This is the most common question in constipation clinic!
The answer for most families is IDIOPATHIC…which is code for “We can’t really explain this.” Unsatisfactory? You bet.
Instead, a simple framework sorts constipation into distinct patterns that can be understood. Remember, it’s J.U.S.T. constipation.
What does J.U.S.T. stand for?
J is for Juvenile: In the first year of life, babies undergo numerous changes and are still developing. Stool patterns can be wildly unpredictable. The key to this phase is supported bowel training, in the same we ‘sleep train’, support feeding, walking and language acquisition.
U is for Unexplained: Yes, for some children we never quite find a rational explanation. The strategy here is accepting the tendency towards constipation and managing well with diet, medications etc.
S is for Syndromic: There is an overarching diagnosis that comes with a tendency to constipation e.g.
Children with developmental delay on long term tube feeding have a restricted, low residue diet
Children on the autism spectrum may have sensory issues that hinder defaecation dynamics, or restricted diets that pre-dispose to constipation
T is for Transitional: Seen in toddlers and older at times of transition e.g. home to nursery or school, toilet training, travel. Withholding behaviour , prolapse and anal fissures are common in this group. The key for this group is breaking the cycle, establishing a bowel routine and long-term dietary hacks.
Very rarely, an underlying and serious problem i.e. Hirschsprung’s disease, can be detected on biopsy.
Importantly, most biopsies done are actually negative.
However, it can be tricky moving forward with recommended treatments if there is an outstanding concern.
For parents, it can be quite difficult to decide if the time has come to discuss a biopsy with your paediatrician.
Paediatric surgeon’s are best placed to review and advise. We manage Hirschsprung’s disease and will have a good sense of whether a biopsy is needed or not.
As their parent, you know them best and will be able to explain in language they will understand.
The hospital environment is scary and disorienting and should definitely not come as a surprise.
Many hospitals have orientation videos on their websites and play therapists to offer distraction.
Trust that the anaesthetist will have met every variety of anxious child and family before. Getting your child through this is what they do best.
Younger children may come for a “special day at the doctor’s…and get a special sticker (dressing / plaster). “
Older children will be “go to hospital and meet some doctors and nurses to help with the problem…”
What about feeding before surgery?
Your hospital will send you clear instructions about when to stop food, feed and fluids.
The risk of milk or food ending up in the wrong place during surgery far outweighs the unpleasantness of a hungry, angry child.
If the team seem blasé about keeping your child hungry, it is because they will have seen nasty chest infections arising from full stomachs at the time of anaesthesia.
Instead, focus on a lovely, comforting feed or meal after surgery, once it is safe and allowed to do so.
Should I read up on the operation?
Yes, if you want to.
We live in an information age and most doctors understand this.
Some people are quite happy to know only as much as they need to know, and trust the knowledge and experience of their team.
Some people need to do their own research! And that’s ok.
Pro tip: we also live in the disinformation age!
Just because you’ve read a lot doesn’t mean you are in full command of all the facts. You will have the chance to discuss the matter with a subject specialist, who also has the benefit of experience. Use the opportunity to lean into this knowledge to make the best decision for your child.
Paediatric surgeons with higher surgical training and accreditation to operate on children.
Adult surgeons with training and experience to perform specific surgeries for common childhood problems e.g. appendicitis , testicular pain etc are common problems that are treated most commonly be general surgeons.
How can I tell?
Ask your GP: For planned care, ask your GP. Your GP makes the referral, they have a good understanding of their local services and can direct you appropriately.
Ask your surgeon: For emergency care, ask your surgeon. This is an expected and appropriate to establish these facts as part of consent for surgery.
Ask the hospital: e.g. Google search [Hospital name + paediatric surgeon + surgery]. Every hospital has a website and staff directory. It should be possible to find out whether there is a paediatric surgery department in that hospital.
Ask the GMC website: Every doctor registered to practice is listed in this searchable database. Their specialist qualifications are also listed, as this is a GMC registration requirement.
Does it matter?
This depends on the condition you require treatment for.
In an emergency, the NHS systems are pretty good at making sure your child is stabilised first, then transferred to a more specialised centre if needed. Hospital’s work in established networks. You can trust the system. However, it is also okay to ask whether your child needs to be transferred.
For planned care, the NHS constitution means you can ask for referral to a specific NHS provider. Your GP is best placed to advise you when they make the referral.
What should I ask?
Is this hospital used to looking after (children this age? children with needs like my child? children needing a surgery like this?)
It can be awkward. But trust me, this is a question that I expect to be asked as a surgeon. All parents understandably want to know who is looking after their precious child.
Pro tip: Ask the nurses. They often know everything there is to know about how the hospital works and can often put your mind at ease.
What about private surgeons?
The advice above applies. Private hospitals check surgeons rigorously before they add them onto their list or providers. One of the checks involves making sure their private work is similar to their NHS work.
This “scope of practice” check ensures that doctors are offering treatments that they would ordinarily offer in their normal NHS role.
GP’s are a great source of advice. Equally, double-checking the surgeons NHS role, and their GMC registration information, will be informative.
What about the anaesthetic?
Most surgery for children requires a general anaesthetic.
Surgeon’s work within hospitals where safe anaesthesia for children can be offered. Each centre will have an established age of care, outpatient and inpatient arrangements.
A child getting burned is a nightmare scenario for any parent or caregiver. Burns in children are most commonly scalding accidents (80%) involving hot water or steam, or open flame burns (14%).
Burns lead to trauma and disability, and can result in a long hospital stay, multiple surgeries and sometimes, life-long impairment of functions. Generally, the more severe the burn, the more likely your child is to need hospital admission, critical or intensive care, and surgery.
First steps: Assessment of burn severity
First aid involves making the child safe (e.g. remove them from the hazard, extinguish the flame etc) and arresting the burn process. This is done by cooling. Remove clothes involved in the scald or burn, irrigate the area with cool water. Cooling cloths, cooling gels as you take the child to the medical centre will help.
Your treatment team will need to decide whether the burn is a “see and treat” or a “see and send”.
This decision is based on burn severity. These grades are assessed based on several factors:
1.Size of burn area: There are several ways to assess area burned. Generally, the team will map the burned areas and assign a percentage e.g. 15% burns.
2. Depth of burn: You may have heard of 1st, 2nd and 3rd degree burns.
3. Body areas
4. Mechanism
A 1st degree burn is superficial and affects the top skin layers. It is quite painful and may increase redness in that area, but the skin remains unbroken in most parts. Scalding injuries and sunburn are good examples.
2nd degree burns involve deeper layers of the skin. The skin is broken , blistering and weeping in parts. These are painful too, as the nerves within the deeper skin layers are triggered. Contact injuries e.g. hot iron, can create burns like this.
3rd degree burns are deeper still. All the skin layers are burned, leaving connective tissue overlying the fat and muscles (fascia) exposed. These take on a dry, waxy, leathery appearance. These are severe because these deeper structures tissues will need to be covered , and skin may need to be taken from other body areas (grafted) to achieve this.
Special body areas:
Burn site matters. Burns to certain body areas are considered severe, due to the level of disability or disfigurement resulting. These special areas are:
1. Face
3. Airway/ inhalation injuries: a burn that affects the throat externally or internally can lead to breathing problems
2. Genitals and perineum
4. Hands and feet
Special mechanisms
Some mechanisms of injury can cause more damage than others. For example:
-Electric burns have an unpredictable course, causing damage between the current’s entry site and its final discharge site
-Chemical burns may need specialised treatment with neutralising agents
If in doubt, treatment teams can seek specialist input from a hospital specialised to deal with burns.
The burn is severe. Now what?
Small and superficial burns can be treated with first aid. Treatment teams will make a plan for pain control, and monitoring the burn area to ensure there is no infection developing. However, the body heals by forming scars. Therefore, burns in sensitive areas e.g. hands will need a plan for follow-up, to ensure that scarring does not lead to disability.
More severe burns need immediate stabilisation. The child will receive a cannula and a drip will be started. Keeping the child hydrated is part of immediate resuscitation.
If there is significant concern about fluid loss, a catheter tube may be used to empty the bladder and measure urine volume produced.
If there is concern about the throat closing over due to smoke inhalation or face and neck burns, a breathing tube may be placed to secure the airway and enable breathing.
Bigger, deeper burns, or burns involving special body sites need specialist review i.e. “see and send”.
Different countries and regions have diverse ways of organising burns services. However, the priority for treatment is:
Early
–effective pain control
-prevent dehydration from fluid loss
-prevent infection, leading to sepsis
During this phase of injury, severe cases may require treatment in intensive care, to support breathing , circulation and sepsis prevention and treatment. General and plastic surgeons may be involved , to begin the management of wounds and supported healing.
Mid term to late
-prevent scarring
-prevent loss of function / disability
For this phase of injury, the child may need input from general and plastic surgeons with specialist knowledge in this area.
Importantly, the psychological consequences of injury should be considered and support put in place.
Non-accidental injury
As part of a child’s safety, treatment teams will think about non-accidental injury. Treatment teams must consider the mechanism of injury, and how it may be prevented from happening again. This will involve a review of the child’s medical, social and education history. Parents and care givers may be asked probing questions. Ultimately, the goal is to prevent further episodes and ensure the child’s and family’s safety.
Global trends
In 2018 the World health organisation launched the Global Burn Registry. From these data, it appears that burns occur most commonly in children from middle-income countries. In 2021, review of these data demonstrated and average age of 5 years, and that 60% were boys.
Circumcision referrals are a common feature in general paediatric clinics. Indeed, cicrumcision is the described as the world’s most popular surgery.
Here’s some valuable information to help filter physiological and pathological foreskins, from London Children’s Surgery.
What is the natural history of the foreskin?
This much-quoted study (Gairdner, BMJ 1949) provides a useful summary of the natural history of the foreskin.
Oster’s follow-up paper (Oster, Arch. Dis. Childh, 1968) should be read simply for its cracking opening paragraph. It also contains useful data on phimosis, preputial adhesions and smegma in Danish boys.
We expect partial or full retraction at the following frequencies:
–Birth: 4%
–Up to 6 Months: 20%
–1 year : 50%
–3-11yrs: 90%
–12-13yrs: 95%
–14+yrs: 99%
Therefore, most foreskin reviews will demonstrate physiological phimosis, and parents can be reassured.
These are frequently used in primary care. The therapeutic goal is making the foreskin more supple. Steroids achieve this by suppresing fibroblast activity, causing thinning of the skin. However, they do have an anti-inflammatory and immunosuppresive effect. This limits their role to pulsed treatments.
Evidence:
-Systematic review, Moreno et al, 2014: Included 12 comparative studies (1395 boys). Compared with placebo, corticosteprids increase the probability of achieving partial or full retraction (RR2.45, 95CI1.84-3.26_
-New South Wales, Wright et al, 1994: 80% retractability achieved in 111 boys completing this betamethasone study
-Barcelona, Orsola et al, 2000: 90% of 137 boys treated with betamathosone with retraction had improvements in retractability
Betamethasone 0.05% applied twice a day over a 4-week period , is a commonly used protocol.
Other steroids favoured include hydrocortisone, clobetasol and triamcinilone.
Golubovic et al, 1996, found a higher frequency of inproved retraction (19/20) in boys treated with betamethasone, compared with boys treated with vaseline alone (4/20 improved).
Importantly, any stretching should be done by the child, who will limit the stretch to what is comfortable. This will avoid secondary scarring.
What is pathological phimosis?
Pathological or True phimosis occurs when the foreskin is scarred. This is seen in :
1. Balanitis xerotica obliterans
2 Scarred balanoposthitis
Circumcision for UTI of reflux ?
UTI and VUR are described in depth elsewhere.
For the purposes of circumcision, a decision for each patient must be made. However, where surgery is proposed as prophylaxis, keep in mind the numbers needed to treat.
Number needed to treat
rUTI : 111 circumcisions to prevent 11 recurrent UTIs
VUR: 111 circumcisions to prevent 4 UTIs in boys with high grade reflux
Constipation is a common problem in childhood. Very rarely, an underlying and serious problem i.e. Hirschsprung’s disease, can be detected on biopsy. Importantly, most biopsies done are actually negative.
For parents, it can be quite difficult to decide if the time has come to discuss a biopsy with your paediatrician.
This is a question many parents will ask. Where there is a medical reason to do a circumcision, parents should have a good understanding of the indications, to prepare for the discussion with a specialist.
Where there are no religious or cultural reasons to have a circumcision, parents should get as much information as possible from a specialist source.
This is a very common condition where the tongue is tethered to the floor of the mouth by a cord or frenulum. There is no obvious cause for this condition, it’s just one of the variations in how we all are made.
In most babies this finding does not cause any problems. However, some babies can experience problems feeding.
The main issue is difficulty breast feeding e.g.
difficulty establishing and maintaining a good latch
cannot seal mouth around nipple, leading to leaking
very painful nipples after prolonged attempts to latch
Advice from a midwife or lactation specialist is important before you consider tongue tie division as many issues can be overcome with adapting technique and breastfeeding aids. ndicated, the procedure is called a tongue tie release.
Tongue tie release procedure
In newborn babies and infants < 6 months, this can be done without a general anaesthetic. Baby is wrapped tight and sterile scissors are used to divide the cord of the frenulum. A little blood spotting is expected. Once this settles, baby is returned to parents for a feed.
We usually recommend that the baby is fed immediately after the procedure.
It is important to observe for a period to ensure there are no immediate complications.
Can tongue tie cause speech problems?
There is very little evidence that a tongue tie affects speech development. Some children who have very severe tongue ties may struggle with the pronunciation of certain letters.
Can baby grow out of this?
In many cases the frenulum stretches as the baby grows.
If baby is already established on bottle feeding and is able to do this effectively, it is possible to wait and see if the tongue tie resolves.
Does the procedure hurt?
It is difficult to be certain that the baby feels no pain at all, however the procedure takes only a few seconds and most babies do not appear to experience any discomfort.
Given the balance of risks, a few seconds of discomfort is often preferred to a general anaesthetic.
Are there any risks?
Complications are rare and recovery is immediate. However, you will be counselled about the following risks:
Persistent bleeding: this is usually minor. It occurs if the division if extended too far into the base of the tongue, or if there is an underlying clotting problem.
Recurrence: this is the risk of needing a repeat procedure as the tongue heals back into a tethered position.
The procedure may make no difference to breast feeding
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