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					 Topics in Pediatric

Kathleen M. Gura Pharm.D., BCNSP, FASHP
        Departments of Pharmacy and
Division of Gastroenterology/Clinical Nutrition
          Children’s Hospital Boston
Learning Objectives
 Review to common causes of constipation in the
  pediatric patient and the methods used to treat and
  prevent recurrence

 List the treatment measures used to manage patients
  with toddler’s diarrhea
Magnitude of the Problem

 16% of toddlers, 8% school age children
 3% of pediatric outpatient office visits
 25% of pediatric gastroenterology consults
 parental distress
Pediatric Constipation

       Definitions
       Red flags
       Testing
       Management

 Definition:
 - a delay or difficulty in defecation, present for 2 or more
  - based on stool character, not frequency
 - any deviation from the norm
 Occurrence
 - 3% of GP OPD visits
  - 25% of pediatric GI consults
 Etiology
  - organic (rare) - less than 5% of all affected patients
  - functional (idiopathic constipation/functional fecal
  retention/withholding constipation)

 Too hard
 Too large
 Painful
 Infrequent
 practically unknown in breast fed infant
  receiving adequate amount of milk
 rare in formula fed infants fed adequate
  amounts of formula
 nature of stool, not frequency, is basis for
            Formula Fed Infant
 associated with inadequate intake
 diet too high in fiber/protein insufficient in bulk
 increase fluid intake may be sufficient for
 older infants: add or increase cereal, fiber ,
  - prune juice 1/2 -1 oz short term remedy
 Normal Frequency of Bowel
  Movements/Week by Age

15                                                     95%
     0-3 months   6-12 months   1-3 years   >3 years
  Normal Frequency of Bowel

           Age                    BM per week     BM per day

0-3 months
      Breast milk                        5-40        2.9
      Formula                            5-28        2.0
6-12 months                              5-28        1.8

1-3 years old                            4-21        1.4

>3 years old                             3-14        1.0

Adapted from: Acta Paediatr Scan 1989; 78:682-4
Age of Onset of Stooling Problems

 Neonatal – probably congenital cause
 < 1 year of age: suggests dietary cause
 > 18 months: suggests behavioral cause
Organic vs Functional
 Organic
  - acute onset

 Functional
  - chronic
  - large caliber stools
Organic Constipation
 Should be ruled out first
 Examples
 Anatomic – anorectal abnormalities
 Neuromuscular disorders
 Hirschsprung’s disease
 Dietary factors
 Always consider sexual assault
Family History
 Constipation
 Hirschsprung’s Disease
 Celiac Disease
 Cystic Fibrosis
 Thyroid Disease
 Parathyroid Disease
 Colon cancer/colonic polyps

 History
     Delayed meconium
     Poor growth
     Bloody stools
     Urinary Incontinence
     Weight loss
     Abdominal pain

 Physical Exam
     imperforate/stenotic anus
     anterior anus
     sacral dimple or tuft
     distended abdomen
        Functional Constipation

 Most common
 No evidence of a pathological condition
 Commonly due to painful BM with subsequent
 voluntary withholding of feces
  - causes: toilet training, stress, dietary changes,
 illness, unavailability of toilets, too busy
 - leads prolonged fecal stasis in colon, fluids
 reabsorbed, increased in stool size/consistency
Common Withholding Behaviors
 Squatting
 Crossing ankles
 Stiffening of body
 Holding onto mother, furniture
 Flushing, sweating, crying
 Hiding during defecation
 Thorough medical history imperative
  -time after birth until first BM
  -family/child’s definition of constipation
  -length of time the condition present
  -frequency/consistency/size of BM
  -medication use
 Physical exam
  -external exam of perineum & perianal area
Labs (if necessary)
 Thyroid function test
 Serum electrolytes
 Serum calcium
 Serum magnesium
 Blood lead level
 Celiac panel
         Medications Associated
           With Constipation
 anticholinergics    aluminum containing
 antidepressants        antacids
 neuroleptics          sucralfate
 antihistamines        calcium supplements
 iron salts            NSAIDs
 narcotics             Diuretics
 calcium channel       Vinca alkaloids
         Treatment of Constipation in
           Children< 1 Year of Age

 Barley malt soup extract
  - breast fed: 5-10 mL in 2-4 oz. water BID
  - formula fed: 5-10 mL q 2nd feeding
 Dark Karo syrup 1 tsp BID if < 2 months old
  - > 2 months: 2 oz apple or prune juice BID
  - 6 months: high fiber foods (prunes/plums)
 Osmotic dehydrating agent
 Increases osmotic pressure, draws fluid into
  colon and stimulates evacuation
 Wet suppository first to avoid stinging when
 Insert suppository high in rectum and retain
  for 15 minutes
 Onset of action 15-30 minutes
      Management of Constipation
      in Children > 1 Year of Age
 Education
 Disimpaction
 Maintenance
 Behavioral modification
 Explanation of pathogenesis of constipation
 Remove negative attributions associated with
  fecal soiling
 Parents must be encouraged to maintain a
  consistent, positive, supportive attitude
 May be necessary to repeat during different
  phases of treatment
 Fecal impaction – hard mass in lower
  abdomen, dilated rectum filled with large
  amount of stool, or excessive stool in the
 Disimpaction necessary prior to starting
  maintenance therapy
 Oral or rectal medications used alone or in
Oral Medications
 Not invasive
 Gives sense of power to the child
 Adherence to regimen problematic
 Examples:
  - mineral oil
  - polyethylene glycol electrolyte solutions
 Magnesium salts/lactulose/senna/sorbital/
  bisacodyl laxatives may also be used
                       Mineral Oil

 Use with caution in patients < 4 years of age due to
    increased risk of aspiration
   MOA: eases passage of stool by decreasing water
    absorption, softens stool, lubricates the intestine
   Onset of action: 6-8 hours
   Emulsified form more palatable that non emulsified forms
   Supplement with MVI is used chronically
   Dose: 1-2 ml/kg/dose qd -bid
     5-11 years: 5-15 mL po qd or in divided doses
    > 12 years: 15-45 mL po qd or in divided doses
Milk of Magnesia
 Magnesium hydroxide 400mg/5mL
 Dose: < 2 years:0.5 mL/kg/dose
      2-5 years: 1-2mL/kg/dose bid
                or 5-15mL/day
      6-11 years: 15-30 mL/day
      >12 years: 30-60 mL/day
 May cause abdominal cramping in higher
     Polyethylene Glycol-Electrolyte
 Go-LYTELY, Co-Lyte, MiraLax
 Usually used in the inpatient setting for bowel
 MOA: osmotic effects
 Dose:
   Occasional constipation: MiraLax™(oral)
   Children: 10-30 kg, 8.5 g daily
   Adults: 17 g (1 heaping tablespoon) daily
 May need to taper dose over time
 Onset of action: bowel cleansing 1-2 hrs
  constipation: 2-4 days
 Acts as local irritant on the colon, stimulates
    Auerbach’s plexus to produce peristalsis
   Docusate may enhance the absorption of senna
   Can be used in infants > 1 month of age
   Available as tablet, granules, syrup
   Tastes awful – mix with plenty of water, juice or milk
   Avoid prolonged use
   May discolor urine, feces
   Onset of action (oral): 6-24 hours
 $$$$$ Laxative
 Dose:
  children: 1 ml/kg dose q24 hours or bid
           7.5 mL/day (5gm/day)
  adults:15-30 mL/day (10-20 gm/day),
         increase to max. 60 mL/day(40gm/d)
 Monitoring: fluid status, stool output
 May cause abdominal cramping /flatus
 Upon d/c of therapy, allow 24-48 hrs for resumption
  of normal bowel movements
Rectal Disimpaction
 Faster but invasive
 Therapies
  - phosphate soda enemas
  - saline enemas
  - glycerin suppositories
  - bisacodyl suppositories
 Soapsuds/tap water/magnesium enemas
  should not be used
 Digital disimpaction
Phosphate Enema
 Exerts an osmotic effect in the small intestine
  by drawing water into the lumen of the gut,
  producing distention, promoting peristalsis,
  and evacuation of the bowel
 Onset of action: 2-5 minutes
               Maintenance Therapy

 Focuses on prevention
 Typically continued for first several months
 Goal: 1 soft stool per day
 Dietary interventions
 Medication
Maintenance Therapy
Dietary interventions
  - increased fluid intake
  - increase absorbable/nonabsorbable
  carbohydrate intake (sorbital containing fruit
  juices: prune, pear, apple juice)
  - balanced diet of whole grains, fruits,
  - increase fiber intake
  - child’s age + 5 gms = daily fiber intake
 Stool softener
 Reduces surface tension of oil-water interface
  of the stool, allowing more water and fat to be
  incorporated into stool
 Do not administer with mineral oil
Docusate with Casanthranol
 Stool softener and laxative
 Casanthranol –stimulant laxative
  - may result in laxative dependence with
  prolonged use
 Onset of action: 8 – 12 hours
Behavioral Modification
 Important component
 Unhurried time on toilet after meals
 Diary of stool frequency (combine with reward
 Goal: achieve regular bowel movements
 Optimizes behavioral modification
 Use laxatives until child can maintain regular
 Daily treatment
  -lubricant laxatives (mineral oil)
  -osmotic laxatives (magnesium hydroxide,
  lactulose, sorbital)
  -stimulant laxatives for daily use not
Rescue Medications
 Used to avoid recurrence of impaction
 Consists of stimulant laxatives
  - senna
  - bisacodyl
  - glycerin suppositories
 Stimulant laxative
 Typically not used in neonates/infants
 Stimulates peristalsis by directly irritating the smooth
  muscle of the intestine
 Tablets- enteric coated – don’t take with milk/antacids
  or crush
 Not for regular use
 Onset of action:
  oral: 6-10 hours
  rectal: 15-60 minutes
 Associated with constipation (93%)
  - responds well to treatment
 Not associated with constipation (7%)
  - difficult to treat
Encopresis with Constipation
 Painful bowel movements
 Withholding stool
 Colonic dilation/impaction
 Impaired sensation
 Overflow incontinence
 Evacuation of impacted stool
  - repeated mineral oil or Fleets enemas
  - soap suds, tap water, or herbal enemas
    should not be used
 If enemas are not successful, patients may be
  admitted for oral or NG administration of PEG
  electrolyte solution
 Initially, diet should be low in fiber and dairy products
Encopresis Suggested Treatment
 Milk of magnesia
  - 60 mL q.i.d. x 3 days, then 30 mL q hs
 Up early, breakfast qd
 On toilet after each meal
 Follow up 1 month, then prn
Encopresis Management, Later Stages
 Usual treatment 6 months – 2 years
 Taper medication gradually
  - start when no soiling seen 2-3 months
  - reinstitute immediately if soiling recurs
 Increase fiber intake when tapering initiated
 Case 1
A six month old white male infant is brought to the emergency room
with a chief complaint of constipation. He was the seven pound
product of an uncomplicated full-term pregnancy. He was
discharged from the nursery in the first twenty-four hours of life. He
has been exclusively breast fed since birth. During the first several
weeks of life, he would pass bowel movements approximately once
every three to five days. As an infant, his stools were extremely
loose, and often quite explosive. More recently he has been
passing stools only once every week or so and his abdomen has
become more and more distended. He was brought to the
Emergency Room because he has not been nursing well for the
past two days, and this evening he became quite fussy and had
several episodes of vomiting.
 Physical Exam

 He is an alert, well-grown male in no distress
 His examination is remarkable for a very distended
 Inspection of his perineum is normal. On digital rectal
  exam, he has a tight anal sphincter with a small
  empty rectum.
 Immediately after the exam, he produces and
  explosive watery stool.
 An abdominal film is performed while he is in the
  Emergency Room and demonstrates a massively
  dilated colon filled with stool.
Case 2
 A 6 year old boy is brought to the office with
 the chief complaint of being constipated. He
 was toilet trained without difficulty at 3 years
 of age and has had no problems with
 urination. He has been gaining weight and
 growing well. How would you evaluate this
Differential Diagnosis

   Functional or voluntarily withholding of stools leading to soiling
   Hirschsprung's Disease- agangliosis
   Anal stenosis or anal strictures
   Anteriorly placed anal opening
   Obstruction of the gastrointestinal tract
   Hypothyroid disease
   Hypokalemia
   Hypercalcemia
   Neuromuscular and spinal cord diseases
   Drugs (narcotics/vincristine/antacids)
   excessive milk in diet, poor fluid intake, lack of bulk in diet
   Botulism
Patient History
 How often does the child have a bowel
 What is the consistency of the stool?
 Is there pain when he goes to the bathroom?
 Does he have associated abdominal pain?
 Are the stools so large that they are
 Is there blood in the stools?
 Does he sit on the toilet?
 How is his diet?
 Age when potty trained
Physical Findings
 Abdominal exam palpating for masses or
  hard stool
 Rectal exam. In Hirschsprung's disease the
  ampulla will be empty and in encopresis the
  ampulla is often full of stool.
 Anal inspection for fissures that can cause
  painful stools
 Reflexes and strength in the lower extremities
 Inspection of the underwear for soiling
 Growth and Development

   If you suspect Hirschsprung's disease, need
    surgical consult for biopsy

   Diet manipulation with plenty of fiber and fluids

   Stool softeners and gentle laxatives may be
    helpful. Prune juice or Maltsupex may be tried.
If you suspect encopresis….
Discussing the problem with the parents and child is important.
      - The child should be instructed to sit on the toilet for 10
   minutes after all meals.
       - The goal is not to have a bowel movement at first, but to
   learn to sit on the potty.

The child should be started on mineral oil at night to lubricate the
  lower intestinal tract and decrease the pain associated with
  passing stool.

Laxatives may also be tried. Enemas may be necessary.

Lots of encouragement to the child and the family is important and
   follow-up should be arranged in 1-2 weeks.
 Occurs commonly
  -second only to URI’s as a cause of illness in
  children < 5 years of age
 1-2 episodes/annually for first 5 years of life
 Risk of severe illness/death due to
  dehydration still a concern, especially in
  children < 2 years of age
Diarrhea - Definition
 Many individual variations for normal stooling
 Noticeable/sudden change in:
  - number of stools
  - consistency
  - fluid content (increased)
  - color – often green
              Types of Diarrhea

• Osmotic
  - malabsorption of nutrients/water/lytes
  - mucosal disease
• Secretory
  - exogenous factors
  bacterial toxins/laxatives/diuretics
  - endogenous factors
  bacterial enterotoxins/hormones/defective
  transport of sodium or chloride
Acute Diarrhea
 In the US, over 200,000 children < 5 yrs
  hospitalized annually with gastroenteritis
 Approximately 300 children <5 die of
 Incidence: 1.3-2.3 episodes/yr children <3yrs
 Caused by virus, bacteria, or protozoa
 Most common cause viral: Rotavirus
Bacterial Diarrhea
 Abrupt onset
 Fever
 Abdominal pain
 Tenesmus
 Mucus and/or blood in stool
                Viral Diarrhea
 Can occur at any age, most often in children
  < 2 years
 Fever rare
 +/- vomiting
 Unusual to have leukocytes
 May include other household members
 Usually in cooler months (November- May)
 More common with increase in world-wide
 May be asymptomatic
 Consider if diarrhea chronic and
  accompanied by weight loss
 Common in daycare, campers, children
  taking swimming lessons
 Persistent diarrhea
 May see weight loss, poor growth
 Treatment
  - metronidazole
  - 10-20% failures
Clostridium Difficile
 Profuse watery diarrhea, cramps, pain
 Appears 4-10 days after antibiotics initiated to
  4 weeks after antibiotics dc’d
 Can occur with any antibiotic
 Most commonly seen with:
  - clindamycin, cephalosporins, penicillins,
  erythromycin, trimethoprim/sulfa
 Diagnosis: + C. difficile toxin assay
 Treatment: oral metronidazole,oral
 Antibiotic with anaerobic and antiprotozoal
  coverage as well as an amebicide
 Dose: 30 mg/kg/day in divided doses
   - max dose 4 gm/day
 Interacts with alcohol
  - review all liquid meds (ex. ranitidine, OTC’s)
  - avoid alcohol at least 48 hrs after last dose
 Reduce dose in hepatic insufficiency
 May cause metallic taste

 Should not be first line therapy for C. difficle
  - metronidazole is first line
 Dose: po: 125-250 mg po QID
 Available as capsule or oral solution
 E Coli 0157
 Enterohemorrhagic
 Hemorrhagic colitis
 Hemolytic uremic syndrome (HUS)
 Watery diarrhea, cramps, +/- vomiting
  -diarrhea bloody in 1-2 days
 HUS (2-13% patients)
  - 2nd week after diarrhea resolved
  - hemolytic anemia, thrombocytopenia, renal
Acute Diarrhea Assessment
               History          Physical Exam
   Onset/duration        Hydration status
   Frequency, color      Tears, weight, mucus
   I &O                   membranes, skin turgor,
   Other symptoms         cap refill
   ? Travel              If > 10% dehydration
   Family history         check electrolytes
   r/o ingestions
   daycare
 Microscopic exam for leukocytes
 Stool cultures if gross or occult blood,
  diarrhea > 7 days, or if rotavirus (-) and (+)
 Consider wet mount for amoebas if (+) blood
Dehydration Fluid Therapy
Goals of Therapy
 Restore circulatory volume
 Restore combined intracellular & extracellular
  deficits of water and electrolytes
 Maintain adequate water and electrolytes
 Resolve homeostatic disturbances (e.g.,
 Replace ongoing losses
Calculation of Maintenance Fluids
 Body weight method:
   < 10 kg       100 mL/kg/day
   10-20 kg 1000 mL + 50 mL/kg (for each kg > 10 kg)
   > 20 kg 1500 mL + 20 mL/kg (for each kg > 20 kg)
 Surface area method (for children > 10 kg):
                1500 mL/m2/day
      Oral Rehydration Therapy (ORT)
 Preferred treatment of fluid/electrolyte losses in
  children with mild/moderate dehydration
 Preferred over IV therapy
 Sodium content 45-50 mmol/liter (less than
  WHO ORT solution)
 Contains 2-3 % glucose to facilitate electrolyte
 Should not be confused with sports drinks
 Replace fluid/electrolyte losses but has no effect
  on duration of diarrhea or stool volume
                       Comparison of ORT Solutions
Solution                CHO      Na        K      Base     Osmolality
                       mmol/L   mmol/L   mmol/L   mmol/L

WHO/ Unicef
  ORT                   111      90       20       30        310

                        140      75       20       20        310

                        140      45       20       30        250

(Ricelyte)               70      50       25       30        200

                        140      45       20       48        265

Sports Drinks
(not appropriate for    255      20        3        3        330
Cereal Based ORT
 Starch, simple proteins co-transport
  molecules with little osmotic penalty
 Increase fluid and electrolyte uptake and
  reduces stool looses
 Contain rice instead of glucose
 Not to be confused with rice water
 Early refeeding can provide similar benefits
Early Refeeding
 If the child is not dehydrated, they should continue to
  be fed age-appropriate diets. Children who require
  rehydration should be fed age-appropriate diets as
  soon as they are rehydrated.
 When used with ORT, early feeding reduces stool
 Fatty foods/foods high in simple sugars should be
 Milk based formulas can be used
Specific Therapy
 No dehydration – age appropriate feeding +
  fluids (10 mL/kg for each stool)
 Mild dehydration – ORT 50 mL/kg +
  replacement of losses (10 mL/kg for each
  stool); feeding should resume once
  dehydration corrected
 Moderate dehydration – ORT 100 mL/kg +
  replacement of losses; resume feeds once
  dehydration corrected
 Severe dehydration- MEDICAL
  EMERGENCY correct with bolus IV fluids,
  use ORT when stable, resume feeds once
  rehydration complete
Lactose Intolerance
 Seen with gastroenteritis
 Diarrhea reappears when child is transitioned
  from ORS to cow’s milk formula
 Due to mucosal border injury
 Lactose free diet allows the brush border to
Antidiarrheal Medications
 No proven benefit in children
 Potential for toxic side effects a concern
 May decrease stool water/electrolyte losses, shorten
  course of illness, relieve discomfort
 Passage of formed stool not a measure of
  therapeutic success, may even cause false sense of
 As a general rule, should not be used to treat acute
Pharmacologic Agents
   Classified by their mechanisms of action
 Alteration of intestinal motility
 Alteration of secretion
 Adsorption of toxins or fluid
 Alteration of intestinal microflora
Drugs that Alter Intestinal Motility
 Loperamide
 Other opiates
 Anticholinergics

     Opiates as well as opiate/atropine
   combination drugs are contraindicated in
  the treatment of acute diarrhea in children.
Alteration of Secretion
 Bismuth subsalicylate
 MOA: inhibits intestinal secretion caused by
  enterotoxicogenic E Coli and cholera toxins
 Theoretical risk of Reye syndrome
 The routine use of bismuth subsalicylate is
     not recommended in the treatment of
          children with acute diarrhea.
Adsorption of Fluid and Toxins
 Work by adsorbing bacterial toxins and by
  binding water to reduce the number of stools
  and improve their consistency
 Examples:
 Disadvantages: absorption of nutrients,
  enzymes, and antibiotics in the intestine
Treatment of Diarrhea in the Older
 Dehydration less of a problem
  - able to communicate and act on thirst
 Offer low sugar, non carbonated drinks
 Continue with regular diet
  - high starch/complex carbohydrates
  - low fat
  - BRAT diet may be too low in energy and
  protein to be useful
             Toddler Diarrhea
    Chronic Nonspecific Diarrhea of Childhood

 Definition: 1 or more liquid or semi-formed
  stools per day for 14 or more days
 Careful H&P imperative
 Factors that contribute to CNDC
  - Excessive fluid intake
  - A diet high in carbohydrate, low in fat
  - Consumption of fruit juices containing
    sorbital or fructose
           Treatment of CNDC

 Alter the diet to restore balance between
  fluid, fiber, and fat
 Reduce fruit juice intake
 Increase fat intake to 35-40% of total calories
 Encourage food high in fiber
 Consult GI if no response or growth failure
Travelers’ Diarrhea
 Affects 20-30% travelers to tropics
 Mostly bacterial; 50% E.coli (not 0157)
 Prevention imperative
  -breast feeding, boiling water, no raw
  -good handwashing
           Medications Used in
           Travelers’ Diarrhea
 Prevention:
  children: co-trimoxazole
  adults: co-trimoxazole , ciprofloxacin
          bismuth subsalicylate
 Treatment:
  children: co-trimoxazole (? Cipro) + hydration
  adults: loperamide + cipro (or co-trimoxazole)
Case 1
 A 10 kg. male presents to your office with
 watery stools and a low grade fever. There is
 no blood in the stool and the child is
 approximately 5% dehydrated. How would
 workup and treat this child?
  Evaluation of the child with
        recent travel
        known exposures
        recent use of antibiotics
        attendance in daycare
        previous state of health
Physical exam
        previous weight- often not available
        Assess for level of dehydration
             Mild dehydration( 3-5%)- mucous membranes are slightly dry
              but vital signs are normal and there is normal capillary refill and
              skin turgor. Tears are usually present and child is alert.
             Moderate dehydration (6-9%)- increased heart and respiratory
              rate and slightly prolonged capillary refill, and tenting of the skin.
              Lack of tears and the child isbecoming listless.
             Severe dehydration(>10%)- blood pressure is decreased and
              the child is very lethargic. Mucous membranes are very dry.
              Skin is cold and clammy.
Deficit of 500mL (50mL/kg.)
Maintenance requirement of 40mL/hr
To correct the deficit after 6 hours, needs about
  125mL./hr. 2 tbs./15 minutes will provide the
  child's needs.
Ongoing losses should be corrected with
  10cc/kg per stool.
Other things to consider
 Breast feeding – don’t stop
 BRAT diet ?
 Drugs?
 Probiotics – yogurt ?
 Lactose free formula
 ½ strength formula
Case 2
 The parents of a 14 month old boy bring their son to
 your office with a 2 month history of 2-6 loose, non-
 foul smelling watery stools per day. At times there is
 undigested food in the bowel movement. The parents
 have gone through multiple diet changes and now the
 boy is only eating a low fat , no dairy products, lots of
 fruit juices, and minimal protein diet. He has had an
 extensive workup including negative stool cultures for
 bacteria and viruses, negative stool for ova and
 parasites, and no polys or blood in the stool. How
 would you approach this problem?
    Assessment of Toddler Diarrhea
 Age between 6-30 months. Most are better by 4 years of age
 2-6 watery stools per day. There can be periods of days without
    stools. Many stools contain undigested material and may drip down
    the child's leg from the diaper.
   Normal weight, height, and head circumference growth curves
    without falling off
   No evidence of infection
   Stools are hematest negative
   The child looks well and there is no evidence of malnutrition and no
    history of abdominal pain
   Growth may be compromised if the diet manipulations that have
    been tried to control the diarrhea have not been enough calories.
   There is often a history of colic, gastroesophogeal reflux, and family
    history of irritable bowel syndrome.
 Increase fat in the diet
 Decrease fluid in the diet
 Avoid fructose and sorbitol- decrease fruit juices
 Increase dietary fiber
 Normal diet for age
 Reassurance.
 There is no role for medications.
 The parents should be told that there is no serious
  sequelae and this is not a precursor to inflammatory
  bowel disease, chronic diarrhea as adults, or cancer
 Most children are better by 4 years of age, and are better
  by the time they become potty trained.