What is the management of an anal fissure in a 3-year-old child?

From the Guidelines

Management of a 3-year-old with an anal fissure should focus on stool softening, pain management, and promoting healing, with conservative care being the initial approach, as it is risk-free and has a relatively high success rate, especially for acute fissures, as noted in the American Gastroenterological Association medical position statement 1.

Key Components of Conservative Care

• Dietary modifications to increase fluid intake and fiber through fruits, vegetables, and whole grains to soften stools
• Use of polyethylene glycol (MiraLAX) at a dose of 0.5-1.5 g/kg/day mixed in beverages to maintain soft bowel movements
• Warm sitz baths for 10-15 minutes 2-3 times daily to relax the anal sphincter and reduce discomfort
• Application of a small amount of petroleum jelly around the anus after bowel movements and baths to lubricate the area
• Consideration of 2.5% lidocaine ointment sparingly before bowel movements if pain is significant

Important Considerations

• Most pediatric anal fissures heal within 2-4 weeks with conservative management
• Avoid using steroid creams as they can thin the skin and delay healing
• If constipation is a recurring issue, address it promptly to prevent recurrence of fissures
• Seek medical attention if there is no improvement after 2 weeks of treatment, if bleeding persists, or if the child develops fever or significant pain

Treatment Goals

• Break the cycle of pain, sphincter spasm, and constipation that perpetuates anal fissures in children
• Achieve prompt but temporary sphincter relaxation through conservative care or other acceptable options like topical therapy or botulin toxin injection, as discussed in the provided evidence 1

From the Research

Management of Anal Fissure in a 3-Year-Old

• The management of anal fissure in children is primarily focused on relieving the spasm of the internal anal sphincter, which prevents healing of the fissure 2.
• Conservative management with stool softeners, topical analgesics, and sitz baths is recommended as first-choice therapy for children with anal fissure 2.
• Nonoperative treatment options, such as glyceryl trinitrate, calcium channel blockers, or botulinum toxin injection, have been shown to be effective in healing anal fissures in children, although the success rates vary between studies 2, 3.
• It is essential to treat constipation to avoid recurrent tears in the anal canal 2.
• Surgical treatment, such as lateral internal sphincterotomy, is typically reserved for chronic and refractory acute fissures, but may not be necessary for most children with anal fissure 4, 5.

Treatment Options

• Topical nitroglycerine has been shown to be effective in reducing anal resting pressure and promoting healing of anal fissures, with a significant reduction in pain and improvement in healing rates compared to other treatments 6.
• Calcium channel blockers, such as diltiazem and nifedipine, have also been shown to be effective in treating anal fissures, with fewer adverse events compared to nitroglycerine 3.
• Botulinum toxin injection has been used as a treatment option for anal fissure, with some studies showing promising results, although more research is needed to confirm its efficacy 3.

Important Considerations

• The goal of management is to relieve symptoms, promote healing, and prevent recurrence of the anal fissure 4, 2.
• It is crucial to address underlying constipation to prevent recurrent tears in the anal canal 2.
• The choice of treatment should be individualized based on the child's specific needs and medical history, and may involve a combination of conservative and nonoperative management options 2, 3.