What is the assessment and management approach for a 2-year and 11-month-old child presenting to the pediatric emergency room (Peds ER) with constipation?

Pediatric Constipation Assessment and Management: SOAP Note

Subjective

For a 2-year and 11-month-old child with constipation for 5 days, I will first obtain a detailed history including:

• Stool pattern: frequency, consistency, and size of stools before and during constipation 1
• Duration of symptoms (already noted as 5 days)
• Associated symptoms: abdominal pain, straining, blood in stool, soiling/encopresis
• Dietary history: fluid intake, fiber content, recent changes in diet
• Toilet training status and toileting behaviors
• Previous episodes of constipation and treatments used
• Family history of gastrointestinal disorders
• Developmental and behavioral history
• Medication use that may cause constipation
• Recent life changes or stressors (daycare, travel, illness)
• Presence of withholding behaviors (crossing legs, hiding, dancing)

Objective

Physical examination will include:

• Vital signs and growth parameters (height, weight, BMI)
• Abdominal examination: distension, palpable stool, tenderness, masses
• Perineal inspection: fissures, skin tags, redness, soiling 2
• Digital rectal examination to assess for:
  • Presence of stool in rectum/fecal impaction
  • Sphincter tone
  • Anal fissures or tenderness
  • Rectal vault size 2, 1

If indicated based on history and physical:

• Complete blood count if systemic symptoms present 2

Assessment

Based on findings, I will classify the constipation as:

1. Functional constipation (most common in this age group)
2. Constipation with fecal impaction
3. Constipation secondary to underlying condition (less likely but must consider)

Plan

For this 2-year and 11-month-old with 5-day constipation, I will implement the following treatment plan:

1. Initial disimpaction if fecal impaction is present:

   • Oral polyethylene glycol (PEG) is the first-line treatment for disimpaction in children 1
   • Dosing: 1-1.5 g/kg/day for 3-6 days
   • For severe impaction: consider glycerin suppository or mineral oil retention enema 1

2. Maintenance therapy:

   • PEG (first-line): 0.4-0.8 g/kg/day, adjusted to achieve 2-3 soft stools daily 1
   • Alternative options if PEG unavailable/not tolerated:
     • Lactulose: 1-2 mL/kg/day divided doses 3
     • Milk of magnesia: 1-3 mL/kg/day 1

3. Behavioral interventions:

   • Establish regular toileting routine (5-10 minutes after meals) 1
   • Proper toilet posture with foot support 1
   • Reward system for successful bowel movements 1

4. Dietary modifications:

   • Increase water intake
   • Add fiber-rich foods appropriate for age (fruits, vegetables, whole grains) 1
   • Limit constipating foods (excessive dairy, processed foods)

5. Parent education:

   • Explain chronic nature of functional constipation
   • Emphasize importance of long-term maintenance therapy
   • Warn against premature discontinuation of treatment 1
   • Discuss withholding behaviors and how to address them

6. Follow-up:

   • Schedule follow-up in 1-2 weeks to assess response to treatment
   • Adjust medication dosage as needed
   • Consider specialty referral if no improvement after adequate trial of therapy

This comprehensive approach addresses both the immediate constipation and helps prevent recurrence through behavioral, dietary, and medication interventions.