The correct answer is 4. The normal range of stool output in young infants is very wide. To suspect aganglionic megacolon there is usually a delay in the evacuation of meconium and often other associated symptoms such as abdominal distension, difficulty in gaining weight, etc.

[HIDDEN] The normal range of stool output in young infants is very wide. To suspect aganglionic megacolon there is usually a delay in the evacuation of meconium and often other associated symptoms such as abdominal distension, difficulty in gaining weight, etc.

A 1 month old infant, exclusively breastfed, consults because he has a bowel movement every 5 or 6 days with straining but with a soft consistency, what would our attitude be?

Supplement breastfeeding with anti-constipation formula.

It is considered normal intestinal rhythm.

Refer to Pediatric Digestive to rule out aganglionic megacolon.

Management of chronic constipation in infants and toddlers.

Infants and toddlers with constipation usually have a history of infrequent, hard and painful bowel movements, often accompanied by screaming and stool-holding maneuvers. Encopresis, the intermittent and involuntary passage of formed-to-liquid feces, is common. Although constipation most often has a functional cause, the history and physical examination should rule out anatomic, endocrinologic, metabolic or neurologic causes. Hirschsprung's disease--aganglionic megacolon--is a congenital cause of severe constipation that occurs in one of every 5,000 births. Treatment consists of fecal disimpaction, laxatives to prevent future impaction, promotion of regular bowel habits and, finally, toilet training. Parents should be reassured that although this disorder is not life-threatening, several months to years of supportive intervention may be required for effective treatment.

Safety of a New Synbiotic Starter Formula.

Breastfeeding is the best way to feed all infants, but not all infants can be (exclusively) breastfed. Cow's milk based infant formula is the second choice infant feeding. The safety of a new synbiotic infant formula, supplemented with <iBifidobacterium lactis</i and fructo-oligosaccharides, with lactose and a whey/casein 60/40 protein ratio was tested in 280 infants during 3 months. The median age of the infants at inclusion was 0.89 months. Weight evolution was in accordance with the World Health Organization growth charts for exclusive breastfed infants. The evolution of all anthropometric parameters (weight-for-length z score and body mass index-for-age z score) was within the normal range. The incidence of functional constipation (3.2%), daily regurgitation (10.9%), infantile crying and colic (10.5%) were all significantly lower than the reported median prevalence for a similar age according to literature (median value of 7.8% for functional constipation, 26.7% for regurgitation, 17.7% for infantile colic). The new synbiotic infant starter formula was safe, resulted in normal growth and was well tolerated. Functional gastro-intestinal manifestations (functional constipation, regurgitation and colic) were significantly lower than reported in literature. Synbiotics (<iBifidobacterium lactis</i and fructo-oligosaccharides) in cow's milk based infant formula bring the second choice infant feeding, formula, closer to the golden standard, exclusive breastfeeding.

Defecation patterns of the infants mainly breastfed from birth till the 12th month: Prospective cohort study.

Studies about defecation patterns have been mostly conducted on infants who were breastfed in a short term but were fed predominantly with formula. In this study, defecation patterns of 125 infants, most of them being breastfed during 12th month were evaluated. Frequency, consistency and color of the stool were analyzed in relation to the feeding pattern at the 15th day and at the 1st, 2nd, 3rd, 4th, 5th, 6th and 12th months. Frequency of defecation was highest in 15th day with a median of 6/day. It decreased with age (p=0.0001), being 4/day and 3/day in 1st and 2nd months respectively, and 2/day between 3rd-12th months. During first 5 months, the stool frequency was higher in infants who were exclusively breastfed compared to those being fed with breastfed and formula (p<0.05). The effect of the feeding pattern on stool frequency disappeared in the following months (p>0.05). Stool frequency decreased by half at the 2nd month when the rate of less than once/day attained its highest value (24.8%). In those who had a rate of less than once/day, stool frequency stayed low until the 6th month and exclusively breastfed rate was also found lower (p<0.05). Besides the age, exclusive breastfeeding was also effective on stool frequency. It points out that infants who are fed with formula in addition to breastfeeding may defecate less than once per day hence should not be diagnosed as having constipation depending solely on defecation frequency and should not receive unneccesary treatments.

Bristol stool scale

Types 1 and 2 indicate constipation, with 3 and 4 being the ideal stools as they are easy to defecate while not containing excess liquid, 5 indicating lack of dietary fiber, and 6 and 7 indicate diarrhoea. In the initial study, in the population examined in this scale, the type 1 and 2 stools were more prevalent in females, while the type 5 and 6 stools were more prevalent in males; furthermore, 80% of subjects who reported rectal tenesmus (sensation of incomplete defecation) had type 7. These and other data have allowed the scale to be validated. The Bristol stool scale is also very sensitive to changes in intestinal transit time caused by medications, such as antidiarrhoeal loperamide, senna, or anthraquinone with laxative effect. Uses Diagnosis of irritable bowel syndrome

Laxative

Laxatives, purgatives, or aperients are substances that loosen stools and increase bowel movements. They are used to treat and prevent constipation. Laxatives vary as to how they work and the side effects they may have. Certain stimulant, lubricant and saline laxatives are used to evacuate the colon for rectal and bowel examinations, and may be supplemented by enemas under certain circumstances. Sufficiently high doses of laxatives may cause diarrhea. Some laxatives combine more than one active ingredient. Laxatives may be administered orally or rectally. Types Bulk-forming agents Bulk-forming laxatives, also known as roughage, are substances, such as fiber in food and hydrophilic agents in over-the-counter drugs, that add bulk and water to stools so that they can pass more easily through the intestines (lower part of the digestive tract).

Constipation in children

Constipation in children refers to the medical condition of constipation in children. It is a functional gastrointestinal disorder. Presentation Children have different bowel movement patterns than adults. In addition, there is a wide spectrum of normalcy when considering children’s bowel habits. On average, infants have 3-4 bowel movements/day, and toddlers have 2-3 bowel movements per day. At around age 4, children develop an adult-like pattern of bowel movements (1-2 stools/day). Children benefit from scheduled toilet breaks, once early in the morning and 30 minutes after meals. The Rome III Criteria for constipation in children helps to define constipation for various age groups. Causes

Constipation  -- Treatment / Management

Laxatives represent first-line treatment for childhood constipation; if an adequate regimen is implemented, they often have a symptomatic improvement. Consensus guidelines recommend daily polyethylene glycol (PEG) of 1 to 1.5 g/kg per day for 3 to 6 days for initial fecal disimpaction, followed by a daily maintenance dose of 0.4 g/kg per day for at least 2 months to prevent reaccumulation. A stimulant laxative should be added if PEG alone does not cause disimpaction after 2 weeks of treatment. Other pharmacological agents used for treating constipation include the following: Bulk-forming agents (fiber) Emollient stool softeners Rapidly acting lubricants Prokinetics Laxatives Prosecretory drugs Osmotic agents

Constipation

The pelvic floor muscles play an important role in helping pass a bowel movement. Injury to those muscles by some of the above risk factors (examples- delivering a large child, lengthy second stage of labor, forceps delivery) can result in constipation. Enemas may be administered during labor and these can also alter bowel movements in the days after giving birth. However, there is insufficient evidence to make conclusions about the effectiveness and safety of laxatives in this group of people. See also Obstructed defecation Rectal tenesmus References External links Constipation - Introduction (UK NHS site) Constipation Guideline - the World Gastroenterology Organisation (WGO) Conditions diagnosed by stool test Digestive disease symptoms Diseases of intestines Nursing diagnoses Waterborne diseases Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate

Pediatrics_Nelson

When disimpaction is achieved, the child begins the maintenance phase of treatment. This phase promotes regular stool production and prevents reimpaction. It involves attention to diet, medications to promote stool regularity, and behavioral training. Increasing dietary fiber and fluid are recommended. For children with chronic constipation, the recommended daily dose of fiber is calculated as 10 grams plus the child’s age in years (e.g., a 10-year-old should take 20 grams of fiber per day). At least 2 oz of nondairy fluid intake per gram of fiber intake is recommended. Sorbitol-based juices, including prune, pear, and apple juice, increase the water content of bowel movements. Lubricants or osmotic laxatives are used to promote regular soft bowel movements. Maintenance medications, including side effects, are listed in Table 14-3. Polyethylene glycol powder is well tolerated because the taste and texture are palatable. Some children may require the use of a lubricant in addition to

InternalMed_Harrison

After the cause of constipation is characterized, a treatment decision can be made. Slow-transit constipation requires aggressive medical or surgical treatment; anismus or pelvic floor dysfunction usually responds to biofeedback management (Fig. 40-4). The remaining ∼60% of patients with constipation has normal colonic transit and can be treated symptomatically. Patients with spinal cord injuries or other neurologic disorders require a dedicated bowel regimen that often includes rectal stimulation, enema therapy, and carefully timed laxative therapy. Patients with constipation are treated with bulk, osmotic, pro- kinetic, secretory, and stimulant laxatives including fiber, psyllium, milk of magnesia, lactulose, polyethylene glycol (colonic lavage

Constipation  -- Pearls and Other Issues

Pediatric Rome IV criteria are met when at least 2 of the following are present for at least 1 month in infants and children up to 4 years. For children older than 4 years of age, symptoms should last for at least 2 months: Fewer than 3 spontaneous bowel movements per week At least 1 episode of fecal incontinence per week after the child has acquired complete bowel control History of extensive fecal retention or withholding behavior by the child Hard and painful stools Large fecal mass on digital rectal examination Large diameter of stools causing rectal outlet obstruction or that obstruct the toilet [39]

CON-COUR study: Interferential therapy in the treatment of chronic constipation in adults: study protocol for a randomized controlled trial.

The prevalence of chronic constipation is about 15 % in Western countries with a significant impact on quality of life and health care costs. The first-line therapy, based on medical treatment combined with laxatives and dietary rules, is often disappointing. Interferential therapy is a new treatment that has demonstrated its efficiency in the treatment of chronic constipation in children and encouraging results in adults. The primary objective of this study is to assess the efficacy of interferential therapy during 8 weeks in adult patients. The secondary objectives are to assess this new and noninvasive therapy in terms of persistence of the clinical efficacy, colonic transit time, ano-rectal manometry, patient satisfaction and quality of life (QoL), and tolerance.  multicenter, prospective, randomized, placebo-controlled, double blind, two-parallel groups study. nine French adult gastroenterology centers. adult patients with a history of chronic constipation refractory to medical treatment for at least 3 months. Treatment groups: (1) interferential-experimental group (effective stimulation); (2) placebo-control group (sham stimulation). 1:1 allocation ratio. Evaluation times: inclusion (T0, randomization), baseline assessment (T1), start of stimulation (T2), intermediary assessment (T3, 4 weeks), end of stimulation (T4, 8 weeks), follow-up (T5 and T6, 1- and 6-month). (1) primary: short-term efficacy at T4 (treatment response defined as three or more spontaneous, complete bowel movements per week); (2) secondary: efficacy at T5 and T6, symptoms (Patient Assessment of Constipation Symptoms questionnaire), colonic transit time, anorectal manometry, patient satisfaction (analogical visual scale), patient QoL (Patient Assessment of Constipation Quality of Life Questionnaire), side/unexpected effects. 200 individuals to obtain 80 % power to detect a 20 % difference in treatment response at T4 between the two groups (15 % of lost to follow-up patients expected). The randomized, double-blind, placebo-controlled design is the most appropriate to demonstrate the efficacy of a new experimental therapeutic (Evidence-Based Medicine Working Group classification). National and international recommendations could be updated based on the findings of this study. Current controlled trials NCT02381665 (registration date: February 13, 2015).

Constipation

Criteria The Rome III Criteria for functional constipation must include two or more of the following and present for the past three months, with symptoms starting for at least 6 months prior to diagnosis. Straining during defecation for at least 25% of bowel movements Lumpy or hard stools in at least 25% of defecations Sensation of incomplete evacuation for at least 25% of defecations Sensation of anorectal obstruction/blockage for at least 25% of defecations Manual maneuvers to facilitate at least 25% of defecations Fewer than 3 defecations per week Loose stools are rarely present without the use of laxatives There are insufficient criteria for irritable bowel syndrome Prevention Constipation is usually easier to prevent than to treat. Following the relief of constipation, maintenance with adequate exercise, fluid intake, and high-fiber diet is recommended. Treatment A limited number of cases require urgent medical intervention or will result in severe consequences.

Successful relactation--a case history.

A healthy, term male infant was weaned at 10 days postpartum because of his mother's illness. The baby was breastfed by his mother's sister, but mostly he was fed with his aunt's expressed milk and with formula by bottle. At 9 weeks postpartum relactation began. Techniques used were a supplemental nursing support system device; frequent suckle at the breast, supplemented by formula given by bottle; breast pumping; domperidone; and support from an International Board Certified Lactation Consultant and family. Problems that appeared during relactation were that at 12 postpartum weeks the baby refused the supplemental nursing system device, and at 12 weeks and 3 days he refused the breast; after 3 weeks of relactation, the milk supply was still low, needing supplementation; and in the first week of exclusive breastfeeding, the baby stopped growing, then he gained weight slowly, and his gain fell down to the 15(th) percentile. Solutions and interventions used to solve the problems were usage of an artificial nipple during breast strike for 3 days and cessation of supplementary formula and frequent suckling at the breast. Four days after relactation started, colostrum appeared (for 2 weeks), and within 1 month from the beginning of relactation the baby was fully breastfed. He was exclusively breastfed until 7 months, and he was continually breastfed until 2 years. His growth was good and was around the 50th percentile on the weight/length curve. Thus relactation is possible at 9 weeks postpartum, if the mother's motivation to breastfeed is strong. The best technique to increase milk supply is frequent, short breastfeedings.

[Constipation--a new approach].

Chronic idiopathic constipation is defined as the emission of less than 3 stools per week. Beside signs evoking a severe form (Hirschsprung's disease, idiopathic megacolon), a treatment with bran, at a dose of 20 grams per day, is instituted right away, which cures almost 60% of the patients (constipation secondary to dietetic errors). If this is not the case, the study of the colonic transit time of markers, anorectal manometry, defecation radiographs, enables to recognize various etiological forms (colonic inertia, irritable colon, anism, descending perineum, etc...) which require a specific treatment.

PROPOSALS TO APPROXIMATE THE PEDIATRIC ROME CONSTIPATION CRITERIA TO EVERYDAY PRACTICE.

Acceptance of the prevailing pediatric Rome constipation criteria, by primary care physician, is still low. Even for research purposes they have not been universally adopted. Thus, it has been indicated that some re-evaluation of these criteria would be welcome. The authors aimed to look at the timing of diagnosis and the dietary treatment recommendations in the criteria, to make proposals trying to approximate them to everyday practice. The literature cited in the Rome criteria was reviewed and the publications pertinent to the subject, searched by Medline up to January 2018, were included. An early diagnosis is fundamental to avoid evolution to bothersome complications and possibly to 'intractable' constipation, but the inclusion of two items of the criteria might hamper it. Thus, one constipation sign/symptom should suffice, usually the easily observable 'painful or hard bowel movements'. Details about dietary fiber recommendations are missing in the criteria, although its increase is usually the first approach in primary care, and overall the data about dietary fiber supplements point to beneficial effects. For diagnosis and treatment of pediatric constipation in primary care, one constipation sign/symptom should suffice. The recommended daily dietary fiber intake, according to the American Health Foundation, should be detailed as a treatment measure, and also for prevention, from weaning on.

Constipation

Since the 1700s in the West there has been some popular thought that people with constipation have some moral failing with gluttony or laziness. Special populations Children Approximately 3% of children have constipation, with girls and boys being equally affected. With constipation accounting for approximately 5% of general pediatrician visits and 25% of pediatric gastroenterologist visits, the symptom carries a significant financial impact upon the healthcare system. While it is difficult to assess an exact age at which constipation most commonly arises, children frequently suffer from constipation in conjunction with life-changes. Examples include: toilet training, starting or transferring to a new school, and changes in diet. Especially in infants, changes in formula or transitioning from breast milk to formula can cause constipation. The majority of constipation cases are not tied to a medical disease, and treatment can be focused on simply relieving the symptoms.

Outbreak of life-threatening thiamine deficiency in infants in Israel caused by a defective soy-based formula.

Between October and November 2003, several infants with encephalopathy were hospitalized in pediatric intensive care units in Israel. Two died of cardiomyopathy. Analysis of the accumulated data showed that all had been fed the same brand of soy-based formula (Remedia Super Soya 1), specifically manufactured for the Israeli market. The source was identified on November 6, 2003, when a 5.5-month-old infant was admitted to Sourasky Medical Center with upbeat nystagmus, ophthalmoplegia, and vomiting. Wernicke's encephalopathy was suspected, and treatment with supplementary thiamine was started. His condition improved within hours. Detailed history revealed that the infant was being fed the same formula, raising suspicions that it was deficient in thiamine. The formula was tested by the Israeli public health authorities, and the thiamine level was found to be undetectable (<0.5 microg/g). The product was pulled from the shelves, and the public was alerted. Thiamine deficiency in infants is very rare in developed countries. The aim of this study was to report the epidemiology of the outbreak and to describe the diagnosis, clinical course, and outcome of 9 affected infants in our care. After the index case, an additional 8 infants were identified in our centers by medical history, physical examination, and laboratory testing. The group consisted of 6 male and 3 female infants aged 2 to 12 months. All were assessed with the erythrocyte transketolase activity assay, wherein the extent of thiamine deficiency is expressed in percentage stimulation compared with baseline (thiamine pyrophosphate effect [TPPE]). Normal values range from 0% to 15%; a value of 15% to 25% indicates thiamine deficiency, and >25% indicates severe deficiency. Blood lactate levels (normal: 0.5-2 mmol/L) were measured in 6 infants, cerebrospinal fluid lactate in 2 (normal: 0.5-2 mmol/L), and blood pyruvate in 4 (normal: 0.03-0.08 mmol/L). The diagnostic criteria for thiamine deficiency were abnormal transketolase activity and/or unexplained lactic acidosis. Treatment consisted of intramuscular thiamine 50 mg/day for 14 days combined with a switch to another infant formula. Early symptoms were nonspecific and included mainly vomiting (n = 8), lethargy (n = 7), irritability (n = 5), abdominal distension (n = 4), diarrhea (n = 4), respiratory symptoms (n = 4), developmental delay (n = 3), and failure to thrive (n = 2). Infection was found in all cases. Six infants were admitted with fever. One patient had clinical dysentery and group C Salmonella sepsis; the others had mild infection: acute gastroenteritis (n = 2); upper respiratory infection (n = 2); and bronchopneumonia, acute bronchitis, and viral infection (n = 1 each). Two infants were treated with antibiotics. Three infants had neurologic symptoms of ophthalmoplegia with bilateral abduction deficit with or without upbeat nystagmus. All 3 had blood lactic acidosis, and 2 had high cerebrospinal fluid lactate levels. Patient 1, our index case, was hospitalized for upbeat nystagmus and ophthalmoplegia, in addition to daily vomiting episodes since 4 months of age and weight loss of 0.5 kg. Findings on brain computed tomography were normal. Blood lactate levels were high, and TPPE was 37.8%. Brain magnetic resonance imaging (MRI) revealed no abnormalities. Patient 2, who presented at 5 months with lethargy, vomiting, grunting, and abdominal tenderness, was found to have intussusception on abdominal ultrasound and underwent 2 attempts at reduction with air enema several hours apart. However, the lethargy failed to resolve and ophthalmoplegia appeared the next day, leading to suspicions of Wernicke's encephalopathy. Laboratory tests showed severe thiamine deficiency (TPPE 31.2%). In patients 1 and 2, treatment led to complete resolution of symptoms. The third infant, a 5-month-old girl, was admitted on October 10, 2003, well before the outbreak was recognized, with vomiting, fever, and ophthalmoplegia. Her condition deteriorated to seizures, apnea, and coma. Brain MRI showed a bilateral symmetrical hyperintense signal in the basal ganglia, mamillary bodies, and periaqueductal gray matter. Suspecting a metabolic disease, vitamins were added to the intravenous solution, including thiamine 250 mg twice a day. Clinical improvement was noted 1 day later. TPPE assay performed after treatment with thiamine was started was still abnormal (17.6%). Her formula was substituted after 4 weeks, after the announcement about the thiamine deficiency. Although the MRI findings improved 5 weeks later, the infant had sequelae of ophthalmoplegia and motor abnormalities and is currently receiving physiotherapy. All 3 patients with neurologic manifestations were fed exclusively with the soy-based formula for 2 to 3.5 months, whereas the others had received solid food supplements. Longer administration of the formula (ie, chronic thiamine deficiency) was associated with failure to thrive. For example, one 12-month-old girl who received the defective formula for 8 months presented with refusal to eat, vomiting, failure to thrive (75th to <5th percentile), hypotonia, weakness, and motor delay. Extensive workup was negative for malabsorption and immunodeficiency. On admission, the patient had Salmonella gastroenteritis and sepsis and was treated with antibiotics. After thiamine deficiency was diagnosed, she received large doses of thiamine (50 mg/day) for 2 weeks. Like the other 5 infants without neurologic involvement, her clinical signs and symptoms disappeared completely within 2 to 3 weeks of treatment, and TPPE levels normalized within 1 to 7 days. There were no side effects. As part of its investigation, the Israel Ministry of Health screened 156 infants who were fed the soy-based formula for thiamine deficiency. However, by that time, most were already being fed alternative formulas and had begun oral thiamine treatment. Abnormal TPPE results (>15%) were noted in 8 infants, 3 male and 5 female, all >1 year old, who were receiving solid food supplements. Although their parents failed to notice any symptoms, irritability, lethargy, vomiting, anorexia, failure to thrive, and developmental delay were documented by the examining physicians. None had signs of neurologic involvement. Treatment consisted of oral thiamine supplements for 2 weeks. Clinician awareness of the possibility of thiamine deficiency even in well-nourished infants is important for early recognition and prevention of irreversible brain damage. Therapy with large doses of thiamine should be initiated at the earliest suspicion of vitamin depletion, even before laboratory evidence is available and before neurologic or cardiologic symptoms appear.

[Treatment of Chronic Functional Constipation during Pregnancy and Lactation].

Natural fibres (bulk-forming agents), docusate sodium (stool-softener), mineral oils (lubricant laxatives), macrogol (polyethylene glycol, PEG), sugars and sugar alcohols (osmotic laxatives) and anthraquinones and diphenolic laxatives (stimulant laxatives) seem to be safe medicaments regarding teratogenicity and lactation. The US Food and Drug Administration (FDA) risk categories for these substances taken during pregnancy and lactation are often the result of the lack of studies than of evidence-based information. So risk categories do not help in the decision-making for the right laxative. Alternative solutions such as proposals of the American College of Gastroenterology's Committee on FDA related matters, (ACG-FDA) and the Motherisk Programme try to improve decision-making. For newer compounds such as chloride-channel-activators and procinetics no data regarding safe use in pregnancy and during breast-feeding are available as yet. We suggest the use of macrogol and lactulose as the first-line therapy in treating chronic constipation during pregnancy. Macrogol shows some advantages, such as faster onset of bowel action and fewer flatulences. If this treatment does not work or starts but then stops working, we recommend in the second and third trimenon a second-line treatment with diphenolic laxatives such as bisacodyl and and sodium picosulfate. During pregnancy the decision on the application of these laxatives is largely determined by the side-effects of tenesmus associated with preterm births. During lactation we recommend macrogol (preferable to lactulose due to the lack of data), lactulose, bisacodyl and sodium picosulfate, according to the nature of the conditions.

Laxative

Properties Site of action: small and large intestines Onset of action: 0.5–3 hours (oral), 2–15 minutes (rectal) Examples: sodium phosphate (and variants), magnesium citrate, magnesium hydroxide (milk of magnesia), and magnesium sulfate (Epsom salt) Stimulant agents Stimulant laxatives are substances that act on the intestinal mucosa or nerve plexus, altering water and electrolyte secretion. They also stimulate peristaltic action and can be dangerous under certain circumstances. Properties Site of action: colon Onset of action: 6–10 hours Examples: senna, bisacodyl Prolonged use of stimulant laxatives can create drug dependence by damaging the colon's haustral folds, making a user less able to move feces through the colon on their own. A study of patients with chronic constipation found that 28% of chronic stimulant laxative users lost haustral folds over the course of one year, while none of the control group did.

Breastfeeding and Infant Nutrition Knowledge, Attitude, and Practices of Parents.

This study aimed to evaluate the knowledge, attitude, and practices of parents about breastfeeding, complementary food, and infant nutrition who have healthy infants born at term and under 2 years of age. This is a cross-sectional study conducted among the parents of infants who came for well-child visits to pediatric clinics of 4 hospitals. Healthy infants under 2 years of age and who had been born at term were interviewed. The questionnaire included 35 questions to evaluate parents' knowledge, attitude, and practices about breastfeeding and infant nutri- tion in addition to sociodemographic data. Data were obtained via questionnaire and were analyzed using Statistical Package for the Social Sciences 20.0 package program. The study group consisted of 679 infants and their parents. The median durations of exclusive breastfeeding and total breastfeeding time were found to be 4 months and 10 months. Although 75% of the participants stated that infants must be exclusively breastfed for 6 months, the rate of exclusive breastfeeding for the first 6 months was 44%. The 393 (58%) participants used formula for infant nutrition and 47 (12%) of those started with complementary feeding. 90% of the participants stated that formula advertisements did not affect their decision on starting formula but the rate of thinking that other people may be affected by the advertisements was 80%. The knowledge of parents on human milk is not insufficient but they need to be supported especially to continue exclusive breastfeeding during the first 6 months and appro- priate complementary food during the weaning period.

Gynecology_Novak

Patients with slow-transit constipation tend to respond poorly to fiber supplementation, although most have already tried an empiric trial of fiber before testing to confirm the diagnosis (160). Some patients may benefit from regular toileting, either in the morning or after meals when there is increased colonic motor activity. Biofeedback may have modest short-term benefits, but the long-term effect is questionable (168). Enemas and suppositories can be used in conjunction with bowel regimens. It is also reasonable to attempt a trial of any of the laxatives listed in Table 28.10. Stimulant laxatives are commonly used, but questions remain about the development Table 28.10 Laxatives for the Treatment of Disordered Defecation PO, by mouth; PR, per rectum. From Wald A. Approach to the patient with constipation. In: Yamada T, ed. Textbook of gastroenterology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1999:921, with permission.

Bowel habits and toilet training in a diverse population of children.

To gather data concerning bowel habits and toilet training of developmentally normal children ages 5 to 8 years. A questionnaire containing information on age, race, and sex was completed anonymously by a parent in 9 pediatric practices. Recall information was elicited about onset and completion of toilet training, frequency and quality of stooling, size of bowel movements, and behavioral components of defecation. Questionnaires were completed for 1142 children. When all of the children were considered together, toilet training started at a mean of 27.2 months and was completed at a mean of 32.5 months. It began and was completed nearly 3 months earlier for girls than for boys (P<0.001). African American children started and completed toilet training at least 6 months earlier than white children (P<0.001). Of the children, 95% defecated either daily or every other day. Straining at defecation and infrequent stooling were reported significantly more often for girls, whereas staining of underclothes and passage of large bowel movements were reported more often in boys. Approximately 10% of children fulfilled criteria for functional constipation. Most of the children between 5 and 8 years of age have a medium-size bowel movement daily or every other day without straining or withholding. Although African American children toilet train at an earlier age than do white children, bowel habits appear to be similar. A sizeable subgroup of children presenting to primary care providers have a history that is consistent with constipation.

[Management of the most frequent functional gastrointestinal dis orders in healthy infants].

Healthy infants during the first year of life often have multiple functional gastrointestinal symptoms such as colic, regurgitation and constipation. The usual fuzziness and/or crying at this stage of life is interpreted as digestive discomfort or pain, and the corresponding concerns result in unsuitable behaviors as overeating, interruption of breastfeeding, multiple changes of formulas, innumerable queries and unnecessary medications. The aim of this paper is to update knowledge on the pathophysiology of the most common functional gastrointestinal dis orders, in order to avoid over diagnosis and select the most appropriate therapeutic approach and convenient nutritional interventions.

Breastfeeding

Growth The average breastfed baby doubles its birth weight in 5–6 months. By one year, a typical breastfed baby weighs about times its birth weight. At one year, breastfed babies tend to be leaner than formula-fed babies, which improves long-run health. The Davis Area Research on Lactation, Infant Nutrition and Growth (DARLING) study reported that breastfed and formula-fed groups had similar weight gain during the first 3 months, but the breastfed babies began to drop below the median beginning at 6 to 8 months and were significantly lower weight than the formula-fed group between 6 and 18 months. Length gain and head circumference values were similar between groups, suggesting that the breastfed babies were leaner. Infections Breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections) and lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria).

Clinical management of constipation.

First, it is important to find out whether the patient is complaining of infrequent defaecation, excessive straining at defaecation, abdominal pain or bloating, a general sense of malaise attributed to constipation, soiling, or a combination of more than one symptom. Second, one must decide if there is a definable abnormality as a cause of the symptom(s). Is the colon apparently normal or is its lumen widened (megacolon)? Is the upper gut normal or is there evidence of neuropathy or myopathy? Is the ano-rectum normal or is there evidence of a weak pelvic floor, mucosal prolapse, major rectocele, an internal intussusception or solitary rectal ulcer? Is there any systemic component such as hypothyroidism, hypercalcaemia, neurological or psychiatric disorder or relevant drug therapy? Choice of treatment will depend on this clinical evaluation. The range of treatments available is: Reassurance and stop current treatment: Patients with a bowel obsession may take laxatives or rectal preparations regularly without need. Increase dietary fibre: Most cases of 'simple' constipation respond to increased dietary fibre, possibly with an added supplement of natural bran. Toilet training and altered routine of life: Young people particularly may need to recognise the call to stool and alter their daily routine to permit and encourage regular defaecation. Medicinal bulking agent: Ispaghula, methyl cellulose, concentrated wheat germ or bran, and similar preparations are useful when patients with a normal colon find it difficult to take adequate dietary fibre. These preparations increase the bulk of stool and soften its consistency. They may be useful for those patients with the constipated form of irritable bowel syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Infant formula

Uses, risks and controversies The use and marketing of infant formula has come under scrutiny. Breastfeeding, including exclusive breastfeeding for the first 6 months of life, is widely advocated as "ideal" for babies and infants, both by health authorities — and accordingly in ethical advertising of infant formula manufacturers. Despite the recommendation that babies be exclusively breastfed for the first 6 months, less than 40% of infants below this age are exclusively breastfed worldwide. The overwhelming majority of American babies are not exclusively breastfed for this period – in 2005 under 12% of babies were breastfed exclusively for the first 6 months, with over 60% of babies of 2 months of age being fed formula, and approximately one in four breastfed infants having infant formula feeding within two days of birth.

[Value of a new thickened formula in infants with regurgitations].

The purpose of this open multicenter study was to evaluate the value of a new starch-thickened formula in infants with regurgitations in ambulatory pediatric practice. The study population comprised full-term infants with an age at inclusion of 1-90 days, who were bottle-fed and presented regurgitations. The formula tested was an infant formula-thickened with starch (2g/100mL). The primary endpoint was the frequency of bottles regurgitated, expressed in percentage of meals per day after 15 days of feeding with the preparation studied. Secondary endpoints were the assessment of regurgitations using the Vandenplas' score, as well as the daily increase in weight, height, and cranial circumference, overall and gastrointestinal tolerance, and formula acceptability. Sixty-four infants presenting regurgitation were included. The frequency of bottles regurgitated estimated at 80.3% at inclusion significantly decreased at D3, D15, and D30 to 40.1, 40.2 and 37.2% (P<0.0001), respectively. Thirty percent of infants did not present regurgitations at all at D30. Similarly, a significant decrease in the Vandenplas' score was observed from 1.9 at D0 to 0.9 at D30 (P<0.0001). Infant growth was similar to the French and European growth curves. The results showed rapid and lasting improvement in decreasing the frequency of feeding-bottles regurgitated by 50% from the first 3 days of using this new starch-thickened formula (2g/100mL). These satisfying results encourage the use of the tested formula in cases of infant regurgitation, in line with the European Society of Gastroenterology, Hepatology and Nutrition (ESPGHAN) recommendations.

Early and late outcomes of primary laparoscopic endorectal colon pull-through leaving a short rectal seromuscular sleeve for Hirschsprung disease.

To report early and late outcomes of laparoscopic colon pull-through leaving a short rectal sleeve for Hirschsprung disease. Laparoscopic endorectal colon pull-through was performed using 4 ports. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was carried out according to Georgeson's technique. However, we left a short rectal seromuscular sleeve of 1.5 to 2 cm above the dentate line. From January 2001 to December 2007, 200 patients were operated upon by the same surgeon. Ages ranged from 14 days to 36 months old. The aganglionic segment was located in the rectum in 112 patients, in the sigmoid colon in 80 children, and in the left colon in 8 patients. The median operating time was 152 minutes. There were no perioperative deaths. Conversion to open surgery was required in four patients. There was minimal blood loss during the surgery. Oral intakes of clear fluid were started 12 hours after surgery and advanced to formula on the second day. In 1 patient, a small intestinal perforation occurred 3 days after surgery, requiring a diverting ileostomy. The mean hospital stay was 6.6 days (range, 4-12 days). Follow-up ranging from 5 to 85 months was obtained in 157 patients; 124 patients (79%) had 1 to 4 defecations a day, 17 (11%) had 5 to 6, and 8 had more than 6. Fecal incontinence occurred in 3 patients (2.0%), constipation in 5 patients (3.0%), and enterocolitis in 15 patients (9.5%). Anastomotic fistula occurred in 2 patients. Laparoscopic endorectal pull-through leaving a short rectal seromuscular sleeve is a safe and effective procedure for Hirschsprung disease.

Pediatrics_Nelson

When rehydration is complete, maintenance therapy should be started, using 100 mL of ORS/kg in 24 hours until the diarrhea stops. Breastfeeding or formula feeding should be maintained and not delayed for more than 24 hours. Patients with more severe diarrhea require continued supervision. The volume of ORS ingested should equal the volume of stool losses. If stool volume cannot be measured, an intake of 10 to 15 mL of ORS/kg/hr is appropriate. Parenteral nutrition (PN) is necessary when enteral feeding is inadequate to meet the nutritional needs of a patient. Enteral nutrition is always preferred because it is more physiologic, less expensive, and associated with fewer complications. Fewer complications are expected if at least some nutrition can be provided enterally.

The Magnesium-Rich Formula for Functional Constipation in Infants: a Randomized Comparator-Controlled Study.

To compare the effectiveness of the magnesium (Mg)-enriched formula vs. control formula in constipated infants. An open-label, interventional, and the comparator-controlled study was conducted to evaluate the effectiveness of the Mg-enriched formula in formula-fed infants ≤6 months old presenting with functional constipation according to modified Rome IV criteria. Infants were randomized 1:1 to intervention or control formula for 30 days. Parents recorded stool consistency (hard, normal, or watery) and frequency on days 1-7 and 23-29. Physicians recorded patient baseline characteristics and performed the clinical examination at the time of three patient visits (baseline, day 8, and 30). Of the 286 recruited infants, 143 received the Mg-rich formula and 142 received the control formula. After 7 days, significantly more infants had stools with normal consistency with the Mg-rich formula compared to the infants fed with the control formula (81.8% vs. 41.1%; <ip</i<0.001). The number of infants passing one or more stools per day was increased at day 7 in the Mg-rich formula group (86.7% vs. 68.2%; <ip</i<0.001). At days 7 and 29, >25% of infants responded completely to the Mg-rich formula compared to <5% of infants fed with the control formula (<ip</i<0.001). Parents of infants in the Mg-rich formula group were very satisfied with the treatment (80.8% vs. 10.2%), with the majority willing to continue treatment after 30 days (97.9% vs. 52.6%; <ip</i<0.001). The Mg-rich formula significantly improved stool consistency and frequency compared to the control formula in constipated infants.

Pediatric Functional Constipation -- Prognosis

The frequency of mandatory toilet visits and the use of laxatives can be reduced after the child develops regular bowel habits (and uses the toilet on their own). The laxative dose is gradually reduced to prevent fecal incontinence and maintain 1 to 2 daily bowel movements. [17]