Pooing and Constipation Throughout Infancy: Part One: What is Normal?

For Emergency Departments, For General Practitioners

We welcome back Dr Marilyn Emedo for a series on pooing and constipation throughout infancy.  First Installment: What is Normal?

BREASTFED newborn babies stool anywhere between 7 times a day and once every 7-10 days. Stool is commonly “loose” in consistency and yellow in colour resembling “mustard seeds”. A reduction in frequency is typically seen from the 2nd month of life. [note]Newborn: First Stool and Urine. Pediatrics in Review. 1994;15(8):319-320. [/note]

BOTTLE FED babies tend to open their bowels fewer times per day.

In 90% of normal term babies, meconium (intestinal epithelial cells, lanugo, mucus, amniotic fluid, bile, and water) is passed within 24 hours of birth and by 48 hours in nearly all normal babies.[note]Duyan Camurdan, A., Beyazova,
U., Ozkan, S. & Tunc, V. T. Defecation patterns of the
infants mainly breastfed from birth till the 12th month: Prospective cohort study.
Turk. J.
Gastroenterol.
25, 1–5 (2015).[/note]

Preterm infants may take longer than this to first open their bowels; one study reported only 37% of preterm infants (25 -36 weeks gestation) open their bowels in the first 24 hours, and 32% are delayed over 48 hours. The ongoing frequency of stool output, and expected colour and consistency thereafter depends largely on what the baby is being fed.

This picture comes from http://www.breastfeedingmaterials.com where you can download a “diaper diary” with pictures of poo of all sorts of different colours and consistencies.

June 2017 PDF

For Emergency Departments, For General Practitioners, PDF digests: Emergency Departments, PDF digests: for General Practitioners, , , ,

Haematuria this month with links to an algorithmic Australian guideline on how to manage it in children, assessing paediatric hypertension, postural orthostatic tachycardia syndrome and the last for the time being in the “decoding the FBC” series – MCHC.

Please do leave comments below:

Mean Corpuscular Haemoglobin Concentration

Uncategorized

(From June 2017 Paediatric Pearls Newsletter: Last in the “decoding the FBC” series by Dr Xanna Briscoe and Prof Irene Roberts for the time being)

Mean Corpuscular Haemoglobin (MCH) is the amount of haemoglobin per red blood cell.  MCHC is an estimate of the concentration of haemoglobin in a  given number of packed red blood cells.

MCHC = (Hb[note]Hb:Haemoglobin[/note] ÷ HcT[note] HcT: haemotocrit or packed cell volume[/note]) x 100

Normal in children is 32-34% (adults 28-36%) depending on the lab

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Chronic Anaemia

Iron Deficiency

Thalassaemia

spherocytosis

folic acid deficiency

Vit B12 deficiency

burns patients

sickle cell disease

 

What is PoTS? Is it an illness?

For Emergency Departments, For General Practitioners, Uncategorized

(From June 2017 Paediatric Pearls Newsletter)

It stands for Postural Orthostatic Tachycardia Syndrome, an autonomic disturbance

From support group POTS UK

leading to light-headedness, sweating, tremor, palpitations and near syncope in the upright position[note]Agarwal A et al. Postural orthostatic tachycardia syndrome. Postgrad Med J 2007;83:478-480[/note]

Definition:

  • Heart rate >120bpm on standing
  • HR increase > 40bpm after 10 minutes of standing (if aged 12-19 yrs. >30bpm if older)[note]http://www.nhs.uk/conditions/postural-tachycardia-syndrome/Pages/Introduction.aspx[/note]

 

  • Despite our traditional concern with lying and standing blood pressures, it
    is the persistent tachycardia that characterises this health condition. Blood
    pressure may not change at all.
  • Recognised in age group 12 – 50, female to male ratio of 5:1
  • Can be primary (eg. adolescence) or secondary (eg. diabetes, hypermobility)
  • Different types and some are associated with a particular gene mutation
  • Can be diagnosed on tilt table or active stand test if necessary
  • Reassurance, a healthy lifestyle with sufficient aerobic exercise and fluid
    intake will help with symptoms and most adolescents grow out of it

 

URINALYSIS

Uncategorized

(From June 2017 Paediatric Pearls Newsletter)

Also see:

Blood

  • Red or brown urine does not always mean blood
  • High false positive rate (eg. haemoglobinuria, myoglobinuria, concentrated urine, menstrual blood in the urine sample, rigorous exercise) so dipstick positive blood needs to be looked at under the microscope to accurately diagnose haematuria
  • False negative possible if specific gravity is < 1007
  • Significant haematuria is defined as ≥ 10 red blood cells (≥ 3 in adults) per high-power field in a properly collected and centrifuged urine specimen
  • Isolated microscopic haematuria in a well child only really needs further investigation after 3 positive samples over a period of a few months
  • Concomitant proteinuria, high BP or a palpable abdominal mass should be investigated promptly
  • Possible causes of haematuria in children:
    • UTI
    • Viral infections
    • Post streptococcal glomerulonephritis
    • Trauma
    • Henoch Schonlein Purpura
    • Wilm’s tumour (median age 3.5 years)

Resources:

Paediatric Hypertension (HTN)

For Emergency Departments, For General Practitioners

(This appears in the June 2017 Newsletter, and continued from the April 2017 Newsletter)

Prevalence of HTN in children aged 8-17 years was approximately 2.2% between 2011 and 2014. Compare this with asthma prevalence of 9%, autism 1%, epilepsy 1%, and yet these all get much more air time than hypertension. Up to 30% of newly diagnosed hypertensive children and young people already have end organ damage, left ventricular hypertrophy in particular. [note]Lewis M et al. Screening for Hypertension in Children and Adolescents: Methodology and Current Practice Recommendations. Front Pediatr. 2017; 5: 51 full text. Great Ormond Street Hospital clinical guideline on the diagnosis, investigation and management of hypertension.[/note]

Hypertension: important points in the history:

  • Symptoms: lethargy, visual disturbances, headache, nausea, vomiting, failure to thrive
  • Past medical history: prematurity, central lines, UTIs, congenital heart disease
  • Family history: essential hypertension, polycystic kidneys, early CVS disease

BP measurement in babies and children is a skill which is often not done well:

  • Cuff size – you need a range of sizes. The bladder width needs to be at least 40% of the child’s arm circumference between olecranon and acromion and 80-100% of the circumference. A small cuff leads to an erroneously high BP measurement. Take BP in the arm, not leg (both if doing 4-limb BP obviously). At birth, BP measured in the legs is often lower than in the arms, equalises at 8/52 of age and after that leg blood pressure tends to be higher than in the arm.
  • Position – the child should ideally be lying down, relaxed, their limb at the same level as their heart.
  • Equipment – centile charts are put together using auscultation and a sphygmomanometer. Mechanical oscillometric devices are easy to use (be sure to still ensure correct cuff size) but are not as accurate which is why nephrologists always insist on a “manual reading”.