremely preterm infant who will most likely need immediate intubation and line placement is being delivered, who should perform the necessary procedures: a skilled performer with known ability to complete them quickly and most likely on the first try or the novice who "needs the experience"? Is this the appropriate teaching experience for the new respiratory therapist, nurse, or first-year resident? Too often the person who "needs" the experience gets the first try, and the experienced care provider intervenes only after the novice is unsuccessful. Simons and colleagues documented that a substantial number of painful interventions were the result of failed attempts at procedures. The researchers reported failure rates of 45.6 percent for central venous catheters, 37.5 percent for peripheral arterial catheters, and 34.6 percent for umbilical catheter placement. They did not report on who performed these failed procedures (i.e., novice or experienced personnel).[8] There is no question that new staff need opportunities to learn, which means that at some point they have to do the first procedure (IVstart, intubation, line placement) on a patient. What NICU pain-prevention teams may need to reassess is how and when those "firsts" take place. A newborn delivered at 23 weeks or a "crashing" infant with sepsis is probably not the best choice for the novice learner—nor is the novice the best choice for the patient. The acuity of the patient and the fast-paced, high-anxiety atmosphere accompanying it are not conducive to learning—or to success at an unfamiliar procedure.

NICU Admission

Admission to the NICU involves handling of the infant by many caregivers, physical examinations by at least the nurse and one physician, bright lights, noise, injections of vitamin K, eye prophylaxis, heel lances for blood collections for laboratory assessment, and one or more attempts to place a peripheral IV. A preterm infant has additional stressors, including intubation, surfactant administration, and line placements. Developmental care may not start until after the infant has been subjected to the very nondevelopmentally appropriate admission process.

Summary

The knowledge base regarding neonatal pain, stress, and the potential adverse outcomes of repeated pain exposure has evolved significantly over the past decade. Despite increased knowledge about the physiology of neonatal pain, the development of valid neonatal pain assessment tools, and statements from professional organizations regarding the need to treat pain in the newborn, there is still considerable confusion and many differences in practice among health care providers in NICUs.

The current challenge is to move beyond intellectual knowledge about pain issues to clinical application of proven methods to reduce painful stimuli in the NICU. Preventing pain should be as high a priority as preventing ventilator-induced lung damage or hypoxia-related central nervous system damage. Effective pain management programs depend on the knowledge, critical thinking skills, and advocacy skills of every neonatal health care provider. Attaining a "minimal-pain" NICU environment is the responsibility of every health care provider as well.

Sidebar

Scenario: The patient is a near-term infant with bilateral chest tubes who requires neither oxygen or ventilator support. The NICU care team is gathered at the bedside for morning rounds. Near the end of rounds, one team member asks, "What are we doing for pain control?" The nurse indicates there is a standing order for "as needed" fentanyl, which is controlling pain well. Another team member questions the need for opiate pain treatment, citing the risk of respiratory depression with the resultant need for ventilator support. The fentanyl order is discontinued, and no other pain medications are ordered.

The following morning, the patient chart is reviewed. Despite elevated pain assessment scores through the night, the infant received no further pain medications. The night nurse had requested an order for pain medications; the request was denied because of "risk of respiratory depression." The infant was treated with nonpharmacologic pain interventions, which did not bring the pain scores into acceptable ranges.

Список авторов см. журнал

Edited by Berryl

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Medscape Medical News

American Academy of Pediatrics Reviews Use of Probiotics, Prebiotics

Laurie Barclay, MD

December 2, 2010 — The currently known health benefits of probiotics and prebiotics, including those added to infant formula and other food products for children, are reviewed in an American Academy of Pediatrics (AAP) report published online November 29 in Pediatrics.

"Efforts to optimize the intestinal microbial milieu have increased the interest in adding probiotics and prebiotics to nutritional products. As with antibiotics, the use and efficacy of probiotics and prebiotics should be supported by evidenced-based medicine," write Frank R. Greer, MD, FAAP, and Dan W. Thomas, MD, FAAP, and the Committee on Nutrition; Section on Gastroenterology, Hepatology, and Nutrition. "The purpose of this clinical report is to review the medical uses of probiotics and prebiotics and to summarize what is currently known about their health benefits as dietary supplements added to food products marketed to children, including infant formula. The guidance in this report will help pediatric health care providers to make appropriate decisions regarding the usefulness and benefit of probiotics and prebiotics for their patients."

Probiotics are supplements or foods containing viable microorganisms capable of changing host microflora. Randomized clinical trials (RCTs) have shown probiotics to be modestly effective in treating acute viral gastroenteritis in healthy children. For otherwise healthy children and infants with diarrhea from acute viral gastroenteritis, giving probiotics early in the course may reduce the duration of diarrhea by 1 -

Despite the lack of evidence for the efficacy of probiotics in treating antibiotic-associated diarrhea in otherwise healthy children, RCTs have shown that they are modestly effective for prevention.

Although more studies are needed, some evidence supports probiotic use to prevent necrotizing enterocolitis in very-low-birth-weight infants (birth weight between 1000 and 1500 g).

Before probiotics can be recommended for treatment of irritable bowel syndrome, Crohn's disease, colic, and constipation, or for prevention of common infections and allergy in children, additional studies are needed.

However, preliminary results were encouraging in RCTs in which probiotics were used to treat childhood Helicobacter pylori gastritis, irritable bowel syndrome, chronic ulcerative colitis, and infantile colic, or to prevent childhood atopy. Evidence to date has not shown a benefit of probiotics in treating or preventing human cancers or in treating pediatric Crohn's disease.

Routine use of probiotics or prebiotics added to infant formula and other foods intended for consumption by children is not supported by currently available evidence of clinical efficacy, but these formulas do not appear to harm healthy infants and children. However, probiotics should not be administered to children with chronic or serious diseases, including children who are immunocompromised, chronically debilitated, or who have indwelling medical devices.

Prebiotics are supplements or foods containing a nondigestible food ingredient that selectively promotes growth and/or activity of indigenous probiotic bacteria. Prebiotics found in human milk may help reduce common infections and atopic eczema in healthy infants, but more evidence is needed before adding prebiotics to infant formula can be recommended.

"Important questions remain in establishing the clinical applications for probiotics, including the optimal duration of probiotic administration as well as preferred microbial dose and species," the report authors conclude. "The long-term impact on the gut microflora in children is unknown. It also remains to be established whether there is significant biological benefit in the administration of probiotics during pregnancy and lactation, with direct comparison to potential biological benefit derived from probiotic-containing infant formulas."

Pediatrics. Published online November 29, 2010.

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Care of the Child with the Desire to Change Genders – Part III: Male-to-females Transition

Bethany Gibson, BSN; Anita J. Catlin, DNSc, FNP, FAAN

Posted: 11/29/2010; Pediatr Nurs. 2010;36(5):268-272

Abstract

In Part I of this three-part article, the psychological and medical care of the child wishing to change gender was described. In Part II, preparation for surgery for young adults who were genetically female and undergo surgery to transition to male identity was presented. This third part presents the surgical treatments for gender reassignment procedures for a genetic male wishing to reassign as female. Discussion is included about how parents are responding to these wishes from their prepubescent and teenage children.

Introduction

In the previous two parts of this series (Gibson, 2010; Gibson & Catlin, 2010), the placing on hold of puberty for youngsters who believe they are in the wrong body was discussed. By administering gonadotropin-releasing hormone agonist, a child can have time to think this through and be certain he does not wish to live as a man. The treatment is fully reversible; thus, if the preteen or teen then "outgrows" this desire, he may revert back to the externally male sexual development. Dr. S. Giordano, from the Manchester Institute of Science, Ethics and Innovation, states it is "not only not unethical to give these medications, [and] if it is likely to improve the child's quality of life and even save his or her life, then it is indeed unethical to defer treatment" (Giordano, 2008, p. 580).

When a child takes these medications, dresses as the selected gender, and lives this life, school nurses, nurses in pediatricians offices, and hospital nurses will need knowledge to be supportive of this process (Vanderburgh, 2009). Additionally, teachers and other children in the schools may need guidance on how to be compassionate, since a boy wearing girl's attire may create anxiety within the school system, more so than a girl who dresses masculinely (Benestad, 2009).

Parents' Responses

Some parents struggle with their own feelings related to their child's transgender identity and should be placed in touch with an appropriate support group. Parents may benefit from hearing the experiences of other parents with transgender children and receiving support from those who have faced similar challenges. This provides a sense of normalization of their experience, so they can be a better resource for their children and more effectively engage in honest and open dialogue (Morris, 2006).

Some studies report parents' experiences with sons who wish to be and who become their daughters (Gold, 2009; Hegedus, 2009). The main results of Gold's (2009) study reported although it may be extremely difficult to come to terms with the transgenderism of one's child, it is possible; parents reported a resiliency beyond what they had imagined. In Hegedus's (2009) study, all parents worried about being gossiped about and rejected by their family and community. Parents reported having never heard of gender transition and had fear of the unknown. Despite these fears, 11 out of 12 parents accepted their child's transition. Parents felt that success would entail holding onto the essence of the love they had for their children and the moral worth of their children.

Mallon and DeCrescenzo (2006) provide an overall review of the developmental needs of transgender children and adolescents, and offer many excellent suggestions for responding to the child in a healthy manner. One such suggestion is that parents develop a "script" they can use to answer questions from neighbors and friends. Mallon and DeCrescenzo (2006) also discuss the possibilities of harm that can come from others to a transgender child. Since many transgender children who are not met with empathy and compassion become runaways, or end up in foster care or the judicial system, much education needs to be done in these arenas as well (Marksamer, 2008). The gender identity influences not only the reasons why children such as these are arrested, but also, their needs once they enter the system (Marksamer, 2008). Safety in placement is essential.

Medical, Surgical, and Nursing Care

When a genetically born male teen or young adult has gone through the processes discussed in Part I of this series, and the decision is clearly made to transition surgically, the procedures may include some or all of the following: breast surgery, removal of male external organs, creation of female external genitalia, reduction of neck cartilage, and other procedures that minimize male secondary sexual characteristics.

Breast Surgery

Augmentation mammaplasty, also known as breast enlargement, is a surgical option for male-to-female (MTF) patients who are not satisfied with the maximum breast size achieved with estrogen treatment after 18 to 24 months (Bowman & Goldberg, 2006; Brownstein, 2008). This is an outpatient procedure, usually performed under general anesthesia, involving implantation of saline inflated or silicone gel breast prostheses (Brownstein, 2008). The most common method uses saline-filled implants placed below the pectoral muscle through an inframammary or periareolar incision (Bowman & Goldberg, 2006). There are different sizes and shapes of implants available, and patients must express their wishes and expectations with their surgeon so consensus can be reached on what is possible.

Dr. Brownstein's Web site (Brownstein, 2008) discusses the pros and cons of three incision sites for inserting the implants. The periareolar incision hides scarring along the skin areola border, but it is only possible if the areolae are large enough to insert the prostheses. An inframammary incision provides easy access to the tissue for creating a pocket to place and inflate the implant, but the incision will be more noticeable because it is in regular skin. The third option is an axillary incision, which removes the scar from the breast area, but it also makes visualization of the surgical area and the control of bleeding more difficult (Brownstein, 2008). Because breast tissue is frequently underdeveloped, tight, and less fatty in MTF patients compared to non-transgender women, tissue expansion prior to placement of the implant may be employed to promote better outcomes (Bowman & Goldberg, 2006). It is important that patients be informed that implants cannot perfectly resemble natural adult breasts; the "nippleareola complex frequently appears under-developed and lateralized even after years of hormone treatment," and age-related natural breast features, such as ptosis and cleavage, are very challenging to create (Bowman & Goldberg, 2006, p. 139).

Post-operatively, the patient will need to leave dressings intact for three days, after which, dressings may be removed. However, the steri-strips should remain in position until they fall off, usually after 7 to 10 days. Showering is permitted, but the steri-strips should not be soaked and should be patted dry afterwards. The patient is instructed to wear an underwire bra or sports bra for compression and support of the breasts (Bowman & Goldberg, 2006; Brownstein, 2008). Erythema around the incision is normal but should not extend beyond 1 to 2 cm from the incision. Swelling is also normal and only cause for concern if it is an unusually large, one-sided mass (Bowman & Goldberg, 2006). Additionally, the suture knots may be visible or felt at the end of the incision and are no cause for concern. Suture knots may work their way to the surface of the skin, usually after three weeks, and may be clipped free. Patients are often comfortable one to two days following the procedure, but it is normal to experience shooting pains, burning sensations, and general discomfort during the healing process for which analgesics are prescribed. These feelings will eventually subside, and patients often return to normal routines within one to two weeks, except for avoidance of strenuous activity for three to four weeks. Patients are instructed to perform implant displacement massage beginning three to five days post-procedure (Bowman & Goldberg, 2006).

Risks are associated with breast augmentation as with any surgical procedure. Wound infection and post-operative bleeding/hematoma are common to all surgeries. Complications specific to breast augmentation include "capsular contracture-thickening and contracture of scar tissue that normally forms around breast implant; asymmetry of breast size, shape or position; asymmetry of nippleareola complex; implant failure, extrusion, or infection" (Bowman & Goldberg, 2006, p. 145). Although there may be permanent loss of sensation in the nipple-areola complex, sensation loss is usually temporary and resolves after several weeks without intervention. Excessive scarring as well as skin wrinkling over the implant is possible, and techniques to minimize scarring, such as massage and sun avoidance, should be discussed with the patient (Bowman & Goldberg, 2006). The patient should be prepared for the possibility of future revisions to address potential complications. According to Bowman and Goldberg (2006), the most reasons for revision are implant replacement, patient desire to change size or type of implants, repositioning of implants, and scar revisions.

MTF Genital Reconstruction Surgical Procedures

The core surgical interventions for MTF transsexuals are penectomy, orchidectomy, vaginoplasty, labiaplasty, and clitoroplasty. Additional surgical procedures undertaken to assist in feminization may include lipoplasty, thyroid chondroplasty or other facial bone reduction, blepharoplasty or other face-lift procedures, and electrolysis (Bowman & Goldberg, 2006; Sutcliffe et al., 2007). As noted in the female-to-male genital surgical discussion (Gibson, 2010), medical preparations should be made prior to surgical intervention. Cross-sex hormones must be discontinued two to four weeks prior to surgeries, drugs inhibiting blood clotting must be discontinued 7 to 10 days prior to surgery, and "bowel prep" and preventative antibiotics will be administered upon admission the night before vaginoplasty, along with nothing by mouth after midnight, which is common to most surgical procedures (Bowman & Goldberg, 2006). As previously noted, patients are recommended to stop smoking to promote skin quality, wound healing, and vascularity during the post-operative recovery (Bowman & Goldberg, 2006). Genital electrolysis referrals will be made to remove hair from the scrotum and base of the penis to prevent intravaginal hair growth in the new vagina because skin grafts are taken from the scrotal region for vaginoplasty (Bowman & Goldberg, 2006).

Orchidectomy. Orchidectomy (also called gonadectomy and orchiectomy) is the removal of the testes and is sometimes performed as a single procedure, without vaginoplasty, to reduce the necessary dosage of estrogen required to oppose endogenous testosterone production. This also reduces the risks and side effects of estrogen treatment (Bowman & Goldberg, 2006). The scrotal skin is preserved as much as possible if there is a desire for vaginoplasty/labiaplasty in the future, but there is risk of damaging the skin or shrinkage following the procedure. For this reason, some surgeons recommend performing the orchidectomy at the same time as the vaginoplasty (Bowman & Goldberg, 2006). Combining procedures also minimizes the risks associated with general anesthesia.

Penectomy. Occasionally, MTF patients who do not wish to have vaginal penetration in the future as adults seek penectomy, the removal of the penis, without vaginoplasty. Creation of a new urethral opening will allow micturation while sitting, and a small vaginal "dimple" is created, which will not require the dilation as with vaginoplasty procedures (Bowman & Goldberg, 2006). Patients who intend to have a vaginoplasty should not have the penectomy as a separate procedure because the penile tissue is commonly used in the construction of the neovagina (Bowman & Goldberg, 2006; Sutcliffe et al., 2007).

Vaginoplasty. Vaginoplasty is the creation of a vagina and usually includes several procedures undertaken to convert the pre-existing male genitals into female genitalia (Bowman & Goldberg, 2006; Spehr, 2007; Sutcliffe et al., 2007). Generally, a plastic surgeon will perform all procedures in one operative session, including bilateral orchidectomy, partial penectomy (penile dissection), vaginoplasty, labiaplasty, and clitoroplasty. However, it should be noted that some surgeons prefer a two-stage operation, performing the labiaplasty and clitoroplasty after the initial vaginoplasty has fully healed (Bowman & Goldberg, 2006; Sutcliffe et al., 2007). Bowman and Goldberg's (2006) review of the literature outlines the primary goals of vaginoplasty as follows: "a) creation of a sensate and aesthetically acceptable vulva-including clitoris, labia minora and majora, and vaginal introitus; b) shortening of the urethra, with creation of a urethral opening that allows a downward urinary stream; c) creation of a stable and sensate neovagina with adequate dimensions for penetrative sexual intercourse, ideally lined with moist, elastic, hairless epithelium; d) elimination of erectile tissue to avoid narrowing of the introitus and protrusion of the urethral meatus/clitoris during sexual arousal; and e) preservation of orgasmic capability" (Bowman & Goldberg, 2006, p. 140).

The new vagina, or neovagina, is most frequently made by inversion of the penis (Bowman & Goldberg, 2006; Sutcliffe et al., 2007). Most of the skin from the shaft of the penis is inverted to line the walls of the neovagina. Some patients have insufficient penile tissue to achieve this and require additional skin grafts from the abdomen or scrotum (Bowman & Goldberg, 2006); the buttocks-hip areas are sometimes used as well (Sutcliffe et al., 2007). Another option, although a more complicated technique, is to use a segment of the rectosigmoid colon if the others fail (Bowman & Goldberg, 2006; Sutcliffe et al., 2007). The female urethra is created from a preserved horizontal segment of the male urethra, and the neovagina is positioned posterior to the prostate, which is left intact during this procedure (Bowman & Goldberg, 2006). Sutcliffe et al. (2007) examined 32 studies and found that positive results were achieved, both aesthetically and functionally, in many studies. One study cited in that review reported 90% of patients were satisfied with both aesthetic outcome result and orgasmic capability as adults, although only 58% acknowledged sexual intercourse at that time.

Risks specific to penile inversion vaginoplasty include "infection, post-operative hematoma, recto-vaginal fistula, partial or complete flap necrosis, vaginal or urethral stricture or stenosis, prolapse of neovagina and unsatisfactory size/shape of neovagina, clitoris, or labia" (Bowman & Goldberg, 2006, p. 145). Patients who did not do electrolysis prior to surgery may experience hair growth in the neovagina. Hypertrophic scarring and impaired erotic sensation in adulthood are potential side effects. Several studies reported orgasmic capability ranging from 63% to 92% following vaginoplasty (Bowman & Goldberg, 2006). Researchers from one facility reported maintenance of sexual sensation in 98.6% and achievement of orgasm (at least occasionally) in 94% of 71 MTF transsexuals after an average of 4.2 years following vaginoplasty. Yet another study reported decreased orgasmic ability, but 75% more sex, resulting in high overall sexual satisfaction (Bowman & Goldberg, 2006). It should be noted that this information is based on studies of adult MTF transsexuals, not adolescents who are having sexual intercourse. However, the information may be of interest to older teenagers and their parents in making decisions that will significantly impact the young person's life later.

Hospital stays for vaginoplasty average six to eight days, most of that time restricted to bed rest. Patient-controlled analgesics, antibiotics, and anticoagulants are often prescribed until mobility is achieved (Bowman & Goldberg, 2006). A Foley catheter is inserted prior to surgery and left in place until approximately five days following vaginoplasty. Additionally, a prosthesis is inserted into the neovagina during surgery to maintain side-to-side junction of the penile skin flap and any other skin grafts used to create the vaginal walls while also maintaining maximum vaginal dimensions. It is also removed approximately five days following surgery to teach the patient care of the neovagina (Bowman & Goldberg, 2006). The prosthesis will be maintained in the vagina, except for removal to perform daily douching initially, and then removed for progressively longer periods over the next eight weeks post-operatively. After eight weeks, the prosthesis is inserted once daily to maintain dilation and prevent stricture. A vibrator may also be used for this purpose, and Madecasol Cr?me 1% applied to the vibrator and massaged into the vaginal wall has been found to prevent scarring and shrinkage while keeping it smooth (Spehr, 2007).

Patient comfort is often greatly increased by the second week post-op. The patient should be monitored for partial or complete flap necrosis, which presents early in the postoperative course as non-blanching erythema or mottling of the skin that becomes progressively darker. If this is suspected, the surgeon should be notified immediately (Bowman & Goldberg, 2006). If urethral stricture or stenosis occurs following the removal of the Foley catheter, it should be reinserted for an additional two to three days until urethral swelling subsides and the patient can void without problem. Urethral stricture or stenosis presents as dysuria, difficulty voiding, diminished stream, and/or increased time and effort to urinate. Patients should be educated regarding these symptoms and instructed to report them to the surgeon if they occur following discharge, since surgical revision may be required (Bowman & Goldberg, 2006). Urethral swelling or irregularities resulting in urine spray generally resolve several weeks following surgery but should be reported if persistent.

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The patient will need to return periodically for follow up to monitor viability and patency of the neovagina and neoclitoris, quality of wound healing, and bowel and bladder function (Bowman & Goldberg, 2006). Due to the intact prostate gland, patients must be educated about the ongoing risk for prostate cancer and the need for screening. Spehr (2007) reports an occasional need for future correction of labia majora, shortening of the perineal space, and reforming of the mons pubis.

Labiaplasty and clitoroplasty. Labiaplasty and clitoroplasty are often performed in the same surgical event as the vaginoplasty, but some surgeons perform them during a second procedure following the healing of the vaginoplasty. The labia are constructed using existing male genital skin segments. The labia minora are fashioned from the penile skin, or prepuce, while the labia majora are created using scrotal skin (Bowman & Goldberg, 2006). There are multiple techniques noted in the literature for creation of the neoclitoris. Most use a segment of the glans penis that remains attached to its dorsal nerve and blood vessels, known as the sensate pedicled clitoroplasty technique (Bowman & Goldberg, 2006; Spehr, 2007; Sutcliffe et al., 2007). Sutcliffe et al. (2007) reported positive results overall in a meta-review, with satisfactory aesthetic and functional outcomes in addition to few complications. Studies using the dorsal portion of the glans penis, still attached to the dorsal neurovascular bundle, resulted in lasting neoclitorides and most of those achieving sexual satisfaction as adults. High risk is associated to techniques in which reattachment of the glans onto the dorsal neurovascular bundle was attempted (Sutcliffe et al., 2007).

Additional Feminizing Surgical Procedures

Blepharoplasty is the surgical reshaping of the eyelids, and rhinoplasty is surgical reshaping of the nose (Myers, 2006). Bowman and Goldberg (2006) discuss post-operative care for several plastic surgery procedures performed to assist the MTF transsexual in achieving feminization, including forehead surgery to advance the scalp, cheek augmentation, rhinoplasty, chin and jaw reduction, and lip augmentation. Swelling and often bruising are common side effects but usually resolve within 10 to 14 days unless significant bone work is done (jaw and chin reduction), which may take weeks to months to resolve.

Cultural Competence

Nurses are responsible for the assessment and implementation of interventions, and overall care of patients. They are ethically bound to do so with compassion and integrity while remaining non-judgmental. Experiences of ridicule, rejection, and lack of acceptance often prevent transgender patients from seeking medical care (Sobralske, 2005). Some tips for helping transgender patients feel comfortable and encourage a trusting relationship were discussed at the Northern California Transgender Health and Wellness Conference. These include addressing patients by their preferred name and pronoun, avoiding questions about their genitals, minimizing intimate examinations unless necessary to provision of care, and reminding other staff members of these basic courtesies and responsibility to confidentiality laws (B.G. Gibson, October 11, 2008).

Conclusion

Ethicist Eva F. Kittay provides an admirable summary for this series. In the text, Surgically Shaping Children, Technology, Ethics, and the Pursuit of Normality, she writes: "When we love and accept our children who deviate from standard norms, we exhibit that they are, in fact, valuable, valued, and desirable" (Kittay, 2006, p. 107). This series serves to educate pediatric nurses to be there for children and their families while modeling the empathy and support every child needs and deserves.

Sidebar

This is Part III of a three-part series on children and young adults who desire to live as a gender different from which they were born. The series depicts the psychosocial, medical, and surgical components of transitioning from one gender to another. The medical and psychosocial issues of transgender change are complex, and ethical questions may be raised by those who would challenge these choices. Pediatric nurses will be best able to care for these patients with awareness of the multiple dimensions of these procedures and the ramifications of caring for them and their families.

Список литературы в журнале.

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Oral Ibuprofen Better Than IV for Closure of Patent Ductus Arteriosus

By Robert Saunders

NEW YORK (Reuters Health) Dec 02 - Very low birth weight (VLBW) preemies with patent ductus arteriosus (PDA) have better closure rates with ibuprofen given enterally rather than intravenously, Turkish researchers report.

Moreover, "the oral form was as safe as the intravenous form," according to Dr. Omer Erdeve and colleagues with the Zekai Tahir Burak Maternity Teaching Hospital in Ankara.

As they point out in the Journal of Pediatrics online November 22nd, IV ibuprofen is not available in most countries - and when it is, it's more expensive than the oral form.

"If oral ibuprofen were as efficient as intravenous ibuprofen with no greater adverse effects," they note, "its simple administration and lower cost would be important advantages." But in fact, their randomized trial showed there were advantages beyond the cheaper cost.

The 102 VLBW infants in the study received either IV or enteral ibuprofen at an initial dose of 10 mg/kg, followed by 5 mg/kg at 24 and 48 hours.

After the first course of treatment, the PDA closed in 46 (84.6%) newborns receiving oral ibuprofen and in 31 (62%) receiving IV ibuprofen (p=0.011), according to the report.

"Oral ibuprofen was more effective than intravenous ibuprofen for ductal closure in VLBW infants," Dr. Erdeve commented via email. "Published data have shown that absorption is slower with oral ibuprofen than with intravenous ibuprofen, and the longer half-life probably prolongs the time of contact with the ductus, leading to a higher response rate."

However, with a second course of treatment as needed, cumulative closure rates were high in both groups and only one patient in each group required surgical ligation.

Because preterm newborn infants have limited drug-metabolizing enzyme activity, they're at particular risk for renal side effects. The authors monitored kidney function with measurements of serum cystatin-C level, which they say "reflects the glomerular filtration rate (GFR) better than creatinine."

Cystatin-C levels increased significantly in the oral group after treatment, but not in the IV group. Even so, there was no significant difference in post-treatment cystatin-C levels between the two groups.

"Our data suggested that oral and intravenous ibuprofen did not have any important renal side effects, as determined using the sensitive marker cys-C," Dr. Erdeve stated. "Although it was not clinically important, the increase in the cys-C level with the oral form suggests that patients with borderline renal function should be evaluated and followed closely."

In summarizing, the authors conclude that while oral ibuprofen was more effective for ductal closure with one course of treatment, "the oral form was as safe as the intravenous form in terms of renal tolerance, hyperbilirubinemia, gastrointestinal perforation or bleeding, (necrotizing enterocolitis), intraventricular hemorrhage, (chronic lung disease), and pulmonary hypertension."

J Pediatr. Posted online November 22, 2010

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Intervention, Screening Tool Target Obesity in Children

Laurie Barclay, MD

December 6, 2010 — A study reviews interventions to reduce obesity in children younger than 2 years of age, and another study evaluates risky weight gain in infants as a screening tool for childhood obesity. Both reports are published in the December issue of the Archives of Pediatric and Adolescent Medicine.

Review of Interventions to Reduce Obesity in Very Young Children

"Despite the increasing need for obesity prevention efforts beginning in early childhood, few studies have been performed with a goal of intervening among very young children," write Philip J. Ciampa, MD, MPH, from Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues. "With recent data providing evidence for the importance of the first 2 years of life in the development of obesity, the objective of the systematic review herein is to provide an updated and rigorous review of interventions aimed at improving weight, nutrition, or physical activity among children from birth to age 2 years."

To identify studies that assessed an intervention designed to prevent or reduce overweight or obesity in children younger than 2 years of age, the reviewers searched MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and bibliographies of retrieved articles. Changes in child weight status, dietary intake, physical activity, parental attitudes and knowledge about nutrition, and other measured outcomes were extracted from included studies. Standard criteria allowed evaluation of scientific quality using an assigned quality score ranging from 0.00 to 2.00, where a score of 0.00 to 0.99 is poor, 1.00 to 1.49 is fair, and 1.50 to 2.00 is good.

Of 1557 citations retrieved, 38 articles were reviewed; 12 articles representing 10 studies met selection criteria. Of these included studies, 8 used educational interventions to encourage healthy dietary behaviors, and the other 2 studies used both nutritional education and physical activity. Most of the interventions lasted less than 6 months. Two studies used home interventions, 3 were in a clinic setting, 4 were in a classroom, and 1 study used a combination of settings.

Although the interventions were modestly effective in improving dietary intake and parental attitudes and knowledge regarding nutrition, no intervention was effective in improving child weight status. Overall, the included studies were only of poor or fair quality, with a median quality score of 0.86 (range, 0.28 - 1.43).

"Few published studies attempted to intervene among children younger than 2 years to prevent or reduce obesity," the study authors write. "Limited evidence suggests that interventions may improve dietary intake and parental attitudes and knowledge about nutrition for children in this age group. For clinically important and sustainable effect, future research should focus on designing rigorous interventions that target young children and their families."

Limitations of this study include those inherent in the included studies; notably, few randomized controlled trials, small study populations, and heterogeneity of interventions and study settings.

Can Risky Infant Weight Gain Predict Childhood Overweight?

The second study was a retrospective cohort study performed at a pediatric office in central Pennsylvania by Darcy E. Gungor, MS, from the Pennsylvania State University in Hershey, and colleagues. The goals were to systematically analyze growth data from infant health maintenance records to identify "risky" weight gain associated with risk for childhood overweight and to obtain additional data from those records that could further refine risky infant weight gain as a screening tool.

Among 129 children aged 6 to 8 years and born in 2000 or later who attended health maintenance visits, receiver operating characteristic curve analysis was used to identify the optimal cutoff for risky infant weight gain, considering sensitivity and specificity for predicting childhood risk for overweight. The investigators also looked for differences in demographic factors, growth patterns, and parental feeding choices between at-risk infants who did and did not become overweight children. US Centers for Disease Control and Prevention growth charts in 2000 allowed determination of childhood overweight, defined as a sex- and age-specific body mass index at ages 6 to 8 years of at least the 85th percentile.

Prevalence of overweight in childhood was 24.8%. From birth to age 24 months, weight gain in at-risk infants was 8.15 kg or more. Although 31.4% of at-risk infants became overweight children, 68.6% were resilient to developing overweight, with certain factors associated with resiliency. Notably, these factors were higher educational attainment in the parents, less weight gain from ages 18 to 24 months and birth to 24 months, smaller area under the weight-gain curve from ages 0 to 24 months, exclusive breastfeeding for at least 6 months, and later introduction to solid foods.

"While most researchers would not recognize weight gain of 8.15 kg or more from ages 0 to 24 months as rapid growth, it was a fair screening tool for childhood overweight in our sample and had the potential to be refined using information about demographic characteristics, growth patterns, and parental feeding choices," the study authors write.

Study limitations include a small, homogeneous cohort; retrospective design; selection bias; and the inability to determine how well the addition of refining factors actually improves infant weight gain as a screening tool for pediatric overweight.

Obesity Prevention Strategies

In an accompanying editorial, Robert C. Whitaker, MD, MPH, from Temple University in Philadelphia, Pennsylvania, discusses obesity prevention strategies in infants.

"Parents should be empowered to make household policies and practices about the ways their infants eat, play, and sleep," Dr. Whitaker writes. "Doing so requires parents to make active decisions about the goals they have for their children's development. Pediatricians have the opportunity to engage in a dialogue with parents about those goals and how the actions parents take to achieve them might also help their children maintain a healthy weight."

Dr. Ciampa's study was supported in part by the Veterans Affairs Quality Scholars Fellowship Program, Robert Wood Johnson Generalist Physician Scholars Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and National Institute of Diabetes and Digestive and Kidney Diseases. Ms. Gungor's study was supported in part by the Huck Institutes of the Life Sciences and the Children, Youth, and Families Consortium at Pennsylvania State University. The editorial was supported by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2010;164:1098-1104, 1091-1097, 1167-1169.

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Vitamin A May Reduce Deaths From Measles and Diarrhea in Children

Laurie Barclay, MD

December 8, 2010 — Giving vitamin A capsules to children aged 6 months to 5 years may reduce deaths and incidence of measles and diarrhea, according to the results of a systematic review reported online December 8 in the Cochrane Database of Systematic Reviews.

"Giving vitamin A is associated with a reduction in the incidence of diarrhoea and measles, as well as the number of child deaths due to these diseases," said senior author Zulfiqar A. Bhutta, chairman of the Division of Women and Child Health at Aga Khan University in Karachi, Pakistan, in a news release. "However, the effects of supplementation on disease pathways are not well understood, so this could be a focus for further studies."

The reviewers note that vitamin A deficiency (VAD), which affects 190 million children younger than 5 years, causes a significant public health burden in low and middle income countries, with many adverse sequelae including death. The goal of this review was to determine the impact of vitamin A supplementation (VAS) in children aged 6 months to 5 years on prevention of death and morbidity.

To identify randomized controlled trials and clusters of these trials studying the effect of synthetic VAS in community-dwelling children aged 6 months to 5 years, the reviewers searched the Cochrane Central Register of Controlled Trials (CENTRAL 2010 Issue 2), MEDLINE (1950 to AprilWeek 2 2010), EMBASE (1980 to 2010 Week 16), Global Health (1973 to March 2010), Latin American and Caribbean Health Sciences (LILACS), the metaRegister of Controlled Trials, and the African Index Medicus (27 April 2010). Trials enrolling hospitalized children or those with disease or infection were excluded, as were trials looking at the effects of food fortification, dietary intake of vitamin A-rich foods, or beta-carotene supplementation.

Two review authors independently determined which studies would be included, with disagreements resolved by discussion. Data were double abstracted, and meta-analyses were carried out for all-cause and cause-specific mortality, disease, vision, adverse effects, and other outcomes.

Among 43 included trials enrolling a total of 215,633 children, a meta-analysis for all-cause mortality was performed in 17 trials enrolling a total of 194,795 children. At follow-up, there were a total of 3536 deaths in both groups. Compared with control groups, vitamin A-supplemented groups had a 24% observed reduction in the risk of all-cause mortality (relative risk [RR], 0.76; 95% confidence interval [CI], 0.69 - 0.83).

Among 7 trials reporting mortality from diarrhea, there was a 28% overall reduction for VAS (RR, 0.72; 95% CI, 0.57 - 0.91). Cause-specific mortality from measles, respiratory tract disease, and meningitis were not significantly affected by VAS. Although VAS was associated with a lower incidence of diarrhea (RR, 0.85; 95% CI, 0.82 - 0.87) and measles morbidity (RR, 0.50; 95% CI, 0.37 - 0.67), there was no significant impact on respiratory tract disease incidence or hospitalizations for diarrhea or pneumonia. Within the first 48 hours of VAS, the risk for vomiting was increased (RR, 2.75; 95% CI, 1.81 - 4.19).

"VAS is effective in reducing all-cause mortality by about 24% compared to no treatment," the review authors write. "In our opinion, given the evidence that VAS causes considerable reduction in child mortality, further placebo-controlled trials of VAS in children between 6 months and 5 years of age are not required. There is a need for further studies comparing different doses and delivery mechanisms (for example, fortification)."

Limitations of this review include some evidence of small-study bias for secondary outcomes and heterogeneity among included trials.

"Fortification, dietary diversification, food distribution programs and horticultural developments such as home gardening and bio-fortification may provide more permanent relief," Dr. Bhutta concluded. "For example, vitamin A content could be increased in staples such as rice or growers may aim to promote use of biofortified foods such as orange sweet potato."

This Cochrane review and its authors were supported by Aga Khan University, Karachi, Pakistan; the Centre for Evidence-Based Intervention, University of Oxford, United Kingdom; and/or the Department of Nutrition for Health and Development, World Health Organization, Switzerland. The review authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online December 8, 2010.

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From Journal of Pediatric Health Care 

Constipation in the Pediatric Patient: An Overview and Pharmacologic Considerations

Allison Beck Blackmer, PharmD, BCPS; Elizabeth Anne Farrington, PharmD, FCCP, FCCM, BCPS

Posted: 12/05/2010; J Pediatr Health Care. 2010;24(6):385-399.

Abstract

Objectives

1. Review the definitions and complications of chronic constipation in the pediatric population.

2. Examine the common causes of constipation and assess the evaluation and diagnosis of constipation in children.

3. Evaluate the current literature, clinical practice guidelines, and pharmacology that direct therapeutic decisions made in the management of constipation in children.

4. Describe the three-step process for managing constipation in the pediatric patient: complete bowel evacuation, maintenance of bowel evacuation, and weaning of medications.

5. Appraise novel and alternative pharmacologic agents in the management of constipation in children.

Introduction

A 10-year-old African American boy presents to your clinic with a history of constipation, encopresis, nausea, and vomiting. Last month he was hospitalized for a 7-day "GoLytely clean-out" for fecal impaction and was discharged with a prescription for MiraLax, 1 capful twice daily. Until 5 days ago, he had been having three to four large stools per week. He states that he involuntarily soils his pants two to three times per day, which requires him to wear special diapers. For the past 5 days he has been completely unable to defecate and has had severe abdominal pain, nausea, and vomiting. This morning his mother gave him eight capfuls of MiraLax in 32 oz of fluid twice, which caused him to have a "large blow out" that relieved his nausea and pain, although he is anxious about this happening again and expresses fear of another hospital admission.

He reports significant anxiety related to accidents and soiling. His accidents occur without the feeling of having a bowel movement coming, and he has had to wear diapers for the past 2 years, which he states is very embarrassing because he is a 4th grader. He reports having "hot flashes" related to nervousness about his constipation and encopresis and wishes he could wear normal underwear and "be normal." He has been the subject of bullying at school, and as a result he was home-schooled at various points throughout the past year. He states that in the past his family members punished him for soiling his clothing, so he attributes this to bad behavior, although he cannot control it. He wants to "be good" for his family and stop soiling his pants. Additionally, he wants to be able to return to school, but he is quite fearful about his social safety, which is a direct outcome of teasing and cruelty in the past.

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Background

This case is a classic example of the manifestations of constipation in children. Constipation has been reported to account for nearly 5% of all pediatric outpatient visits and more than 25% of referrals to gastroenterology specialists (Abi-Hanna & Lake, 1998). In 2009 it was noted that functional constipation had a worldwide prevalence of 7% to 30%, with approximately 30% to 75% of cases of chronic constipation in children resulting in rectal fecal impaction (Bekkali et al., 2009). Of these children, up to 90% will experience fecal incontinence. As can be imagined, chronic functional constipation with or without additional complications such as encopresis is a distressing problem for children and their families (Rahman & Carter, 2009). Despite its prevalence and the physical and emotional severity of the problem, good clinical trial data guiding the management of constipation in children are scarce. Thus the treatment of pediatric constipation is primarily based on clinical experience as opposed to strong clinical trial data (Coccorullo, Quitadamo, Martinelli, & Staiano, 2009). This article reviews the basic definitions and complications of constipation in children along with the current literature, clinical guidelines, and pharmacology that direct the management of chronic constipation in the pediatric population.

Definition of Constipation

Constipation can be defined three ways: a stool that is hard, pain associated with defecation, or the passage of fewer than three stools per week (Abi-Hanna & Lake, 1998). For pediatric patients, this definition may be stretched to include the inability to fully evacuate the lower colon (Abi-Hanna and Lake, 1998, University of Michigan Health System Functional Constipation and Soiling in Children Guideline Team, 2003). For example, a patient who has three or more small stools per week but does not fully empty the colon may have constipation, whereas a child who passes two large, soft stools, entirely emptying the colon, may not fit the definition or diagnosis for constipation.

When assessing constipation, it also is important to consider the normal frequency and stooling patterns in children. During the first week of life, neonates defecate an average of four times per day, whereas by 2 years of age, the average number of bowel movements per day is 1.7 (Abi-Hanna and Lake, 1998, North American Society for Pediatric Gastroenterology, 2006, Weaver and Steiner, 1984). With this physiologic decrease in the number of bowel movements per day comes an increase in the stool volume. It is important for parents and caregivers to understand these physiologic changes and to recognize that stool frequency and consistency may change throughout a child's life and may not represent constipation. Because stool frequency also varies between individuals, assessments of constipation must address what is normal for each individual child.

Physiologically, continence is maintained through resting tonicity of the internal anal sphincter (Abi-Hanna & Lake, 1998). When more than 15 mL of stool is in the rectum, nerves as well as stretch receptors are activated, the resting tone in the involuntary smooth muscle of the internal anal sphincter is decreased, and stool is able to reach the external anal sphincter, which is made up of voluntary smooth muscles. Once stool reaches the external sphincter, children feel the urge to defecate. At this point, the rectum can be evacuated of stool should the child initiate defecation through squatting and increasing intra-abdominal pressure with the Valsalva maneuver. However, the child also may choose to tighten the muscles of the external anal sphincter and the gluteal muscles, an action that causes stool to re-enter the rectal vault, thus subsiding the urge to defecate. If a child repeatedly tightens these muscles, eventually the rectum and the lower colon stretch, muscle tone is reduced, and the child will begin to retain stool. As stool retention time increases, so does water absorption. While the normal water content of stool is approximately 75%, when stool is cyclically retained in the rectum and/or colon, water absorption increases, and the stool becomes hard and may even reach the point of impaction. Fecal impaction can be defined as a large fecal mass found upon rectal evaluation or abdominal palpation that is unlikely to be passed on command (Bekkali et al., 2009).

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 Сomplications of Constipation

Encopresis, also referred to as fecal soiling, is a common complication of prolonged constipation (Abi-Hanna & Lake, 1998). One definition of soiling proposed by the UMHS includes the involuntary passage of stool and/or the voluntary or involuntary passage of stool (formed, semi-formed, or liquid) into a place other than the toilet after the age of 4 years (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). Soiling occurs when overflowing and leaking of loose stool occurs around retained, hard, and sometimes impacted stool in the distended rectum. Encopresis appears more commonly in male children and also appears to occur more frequently among younger children. Encopresis is usually associated with functional fecal retention (90%); however, it also may be caused by organic incontinence in children with damaged corticospinal pathways or in patients with anorectal dysfunction or pelvic floor muscle fatigue. Additionally, in some cases, children exhibit functional encopresis as a form of severe passive-aggressive or oppositional defiant behavior. This phenomenon is not a traditional form of constipation, however, and in these cases conventional treatment approaches for constipation will not be effective.

Another complication of constipation includes enuresis, involuntary urination, or bed-wetting, which occurs in up to 40% of children (Abi-Hanna & Lake, 1998). The large, dilated colon contributes to enuresis, and therefore this complication often resolves with the alleviation of any impaction and the passage of stool. Further urologic concerns include recurrent urinary tract infections secondary to a dilated colon and retained stool. Additionally, a largely dilated colon may eventually lead to prolapse, intussusceptions, rectal ulceration, and even protein-losing enteropathy.

Beyond physical complications, chronic constipation also has social ramifications. Children often are not aware of the soiling until it is nearly complete, a complication that can affect a child's sense of self, and his or her emotional as well as social development. A child with encopresis and soiling must face the social stigma associated with flatulence and soiling. The child may be required to wear special underwear or diapers, which may cause social exclusion, teasing, and bullying, often leading to social exclusion, anxiety, and depression (Abi-Hanna & Lake, 1998). Children may be inappropriately quiet or withdrawn (Fitzgerald, 1987). Some children may experience devastating social and emotional difficulties that cause the child to lose friendships and perform poorly in school, and in some cases, children with constipation may have to switch schools because of these social implications. Furthermore, in severe cases, recurrent hospital admissions are required to entirely clean out the bowel; hospitalizations may further exacerbate problems faced at school, affect the parents' or caregivers' ability to hold employment, and disrupt the family's social situation. Children also face significant anxiety related to hospital admission, often resulting from invasive procedures such as the placement of a nasogastric tube.

Edited by Berryl

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Causes of Constipation

Constipation may have functional, anatomic, neurologic, obstructive, endocrine, metabolic, and medicinal causes; however, to examine all of them in depth is outside of the scope of this review. A brief overview of the causes of constipation will follow, with an emphasis on functional constipation.

Neurologic causes of chronic constipation include Hirschsprung's disease or aganglionosis, which occurs in approximately 1 in 5000 births (Abi-Hanna & Lake, 1998). A lack of ganglion cells in the myenteric and submucosal plexus of the bowel characterize this disorder. Difficulty with evacuation is seen immediately at birth in persons with this disorder, and often there is failure of early passage of meconium. These patients often have severe abdominal distension, nausea, and emesis, as well as a failure to thrive. Hirschsprung's disease is a heterogeneous genetic disorder that may be associated with several syndromes, including trisomy 21 and the deletion of chromosome 13q. Other causes of neurologic constipation may include neuronal dysplasia, hypoganglionosis, spinal cord dysplasia, and botulism.

Obstructive conditions also may be the cause of constipation. Such conditions as anterior ectopic anus, congenital or acquired anal ring stenosis, meconium ileus, cystic fibrosis, adenocarcinoma, or a pelvic mass may be implicated (Abi-Hanna & Lake, 1998). Endocrine and metabolic causes of constipation include motility disorders such as delayed gastric emptying and small bowel stasis. Some endocrine and metabolic causes may include visceral myopathy, diabetes, hypothyroidism, and porphyria.

Functional constipation, the passage of less than two large-diameter stools per week with or without the presence of retentive posturing or behaviors, is defined as constipation in the absence of genetic, structural, endocrine or metabolic disorders (Bishop, Lorenzo, Loening-Bauke, Pashankar, & Tucker, 2004). In neonates and infants, functional constipation is considered to be normal because it is difficult for babies to coordinate pelvic floor relaxation and the Valsalva maneuver (Abi-Hanna & Lake, 1998). In older babies, toddlers, and preschool children, functional constipation is pathogenic and is described as the presence of pebble-like, hard stools for the majority of stools or hard stools two or fewer times per week (Bishop et al., 2004). For toddlers and older children, functional constipation is commonly a result of the child's desire to obtain control over stooling. This functional constipation may be a result of difficulty in toilet training, painful passage of stools, perianal infection, and anxiety related to defecation outside of the home or out of fear of defecation entirely. Functional constipation also may be a result of changes in routines. For example, constipation may occur when a child first attends day care or starts school for the first time or after a summer vacation. It may be a result of a stressful situation or time. Alternatively, in younger children constipation may be a product of hyperactivity or distraction; a child may become too busy with child's play to stop to empty his or her bowels. In some older children, irritable bowel syndrome may be an additional cause of functional constipation.

Is functional constipation associated with fiber intake? A study published in 2009 that assessed dietary fiber, fluids, and physical activity in relation to constipation found that fluid and fiber intake was not significantly different among children presenting with constipation; however, children with constipation did report a higher level of physical activity and a lower water intake, indicating that constipation may be correlated to dehydration (Jennings, Davies, Costarelli, & Dettmar, 2009). Despite these data, many practitioners believe that an adequate amount of dietary fiber is necessary to maintain healthy stooling patterns. Overall, although it is not entirely known what role fiber plays in constipation, most investigators agree that maintaining a good balance of hydration, fiber intake, and physical activity is important for normal stool formation and bowel motility.

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Functional Constipation—A Cyclical Process

Regardless of the previously described causes, functional constipation is described as a cyclical process, as depicted in Figure 1 (Borgo & Maffei, 2009). If the child has passed hard stools in the past, he or she may become fearful of the next defecation, and thus begins a cycle of stool retention (Fitzgerald, 1987). This cycle escalates because the next passed stool is even harder and more painful to pass because of the previous retention. This pain may eventually lead the child to be determined to avoid defecation altogether, which eventually leads to fecal impaction, bowel dilation, and the complications previously described (NASPGHAN Constipation Committee, 2006).

Evaluation

When evaluating a child for symptoms of constipation, history is of the utmost importance (Abi-Hanna and Lake, 1998, North American Society for Pediatric Gastroenterology, 2006). In addition to family history, the historical bowel patterns, including the time after birth of the first bowel movement, dietary history, and social situations such as day care attendance and toilet training efforts should be included. A detailed description of the character of the stools as well as any presence of blood is essential. If encopresis exists, the age of onset as well as the frequency should be documented. A medical history should address history of physical or emotional abuse, prior surgeries, neonatal complications, and medication use. A dietary intake history should be assessed.

The physical examination should include an assessment of weight, height, and growth velocity (Abi-Hanna & Lake, 1998). The abdomen is assessed for the degree of abdominal distension, bowel sounds, and palpable stool, and the perineum is inspected for evidence of encopresis, infection, hemorrhoids, and fissures. In about 50% of patients, the abdominal examination is positive for palpable stool, and the presence of firm, packed stool in the rectum has a positive predictive value of more than 84% for impaction (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). Guidelines recommend that at least one rectal examination should be performed to assess the sphincter tone, the size of the rectal vault, and to detect any physical abnormality that may lead to diagnosis of an organic disorder (North American Society for Pediatric Gastroenterology, 2006, University of Michigan Health System Functional Constipation and Soiling in Children Guideline Team, 2003). Laboratory testing for hypothyroidism and electrolyte abnormalities as well as a urinalysis also should be performed to rule out or rule in alternative causes for constipation. Radiographs as well as anorectal manometry may be a part of the initial or ongoing evaluation of a child with constipation. To rule out certain neurologic conditions (e.g., Hirschsprung's disease), rectal biopsies also may be necessary.

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Signs and Symptoms

Children demonstrate a wide variety of signs and symptoms related to constipation. For example, a child may have certain rituals such a gluteal tightening and posturing (Abi-Hanna & Lake, 1998). The child may rock back and forth while standing on their tiptoes; they may wiggle or become excessively fidgety, or assume quite unusual positions (NASPGHAN Constipation Committee, 2006). These rituals are sometimes mistaken for an attempt to defecate, but they usually represent an effort to retain stool and avoid defecation. Children also may demonstrate early fullness after meals and/or the desire to eat smaller amounts as a result of fecal accumulation in the colon. Complaints of gastrointestinal spasms and abdominal pain, nausea, vomiting, or unusual irritability are also common. Furthermore, with the passage of very large, hard stools, rectal bleeding may be present.

Management

The management of functional constipation will be reviewed and differences between age groups emphasized. Functional constipation is rarely a short-term process and requires a prolonged treatment plan, family compliance, and multidisciplinary support (Bishop et al., 2004). The treatment of nonfunctional constipation is beyond the scope of this article.

Neonates/Infants Younger Than 1 Year

The frequency of bowel movements is quite variable among neonates and infants younger than 1 year. For example, it is not uncommon for breastfed infants to have multiple stools per day, most commonly ranging between three to five stools per - For formula-fed babies, the average number of stools most commonly ranges between two to four stools per - Therefore, dietary and stooling histories are of the greatest importance in this age group. If a child presents with constipation within the first year of life, treatment differs from that of older children and adolescents. Constipation during infancy should be evaluated for structural and congenital causes such as anal atresia with or without a fistula, an anteriorly displaced anus, or a tethered spinal cord. In addition, disorders such as Hirschsprung's disease, neuronal intestinal dysplasia, pseudo-obstruction, or cystic fibrosis should be ruled out (Bishop et al., 2004). Once medical causes of constipation have been excluded and functional constipation has been diagnosed, it is reasonable to insert a glycerin suppository or perform occasional rectal stimulation to induce rectal reflexes; however, routine rectal manipulation is discouraged (Abi-Hanna and Lake, 1998, North American Society for Pediatric Gastroenterology, 2006). Glycerin suppositories help to soften and ease the passage of stool that is in the rectum. If used on an outpatient basis, glycerin should not be used for more than 3 days without a medical evaluation. Alternatively, if stool is very firm, barley cereal can be substituted for rice, and vegetables that contain higher levels of fiber along with nondigestible sugar such as sorbitol, fructose, or lactose (e.g. prune juice) can be incorporated into the diet in patients older than 6 months of age. It is reasonable to increase the fluid intake in all children who are younger than 1 year. The use of mineral oil, stimulant laxatives, and phosphate enemas should be avoided in this age group because of potential toxicity (NASPGHAN Constipation Committee, 2006). The use of honey in home remedies should be avoided because it may contain botulinum spores.

Older Children/Adolescents

The remainder of this review will focus on the management of constipation in older children and adolescents. In 2006, NASPGHAN developed a clinical practice based guideline to help health care professionals make clinical decisions with regard to the treatment of functional constipation (NASPGHAN Constipation Committee, 2006). The UMHS also has published treatment guidelines for functional constipation and soiling, which overall are very similar to those published by NASPGHAN (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). The management of chronic constipation in children has three phases: complete evacuation if impaction is present, sustained evacuation of impaction, and weaning from intervention through adjustment of medications if necessary (Abi-Hanna and Lake, 1998, North American Society for Pediatric Gastroenterology, 2006, University of Michigan Health System Functional Constipation and Soiling in Children Guideline Team, 2003). In all phases of management, education is extremely important for the family as well as the patient. Education should include an explanation of the pathogenesis of constipation to help families and patients better understand the problem and the treatment approach (Coccorullo et al., 2009, North American Society for Pediatric Gastroenterology, 2006, University of Michigan Health System Functional Constipation and Soiling in Children Guideline Team, 2003). Families should be counseled on the following topics: normal toileting patterns, both the physical and psychological components of chronic constipation, and the role of diet. Additionally, a strong support network is paramount, and realistic expectations must be set. A positive attitude and a strong supportive nature are necessary. Negative associations of fecal soiling need to be removed and punishments should be avoided (Bishop et al., 2004). Reward systems such as sticker charts, toileting calendars, and rewards for successes play a key role in the management of constipation. Additionally, every effort should be made to make the child comfortable during defecation; for example, a footstool may help a child successfully perform the Valsalva maneuver. Steps should be taken to make the bathroom an enjoyable place for the child to be; for instance, many families will place a radio or books in the bathroom.

From a dietary perspective, constipating foods should be reduced or eliminated completely from the child's diet (Abi-Hanna & Lake, 1998). Examples of constipating foods include meat, bread, pasta, potatoes, fried greasy foods, corn, foods that contain a high level of sugar (e.g., cookies and pies), and dairy products (ice cream, cheeses, and milk). Once constipation resolves completely and rectal tone begins to improve, additional fiber can be added to the diet to improve the efficiency of bowel evacuation. Dietary fiber increases water retention and increases colonic flora by providing substrate for bacterial growth (Chao et al., 2008). Table 1 contains a list of foods high in water-soluble and water-insoluble fiber. Although the subject is still somewhat controversial, most practitioners agree that once initial bowel evacuation has been accomplished and bowel habits have returned to normal, increasing dietary fiber is an effective and achievable task.

Step 1: Complete Evacuation. The following recommendations are from guidelines and expert opinions rather than from randomized clinical trial data. Complete bowel evacuation is necessary as the first step in treating chronic constipation because if initial disimpaction is omitted, maintenance therapy with oral stool softeners and laxatives may initially result in worsening of incontinence (Bekkali et al., 2009). Enemas are often necessary, and their use has been advocated for a period of 3 to 7 days to achieve complete evacuation (Abi-Hanna and Lake, 1998, Bekkali et al., 2009). In older children, hypertonic phosphate enemas (occasionally in combination with mineral oil) are used, and usually are administered at home in the evenings. Saline solution enemas also may be chosen (NASPGHAN Constipation Committee, 2006). If a mineral oil enema is used, it should be administered 1 to 3 hours prior to a phosphate or saline solution enema (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). The mineral oil enema acts to soften and lubricate the stool. Hypertonic enemas directly stimulate contraction in the colon, thus emptying of a fecal mass with a lower incidence of fecal incontinence. For children who are preschool aged or older, an adult-sized enema is required to relieve impaction, and one to three enemas may be required within a 12- to 24-hour period (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). If relief is not achieved in 7 days, continued home use is not recommended because of the potential for electrolyte disturbances. Children often do not tolerate enemas because of the discomfort of placement as well the associated abdominal pain and cramping due to pulsatile contractions. Enemas can be traumatic for children; however, results are seen rapidly (Bulloch & Tenenbein, 2002). Home remedies such as tap water, herbal concoctions, and soap suds enemas should not be used as a substitute because of the potential for toxicity (Abi-Hanna and Lake, 1998, North American Society for Pediatric Gastroenterology, 2006).

Oral therapies, such as polyethylene glycol solutions, have been suggested as an option for outpatient management of fecal impaction. Oral therapies are not as invasive as enemas; however, adherence to these regimens is often quite poor, because palatability may be problematic for children. If an oral route of administration is chosen, effective use of high doses of mineral oil, polyethylene glycol solutions, or a combination of the two, in addition to other agents such as magnesium hydroxide, magnesium citrate, lactulose, sorbitol, senna, and/or bisacodyl, has been demonstrated in practice. Data to help guide the decision between the use of enemas and oral solutions has historically been lacking, and the choice of treatment is commonly determined after in-depth discussions with the family and the child. Allowing the child to have choice and some amount of control in the decision may improve adherence and lead to more successful disimpaction outcomes (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). Some clinicians recommend a combination approach for bowel evacuation (NASPGHAN Constipation Committee, 2006).

In a 2009 published clinical trial, enemas and oral administration of high-dose polyethylene glycol (PEG) (MiraLax) were compared to assess their efficacy in removing a fecal impaction as well as overall tolerability in children with functional constipation and rectal fecal impaction (RFI) (Bekkali et al., 2009). A secondary goal of the study was to evaluate the effect of disimpaction on overall bowel habits and colonic transit time (CTT). Ninety patients between the ages of 4 and 16 years of age with demonstrated evidence of RFI and who were diagnosed with functional constipation were randomly assigned to receive rectal enemas (dioctylsulfosuccinate sodium) once daily (n = 46) or PEG 3350 with electrolytes at a dose of 1.5 g/kg per day (n = 44), each for 6 consecutive days. Maintenance therapy was initiated 6 days after disimpaction; maintenance therapy consisted of orally administered PEG 3350 with electrolytes at a dose of 0.5 g/kg/day for at least 2 weeks. Behavioral questionnaires and bowel diaries were filled out throughout the study period, and CTT was assessed through the use of a radio opaque marker. A total of 41 patients in the enema group and 39 in the PEG group completed the study and had complete follow-up data. Successful disimpaction was achieved for 37 patients (80%) from the enema group and 30 patients (68%) from the PEG group (P = .28); this result was not statistically significant. For patients in whom successful disimpaction was not achieved, a second attempt to achieve disimpaction was successful in a total of eight patients with combination enema and PEG therapy. The remainder of the patients (n = 5) were admitted to the hospital for colonic lavage. Bowel movement frequency was increased during the disimpaction period in both groups; however, more patients reported fecal incontinence and watery diarrhea in the PEG group. No differences were elucidated in CTT between the two groups. Tolerability was nearly equally between the two groups, but patients reported a greater degree of abdominal pain in the enema group. This study is the first prospective randomized clinical trial that has evaluated rectal enema versus oral PEG use for the initial treatment of RFI. This study found that no statistically or clinically significant difference exists between the two treatment options, suggesting that both agents can be considered as first-line therapy.

If disimpaction is not achieved through the previously described methods, patients are admitted to the hospital for oral lavage with polyethylene glycol electrolyte solution. Administration via an oral or nasogastric tube at a rate of 25 mL/kg/h for 6 hours is one example. Adding a flavor packet such as Crystal Light may enhance the palatability of the solution. Disimpaction frequently requires the placement of a nasogastric tube and the administration of larger volumes of solution, however. Volumes of 10 to 40 mL/kg/h (maximum 1000 mL/h) may be necessary (Abi-Hanna & Lake, 1998). Evacuation often takes 8 to 24 hours; however, in more severe cases of impaction, oral/nasogastric lavage may be continued for several days. Because the polyethylene glycol-electrolyte lavage solution results in no net absorption or secretion of electrolytes, large amounts can be administered without an associated risk of fluid or electrolyte disturbances. One study noted that an average of approximately 575 mL/kg total was required to achieve disimpaction during a period of nearly 24 hours (Bulloch & Tenenbein, 2002). Nausea and vomiting may result because of the large volumes of polyethylene glycol-electrolyte lavage solution administered, and thus supportive care with antiemetics may be required. Promotility agents such as metoclopramide (0.1 mg/kg/dose, with a maximum 10 mg/dose administered intravenously or by mouth every 6 hours) also are commonly used during "clean-out" regimens.

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Step 2: Sustain Complete Evacuation. After complete evacuation, maintaining evacuation is a challenge and focuses on the prevention of recurrence (NASPGHAN Constipation Committee, 2006). This phase of treatment relies on education, dietary interventions, behavioral modifications, and the use of stool softeners and laxatives. The goal of this phase is to allow the colon and the musculature of the rectum to return to normal and for functional fecal retention and encopresis to resolve. This process may take several months, and thus educating families on the importance of long-term treatment is essential for success. Achieving a regular stool pattern may entail setting a goal of one to two soft stools per day; a mushy consistency aids in more complete evacuation of the bowel (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). Habitual, unhurried toileting needs to be encouraged, and stool softeners as well as laxatives are used for 2 to 6 months or longer (Abi-Hanna and Lake, 1998, Coccorullo et al., 2009, Fitzgerald, 1987; & NASPGHAN Constipation Committee, 2006). Scheduled "toilet time" for a period of 5 to 10 minutes after meals is encouraged to take advantage of the physiologic gastrointestinal reflex and to establish a regular bowel pattern. Making scheduled "toilet time" more enjoyable by allowing the child to listen to music and/or read a book may further encourage regular bowel movements (Bishop et al., 2004). The use of a bowel diary is encouraged in which a child keeps a record of each stool that is passed in the toilet (NASPGHAN Constipation Committee, 2006). As mentioned earlier, calendars with stickers and reward systems can act as motivational tools and have been linked to success.

For babies, stool softening may be achieved through dietary modification. Barley cereal, barley malt extract, and certain juices can be administered after 6 months of age (Abi-Hanna & Lake, 1998). Dietary changes also are commonly advised in older children and include suggestions such as the addition of absorbable and nonabsorbable carbohydrates, especially sorbitol, which is found commonly in prune, apple, and pear juices, as well as the foods listed in Table 1 (NASPGHAN Constipation Committee, 2006). Overall, a well-balanced diet is encouraged, including fruits and vegetables. It is not advised, however, to force a child to eat foods that do not appeal to that particular child. Increasing the amount of fiber in a child's diet may be recommended once the colon and the rectum have returned to normal.

In addition to education and dietary changes, medications are usually necessary to help children with chronic constipation achieve regular bowel patterns (Abi-Hanna and Lake, 1998, North American Society for Pediatric Gastroenterology, 2006). Indeed, studies have noted that children treated with medications in combination with behavioral modifications have achieved remission earlier than do children who do not receive medications. Toddlers present a particularly challenging age group to treat because they are resistant to medications and often are also under-medicated because of parental concerns. Additionally, toilet training is more challenging in this particular age group. If a child has not yet been toilet trained, this should not be attempted until constipation has resolved and the child is passing two soft stools per day (Bishop et al., 2004). Often during this phase, dose reductions of medications previously prescribed for constipation are needed after bowel clean-out to avoid excessive or loose stooling.

The choice of medication, much like in step 1 of treatment, is directed by clinical guidelines only. Oral laxatives with or without the addition of a lubricant can be used (NASPGHAN Constipation Committee, 2006). Commonly recommended agents include mineral oil (lubricant), magnesium hydroxide, lactulose, sorbitol, and PEG (MiraLax). Early reports indicate that PEG may be more efficacious than other osmotic laxatives; however, the other aforementioned agents appear to be equally efficacious to one another. Therefore, the choice of these agents relies on the ability of the family to obtain the medication, along with the cost, taste, ease of administration, and personal preference. At the maintenance phase of treatment, routine use of stimulant laxatives is not recommended because of the increased likelihood of the development of bowel dependence. However, stimulants may be used intermittently for short periods as necessary to avoid the recurrence of impaction. For example, if a child has not defecated in 3 days, it is advisable to administer a stimulant laxative for a period of 1 to 3 days to avoid impaction and the necessity of returning to step 1 of treatment. In a study published in Pediatrics in 2005 that assessed the treatment of childhood constipation by primary care physicians, 87% of physicians prescribed some form of laxative or stool softener (Borowitz et al., 2005). Magnesium hydroxide was the most commonly prescribed laxative (77%), followed by senna (23%), mineral oil (8%), and lactulose (8%), and combination therapy was prescribed 15% of the time. This study demonstrated that the choice of agent, the number of agents used, or the number of times per day that medication was administered did not influence outcome. However, children who underwent disimpaction prior to maintenance therapy achieved greater success. In another study published in Clinical Pediatrics in 2006, polyethylene glycol was reported to be the most commonly prescribed agent (Focht, Baker, Heubi, & Moyer, 2006). Overall, despite the NASPGHAN and UMHS guidelines, variability still exists among providers in the treatment of childhood constipation.

Polyethylene glycol has become an increasingly appealing agent for the management of constipation in children. Numerous successful reports as well as unblinded trials have been performed, as summarized in Bell and Wall (2004), and support its use. While additional controlled trials are needed, polyethylene glycol appears to be a safe and efficacious agent at a starting dose of 0.5 g/kg/day titrating up to 1.5 g/kg/day if necessary. One major issue that may be present with the choice of polyethylene glycol is cost. When using over-the-counter polyethylene glycol, MiraLax doses are often rounded to 1 capful (17 g) or measurable portions of a capful (i.e., ? cap or ? cap). Additionally, large amounts of fluid volume are required.

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Step 3: Weaning from Medication. In general, about half to two thirds of patients will recover and be able to be weaned from maintenance medications (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). Once habits have returned to normal and evacuation has been sustained, the use of laxatives should be reduced gradually (Abi-Hanna and Lake, 1998, North American Society for Pediatric Gastroenterology, 2006). Relapse is common, and thus an individualized tapering schedule should be designed based on the length of time a patient has used maintenance doses of stool softeners and laxatives. In addition to the weaning of medication, at this point in the treatment algorithm, dietary fiber, both soluble and insoluble, should be increased and behavioral therapy should continue. The amount of daily dietary fiber that is recommended for all children is 5 g plus the child's age in years (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). Although its effects are not clinically proven, some practitioners recommend a higher amount of fiber in the diets of children who are recovering from functional constipation. With an increase in fiber intake, an associated increase in fluid is also recommended. In general, 2 oz of fluid are recommended for each gram of fiber intake. Long-term follow up is required to maintain regular bowel movements. It is recommended that follow-up intervals be as frequent as once per week during clean-out and the initial maintenance periods and then reduced to monthly and then 3-month intervals until weaning from medication is completed (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003).

Set-backs and Recurrence

In children a successful recovery has been defined as independent toileting of normal stool volumes without the need for medications (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). Other definitions of successful recovery include three or more bowel movements per week, fewer than two soiling episodes per month, no complaints of abdominal pain, and no use of medications for at least 1 month (Bishop et al., 2004). However, successful recovery is often met with bumps along the road and episodes of impaction or rectal withholding. If this occurs and if defecation has not occurred for more than 3 days, a stimulant suppository should be given to prevent the recurrence of constipation and colonic distension (Abi-Hanna & Lake, 1998). Despite the best treatments, however, multiple cohort studies have demonstrated that recurrence can be as high as 50%. Specifically, after 1 year of treatment, persistent constipation was seen in 53% of children, with 51.6% of children still maintaining constipation at 5 years (Coccorullo et al., 2009). Treatment failure is more likely to be seen in patients who are not yet toilet trained and in those who have a history of both constipation and encopresis (Bishop et al., 2004). Treatment failure may be a result of lack of adherence to treatment recommendations or a lack of recognition of suboptimal treatment or untreated small impactions along the way (UMHS Functional Constipation and Soiling in Children Guideline Team, 2003). Treatment failures also coincide with changes in routine such as vacations, holidays, and changes in medications or physical activity. Consultation with a specialist may be recommended if the previously described treatment fails (NASPGHAN Constipation Committee, 2006). It may become necessary to evaluate whether any organic disease exists or if an underlying process is occurring outside of functional constipation. The high recurrence rate highlights the need for ongoing education and behavioral modifications as well as close follow-up and continued interventions for acute episodes of retention.

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Novel and Alternative Therapies

Several new therapies have been suggested for the treatment of constipation. Although a complete review is outside the scope of this article, it is important to become familiar with some of the options. Substances that bind to the serotonin receptors as well as to chloride channels have been proposed (Coccorullo et al., 2009). Agents that affect fluid secretion in the intestines may improve constipation. Lubiprostone (Amitiza) increases chloride in the gut, which facilitates an increase in intestinal fluid that may facilitate intestinal transit and the passage of stool. Although it was approved for adult patients in January 2006, no studies in children have been performed to date. Other agents such as alvimopan (Entereg), a peripherally acting mu-opioid receptor antagonist, and prucalopride, a promotility agent that acts in the colon, have been investigated. With all of these agents, pediatric data are lacking and further studies are required that assess safety, efficacy, and tolerability before they enter the armamentarium of medications used for the treatment of constipation in children.

Biofeedback has been proposed and evaluated in multiple open-label studies (NASPGHAN Constipation Committee, 2006). Biofeedback has been shown to demonstrate some efficacy; however, long-term success has not been confirmed. Intensive psychotherapy also may be useful in some extreme cases.

Сonclusion/Summary

Constipation in the pediatric patient is a problem that occurs commonly and requires prompt attention, education, and acute and long-term management to avoid physical and emotional complications. Constipation may be a difficult problem to treat, often requiring several months of therapy. However, it is important that children with constipation be treated medically as outlined by the three-step management algorithm: complete evacuation, sustained evacuation, and weaning from medications. In addition to medical interventions, education, behavioral modifications, and a strong, positive and supportive environment is necessary for a successful endpoint in a child experiencing chronic functional constipation. Because of the interaction between physical and psychological factors, it is unlikely that one single treatment approach alone will be effective. Ongoing follow-up is necessary, and treatment approaches should be tailored to individual patients.

Edited by Berryl

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