2 paragraphs responding to student. Adding to the discussion or disagreeing professionally. See attachment
Case Scenario 1: Russell is a 7-year-old boy who weighs 50 pounds. He is frequently
teased at school because he soils his pants and is called the “stinky kid” by his peers. His
mother states that this has been occurring for the past 8 months. She brought him into
the clinic because she thinks he might have an intestinal infection. She also reports that
once a week, he has very large bowel movements that completely clog the toilet.
What more does the APRN need to know about Russell’s bowel problems?
To determine if there is underlying constipation for an appropriate treatment plan. As
noted in Garzon Maaks et al. (2020), history taking can include these questions:
• Is there a significant family or child history related to stooling (e.g., Hirschsprung,
constipation in infancy, late meconium passage)
• Does the child complain of abdominal pain, bloating, or loss of appetite?
• How often does the child have a bowel movement?
• Are there situations when the child refuses to defecate or urinate (e.g., at school, in
public bathrooms, when playing)?
• Describe the process of when the child defecates (e.g., painful? Child resists using the
toilet? Child hides, defecates outside the toilet?).
• What is the quality of stool (e.g., ribbon, hard, large-caliber)?
• Describe any issues with hygiene (e.g., stained underwear, odor, leakage of stool).
• Does the child have enuresis? A history of UTIs?
• Are there any major family or life adjustments?
• Does he have any history of behavioral issue?
• Does he have a fear or feel uncomfortable of going to unfamiliar bathrooms, such as
bathrooms at school?
On physical examination, the APRN should assess for:
• Overflow soiling
• Abdominal distention
• Abdominal tenderness on palpation
• Mass felt at the midline in the suprapubic area (descending colon)
• Anal fissures
• Sacral dimple or hair tuft
• Neurologic signs: absent or diminished abdominal, cremasteric, anal wink reflexes,
and deep tendon reflexes (DTRs) in lower extremities.
What type of diagnostic testing should the APRN order?
Tabbers et al. (2014) recommended:
• Abdominal flat-plate radiograph or a KUB (kidney, ureter, bladder) when fecal
impaction is suspected. It can show stool accumulation in the sigmoid colon.
• TSH and Free T4 can be done to ensure that fecal retention is not associated with
hypothyroidism.
• Sweat chloride test to ensure that fecal impaction is not associated with cystic
fibrosis.
Based on Rome IV criteria, encopresis with functional constipation is the diagnosis of
choice. Patient met 2 of the criteria for functional constipation: (1) soils his pants at least
once per week, (2) large stools that can obstruct the toilet. This has been going on for 8
months.
Differential diagnosis includes:
• Hypothyroidism: Hypothyroidism slows down metabolic process and reduce
gastrointestinal motility.
• Cystic Fibrosis: thickened mucus reduces intestinal motility, leading to stool
retention.
• Encopresis without constipation: Children with functional non-retentive fecal
incontinence are not constipated but have overflow incontinence. They may exhibit
more behavioral problems or may have developmental delays
What treatment plan should the APRN prescribe and what is the rationale for this
treatment? Include dosages and administration instructions if appropriate
• The goal of therapy is for the patient to have 1 to 3 bowel movements per day in the
toilet, with no episodes of soiling (Hyams et al., 2016). Bowel evacuation using oral
polyethylene glycol (PEG) solution: PEG 4050 11.4 g, by mouth twice daily. Take 3-5
days or until stool output is runny. PEG can be premixed and refrigerated for 48
hours. For maintenance, PEG 4050 starting at 0.4 and up to 0.8 g/kg/day PO in two
divided doses. Adjust daily medications to achieve one to three soft, mushy stools
per day. Continued treatment for at least 1 month after all symptoms are resolved.
Gradual tapering of laxative. PEG solutions are effective as enemas and are
preferred, as they are better tolerated and more acceptable.
• Bowel retraining to establish a regular pattern of stooling.
• Ongoing maintenance with medications as needed.
• Regular toileting hygiene to prevent recurring constipation.
• Ensure adequate fluid and dietary fiber intake.
• Child mental health referral may be indicated if there are indications that mental
health interventions may be helpful to the child and/or family.
References
Garzon Maaks, D. L., Starr, N. B., Brady, M. A., Gaylord, N. M., Driessnack, M., &
Duderstadt, K. (2020). Burns’ pediatric primary care (7th ed.). Elsevier.
Hyams, J. S., Di Lorenzo, C., Saps, M., Shulman, R. J., Staiano, A., & van Tilburg, M.
(2016). Childhood Functional Gastrointestinal Disorders: Child/Adolescent.
Gastroenterology, 150(6), 1456-1468.e2.
Tabbers, M. M., DiLorenzo, C., Berger, M. Y., Faure, C., Langendam, M. W., Nurko, S.,
Staiano, A., Vandenplas, Y., & Benninga, M. A. (2014). Evaluation and Treatment of
Functional Constipation in Infants and Children. Journal of Pediatric Gastroenterology and
Nutrition, 58(2), 265–281.
