Measures for treatment of chronic functional locks at children
Professor of Antonio Celso CALQADO, the Associated Professor and the Director of Laboratory of Pediatric Gastroenterology, Faculty Of Medicine, Federal University Of Rio De Janeiro, Brazil
In case of chronic functional locks at the child it is necessary to consider important factors in the history of his illness; to establish good relationship between the medical employee and the child family for implementation of the offered treatment properly; many patience from two parties with repetition of guarantees that the situation will gradually improve, and courage in cases of possible recurrence, - make the best way of treatment of the children suffering from locks.
Condition of a question
• Children of preschool age often ask for the help with the case history consisting in the heavy evacuation of a big and firm chair arresting them to toilet sitting each 3-10 days. Lack of symptoms in the first six months of life are important for an exception of a disease of Hirshsprunga. Chronic locks and fecal losses though in 25% of cases appear at children before 1 year, are usually observed at the age of 2-4 years.
• Children refuse to be exempted from a chair as it is disease process. They do huge efforts to keep fecal masses and soil linen. It afflicts them, in most cases they long and are nervous, are ashamed of the parents, brothers and sisters, members of the family, neighbors, school friends and even teachers. They refuse to eat normally, their nutritious mode is poor in vegetable fibers and is based on dairy products.
• These children already consulted at many pediatricians, accepted various laxatives, enemas and candles. Parents do not understand why their children are not capable of the similar physiological act. They try everything: promises, gifts and punishments. They accompany children in a toilet and explain on own example as it is simple. Children strongly worry, afraid of toilet sitting and keep from what can calm parents. They think: "It is easy for you and is very sick for me".
• During the first medical consultation of parents overcome sense of hopelessness, and the child - shame. Parents point to the child, declaring that they never did not see anything similar and except for consultation with the doctor and medicines, see other exit. They declare that they tried everything, however were tired and have no more patience. Children watch all this, looking in a floor or walking around bureau and avoid to listen to all these charges.
• During this visit the doctor establishes that, since the early childhood or after an all-widespread infectious disease, in connection with a hyponutrient parents returned to a small bottle and to milk soups for improvement of acceptance of food again. It is not necessary to allow it as afterwards the child continues to demand this type of food. Often proctal cracks or other forms of perianal irritation take place. Such changes as the residence or schools, the birth of the brother or sister, travel or family problems also cause locks.
• Psychological pressure or various situations of emotional discomfort aggravate a problem. Sensitivity of rectal overflow is lost and big fecal masses forms. Besides the fecal pachkaniye with all that it implies is observed by social effects.
Treatment of locks at children
• The task consists in elimination of fecal losses, recovery of normal nutritious habits, resuming of desire to defecate and prevention of fecal consolidations. With our patients we practice four main methods (the general management, laxatives, exercises in a toilet and the nutritious mode) and we observe improvement at all patients except for cases of organic diseases when primary supervision already gives the diagnoses noting serious psychological problems or at children whose families do not promote treatment for many reasons, including social and economic and cultural and when for these reasons it is impossible to observe the necessary nutritious mode in Wednesday, adverse for the child.
• To explain physiology of an excrement and effect of locks. To explain to parents how to treat and how to resolve problems, especially in cases with a long current and for the patients who had before other attending physicians. We have to promise children that the chair will be softened and afterwards will not hurt at an excrement. At the same time excrements need to ask the child not to detain. To convince that if he observes treatment, in this case fecal pachkaniye will disappear. The main task concerning the child consists in elimination of pain.
• Addressing parents, we ask them not to allow the unnecessary and humiliating comments. It is not their wine and it should not create a psychological problem. Nevertheless it is necessary to eliminate from their consciousness ideas about the anatomic reasons. This opportunity was already excluded in the clinical way, however, in case of need, procedure of an anorectal manometriya can be useful and less aggressive, than a barium enema. It is necessary from 3 months to 2 years before the situation is normalized. Time demanded for this purpose depends on the previous duration of the locks, the correct observance of treatment enclosed tranquility and patience. It is important that parents developed positive reaction when children begin to control excrements, and avoided to punish children in cases of recurrence.
• Usually we use mineral oil, daily from 60 to 90 ml counted on two receptions, in the morning and in the evening. The picked-up dose allows every day soft excrements without pain. Mineral oil reduces fecal density and promotes recovery of a chair, thus, to children to keep from a chair much more difficult. We use this method throughout rather long time, however we try to stop treatment after 3-6 months, depending on a clinical state. Parents have to be warned about increase in pachkaniye in an initial stage and about oil leak which will contaminate linen. This everyday occurrence which will gradually disappear how the child as it allows to increase every time quantity of excrements relaxes. Leak of oil can mean an excess dosage though more often it indicates that the child continues to keep from a chair. In spite of the fact that this measure has no special justification, all children accepting mineral oil receive vitamin supplements.
• Other type of laxative is sometimes necessary. The Alexandria leaf or lactulose can be used for some patients though to some it can be useful tsisaprid. For improvement of the carried-out treatment the laxatives increasing fecal weight, for example psillum can be also ordered.
• At children with a considerable fecal masses in the beginning we practice daily glyceric enemas, up to full evacuation. If fecal masses is less considerable, we resort to this way only in cases when after the 2-hnedelny term of continuous treatment, evacuation of mineral oil is absent.
Exercises in a toilet
• We agree with children and parents that after each reception of a significant amount of food, children have to be located in a toilet (with a support for legs) at least for 10 minutes. We explain to parents that children are not obliged to defecate every time, however if they try, to convince them that it not painfully.
• It is the most important measure (depending, however, on family habits), though the most difficult feasible. We have to convince parents that children with locks, in particular, if history of a family has similar problems, have to have a nutritious diet with the high content of vegetable fibers. Sometimes it is necessary to change habits of all family.
• If it is required to increase consumption of the food promoting forming of fecal masses vegetables, fruit and cereals are recommended. The number of consumption of fibers has to be "age + 5-10 grams a day" for children over 2-hletny age. It is useful to add wheat bran for enrichment of a nutritious diet poor in vegetable fibers. First of all it is necessary to watch and avoid consumption of the foodstuff promoting locks such as cow's milk, vermicelli, bananas, carrots and the crude apples. To enter calcium additives (1 g/day) and calories by consumption of the food which is not promoting locks, such as meat, eggs, nut oil, mayonnaise. It is important to provide consumption of a large amount of liquid and to avoid drinks with caffeine.
• Nutritionists have to carry out a special role, in particular concerning "heavier" patients or children demanding more various menu. It is interesting to make the list of various foodstuff with the indication of content in them vegetable fibers.
• Except for surgical correction of anatomic anomalies, surgical intervention is not applied in cases of locks. The methods used for change of behavior or the return biological communication have good results in certain cases; these alternative ways can be used in the absence of a possibility of clinical treatment.
The recommended literature: 1. Leoning-Baucke V: Chronic constipation in children. Gastroenterology 1993; 105: 1557-64 2. Roy CC, Silverman A, Alagille D, editors. Pediatric Clinical Gastroenterology. St. Louis: Mosby-Year-Book, 1995: 495-503 Williams CL, Bollella M, Wynder EL. A new recommendation for dietary fiber in childhood. Pediatrics 1995; 96 (Suppl 2): 985-i
Information only for health workers.
According to the publication Nestec and Help Medical.