Pediatric Constipation

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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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django -

i'm usually another face in the crowd., but had to really shout out at this article. I disagree with this chapter. this rome 3 criteria is useless. realistically, how many times does kids come in with vague abdominal complaints with minor discomfort on exam. you worry is this the beginning of a more serious appy? the parents swear their bowels are really good. That reliable KUB helps to realize their full of stool.

Anthony C., MD -

Thank you for your email. I have found it challenging in the past when new research points me away from practice beliefs I've held.

Calling the Rome III criteria "useless" is an overstatement and the best available evidence leads us to understand that KUBs are not useful in this population and that they in can mislead our diagnosis. As I'm sure you'll agree, when we worry about appendicitis in children with vague pain, the better test would be an ultrasound.

It is worth mentioning that the evidence is also only one part of what makes up EBM. Your experience and the values of your patients are also important to decision-making. See: https://www.youtube.com/watch?v=Z_yiUf3f92s

Anthony Crocco

Mike -

Dear EM RAP,

it is with great interest that I listened to Anthony Crocco's segment on Pediatric constipation and X-rays. I am a Pediatric Emergency Physician at the Children's Hospital of Eastern Ontario (CHEO) and am thus well aware of how frequently this diagnosis is made in the emergency department.

I was pleased to hear Dr. Crocco reiterate that this is a clinical diagnosis as well as his review of the evidence that suggests X-rays should not be ordered. This is something that I strive to teach my learners about this condition.

I must, however, also add that as with all things in medicine, never say never.

Occasionally I am faced with a patient who clearly has constipation but whose parents refuse to accept the diagnosis nor administer the appropriate therapy to their child. These are the families who have already been given the diagnosis by their primary care givers and are seeking second or third opinions due to disbelief in the diagnosis. They will make statements like "I haven't given the PEG3350 because I know this can't be constipation."
Though it is absolutely critical to listen to the parents concerns and consider alternative diagnoses, once or twice a year I find myself doing a "convincogram" (X-ray to show the parents the stool quantity).
This can be an essential part of bringing the parents on board with the diagnosis and ensuring that the child receives the appropriate therapy.

Anyone who believes that they can convince any family of this diagnosis 100% of the time with a simple history, physical, and good communication is fooling themselves. Trust me... I've seen your patients in my emergency department and they didn't believe your diagnosis.

In summary, I believe that 99% of the time constipation should be a diagnosis based on history and physical, but listen to your families' concerns and consternation and use your best judgement as to who needs a bit more time, follow-up, or dare I say an abdominal x-ray.

Sincerely,

Dr. Michael Pierse

P.S. Please politely inform you sound designers that their "irony" sound bite has not been used correctly for the past year. Indeed the only thing ironic about this sound bite is that it is never being used for irony. I believe the sound bite they are looking for in most of these situations would be "sarcasm."

Anthony C., MD -

See below...

Josh K. -

Hi Dr. Pierse, JoshK, here. On behalf of the sound designers, we wanted to thank you first of all for listening so closely to the program but also for drawing attention to a chronic condition in America which is the confusion of sarcasm and irony. When it comes to statements, Irony is defined as “the expression of one's meaning by using language that normally signifies the opposite, typically for humorous or emphatic effect.” Sarcasm’s definition is: “a sharp and often satirical or ironic utterance designed to cut or give pain.” So while sarcastic statements often employ irony, in the case of EM:RAP, our contributors rarely use sarcasm’s stinging bite to inflict pain (they are very nice people). And although their comments may contain tinges of sarcastic undertones we’ve preferred to identify them as Irony. We did this because it seemed more relevant to point out that intended meaning of the contributor statements in question are usually the opposite of their literal meaning. You'll be excited to know that there was also great debate about whether we should be identifying other figures of speech like metonymy and synecdoche but EM:RAP decided our hands should be focused elsewhere. Thanks for listening!

Anthony C., MD -

Michael,

Thank you for your message. I agree that there is a limited role for KUBs in children with abdominal pain. I have found that it can add some value where there is no reliable history, such as when there are caregiver issues or developmental concerns limiting communication with the child.

Regarding the "convincogram", I take a strong stance against exposing children to ionizing radiation to appease parents. I have heard the same arguments in the past around prescribing antibiotics to children with viral infections and prescribing opioids to addicts. I believe what separates us from the hoards of well-meaning snake-oil salesmen is that we commit ourselves to first doing no harm. If KUBs were free, had no adverse effects and were not associated with misdiagnosis, I might agree with your opinion. Since that is not the case, I respectfully do not. It is also interesting what the evidence tells us about focusing on patient satisfaction... http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108766

To paraphrase The Rolling Stones: We can't, and shouldn't, always give people what they want. We should, however, always give them what they need.

I am very concerned to hear that my patients are leaving our tertiary care pediatric ED in Hamilton, driving four hours past another tertiary care pediatric ED in Toronto to see you in Ottawa to get a KUB. In the future, if there are further patients making that drive, I would appreciate being able to do a chart review to see what we could learn from their patient experience. As the chief of our ED, I am unaware of any patient complaints related to this issue.

Anthony Crocco

Mike -

Thank you very much for this reply Anthony.

I suspect that we agree almost completely about the role that plain films should play in children with constipation.

I certainly agree with you that I would not be performing an X-ray simply to appease a parent.
I am however, curious as to how you see the risk-benefit ratio of the ~0.5mSv of radiation from a plain abdominal film versus a child with chronic pain and overflow diarrhea from constipation whose parents are not convinced through history and physical that this is constipation.

To expand on your example from the podcast:
A 5 year old who presents with a history of weekly stools that are hard to pass and plug the toilet. In between bowel movements, he is incontinent to liquid stool. This has been going on for 2 years and the parents have been investigated by both their primary care provider and a pediatrician who have both suggested the use of PEG3350. The parents have never administered this medication for more than a day as they do not believe this could be constipation given the liquid stool they are seeing.

Do you have a particular approach to counseling these families that you feel will have more success in convincing the parents of the diagnosis than their previous physicians? Is the negative outcome of having this child continue to be untreated outweighed by the ionizing radiation of the flat plate?

Though further head to head studies are needed, I suspect that the risks of driving on the 407 and 401 outweigh the risks of an abdominal X-ray and will most likely be ordering a flat plate for any child whose families are likely to make the drive.

Mike Pierse

Anthony C., MD -

Mike,

Appreciate the discussion. My personal approach with these patients and families is to spend some time with them. These are NOT the kids/families who we can see and send in a couple of minutes with a prescription for PEG3350. What I do:

1) Affirm that it's normal to feel frustrated is normal as chronic constipation is a very difficult experience for their child and for them to go through. ("I have yet to meet parents with a child like yours who aren't very tired and frustrated by what they're going through... how are you guys managing?")

2) Let them know that we used to think that XRAYs (esp. if they're asking for them) were helpful, but as it turns out they are not. That the specialists all over the world got together and agreed on how we, in the front lines, can best tell if someone is constipated or not.

3) I draw them a picture of the rectum explaining how chronic constipation leads to stretching of the muscles making it hard for the bowel to push out the stool. I explain that the gut usually senses when it's full but when it's chronically full, this doesn't happen well. I explain that over time the hard stool in the colon acts as a block and liquidy stool seeps around it causing soiling.

4) I tell parents that there's good news and bad news. The bad news is that "curing" chronic constipation is neither easy nor fast. Even though we know PEG3350 works really well, I let parents know that we are going to start the treatment but that the treatment may need to be modified based on response. I also explain that it took weeks/months for the bowel to get stretched out and that it will take weeks/months for the bowel to return to normal. The good news is that this can get better. We just need a good plan with air-tight follow-up (primary care, NOT ED).

As for exposing children to unnecessary radiation to appease parents - I take a firm stance on this. My experience is that KUBs are more often done when clinicians don't want to invest the time empathizing and explaining to parents. Ignoring the added cost, time and association with missing other diagnoses, my question would be: "What is a reasonable amount of unnecessary radiation we should expose children to in order to treat parental anxiety?" I could rephrase it: "What is a reasonable amount of antibiotics to give a child with a viral infection to treat parental anxiety?" "What is a reasonable amount of opioids to prescribe a known addict in the ED?"

Again, I'm happy to hear of any families leaving our PED dissatisfied so we can review the care provided. If parents are willing to drive all around Ontario looking for, in my opinion, poor care for their children, that's on them. Giving them what's best for their child? That's on me. Primum non nocere.

Anthony

Mike -

Thanks again for replying Anthony,

though I haven't found myself drawing pictures of GI tracts (I'm a terrible artist), I otherwise couldn't agree more with your approach to counseling families on this condition... and yet I am still having to humble myself once or twice a year for parents with whom my and my colleagues words just aren't resonating. If it is a choice between having a parent accept this diagnosis and administer the appropriate therapy versus staying firm in my stance, I'm happy to alter my practice in this rare circumstance.

In my opinion, good care for patients involves recognizing that the complex dynamics of health mean there will always be those rare and unique situations that warrant changing our approach/rules. Or to quote a higher authority:
"It is worth mentioning that the evidence is also only one part of what makes up EBM. Your experience and the values of your patients are also important to decision-making." - A. Crocco

Once again I couldn't agree more,

Mike

P.S. As to the rhetorical questions:

Q: What is a reasonable amount of antibiotics to give a child with a viral infection to treat parental anxiety?
A: Well technically nothing for a parents anxiety... but pointing to issues such as AOM where more recent evidence suggests minimal benefit from antibiotics and yet guidelines still recommend their use, it doesn't seem like the experts have this sorted out either.

Q: What is a reasonable amount of opioids to prescribe a known addict in the ED?
A: Well certainly the answer isn't always none! Surely we aren't looking to potentiate withdrawal and are more interested in helping our patients safely access support services and addictions counseling ?

Anthony C., MD -

Mike,

I agree (with myself!) that you are entitled to look at the evidence and incorporate it into your practice as you see fits your experiences and the population you serve. This doesn't, however, preclude me from disagreeing with your choice of decisions. We will have to (respectfully!) agree to disagree on management of these patients.

Anthony

Andy M. B., M.D. -

Well how do you treat it?!

Also imagine the 4 wk old that keeps crying and all the nurses are laughing at you for doing a workup! ..." he just has Colic" why are you so nervous !!"

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