Pediatric emergency medicine trisk 119

mass did not extend above the level of the umbilicus, PEG 3350 at a dose of 1 to
1.5 g/kg/day (up to a maximum of 100 g/day) given for 3 days was an effective
method of disimpaction and evacuation. Other oral options include lactulose,
sorbitol, senna, bisacodyl, PEG electrolyte solution, magnesium hydroxide, and
magnesium citrate. A combination of oral osmotic and stimulant agents may be
effective for disimpaction. Oral phosphosoda was removed from the US market
due to serious adverse events. Rectal disimpaction can be accomplished with
saline (Fleet or Pedia-Lax) enemas or bisacodyl suppositories. A mineral oil
enema administered the night before the first saline enema may soften existing
stool, allowing less painful passage. Saline enemas are typically dosed at 10 to 15
mL/kg generally with a maximum of 500 to 1,000 mL. The enema may be
repeated, spaced 24 hours apart, with a maximum of three total doses. Subsequent
doses should only be given if evacuation of the previous dose has occurred.
Sodium phosphate enemas are still available but can only be used in children
older than 2 years of age. Phosphate enemas should not be used in patients with
renal insufficiency and should not be repeated more than once due to the
possibility of life-threatening hyperphosphatemia or hypocalcemia. Phosphate
enemas are no longer available due to life-threatening adverse events. If there is
no response after 3 days, more aggressive disimpaction under physician
supervision is indicated.
The long-term maintenance phase of therapy is equally as important as the
disimpaction and evacuation phase and involves nonstimulant osmotic laxatives,
lubricants, fluids, fiber, and behavioral therapy. Laxatives include hyperosmolar
agents such as PEG 3350 and lactulose. Lubricants such as mineral oil are helpful
to lubricate the intestine for easier passage of stool but should not be used in
infants, patients with reflux, or those who are neurologically impaired due to the
risk of aspiration pneumonitis. Increasing fluid and fiber intake is also critical to
long-term success in treating constipation. Table 18.8 outlines the recommended
daily fiber intake by age. Fiber should be increased gradually toward the goal to
minimize flatulence. Regular toileting should be encouraged with positive
reinforcement in the school-aged child. Toilet training should be discontinued in

the training toddler until retentive behaviors improve. Education of patients and
parents about the pathophysiology of constipation, the etiology of encopresis
when present, and the expectations of therapy is vital. Close follow-up is a
mainstay of treatment. Successful therapy may take several months to years to
complete.


TABLE 18.8
RECOMMENDED FIBER DOSE IN GRAMS PER DAY
Toddler
Preschool
School age
Adult

8–10
12–14
14–16
20–35

Approach to the Patient With Severe Chronic Constipation
Disimpaction and evacuation of stool in the patient with severe chronic
constipation or one who has failed simple therapy presents a challenge,
particularly in the emergency department setting. A series of enemas in
conjunction with an oral disimpaction regimen may not be sufficient to disimpact
a larger stool mass. Use of PEG with electrolytes solution (GoLYTELY) as a
lavage either orally or via nasogastric tube at a dose of 10 to 25 mL/kg/hr up to
1,000 mL per hour until stool is clear may be helpful to treat more severe
impactions. This method should be done in the hospital under supervision of a
physician with close monitoring of the patient’s volume, cardiovascular status,
and electrolytes. Risks may be higher in patients with complex medical

conditions such as cardiac, renal, or metabolic diseases. Gastrografin or N acetylcysteine enemas may be an additional method of disimpaction, especially in
the case of distal intestinal obstructive syndrome as occurs in patients with cystic
fibrosis. In cases of very severe fecal impaction, surgical disimpaction may be
necessary. Milk and molasses, soap suds, and tap water enemas have fallen out of
favor because of safety concerns following several case reports of serious adverse
events, including one death. The other components of constipation therapy apply
as outlined previously and in Table 18.7 .
Suggested Readings and Key References
Gordon M, MacDonald JK, Parker CE, et al. Osmotic and stimulant laxatives for
the management of childhood constipation. Cochrane Database Syst Rev 2016;
(8):CD009118.
Gordon M, Naidoo K, Akobeng AK, et al. Cochrane Review: osmotic and
stimulant laxatives for the management of childhood constipation (Review).
Evid Based Child Health 2013;8(1):57–109.


Madani S, Tsang L, Kamat D. Constipation in children: a practical review.
Pediatr Ann 2016;45(5):e189–e196.
Tabbers MM, Benninga MA. Constipation in children: fibre and probiotics. BMJ
Clin Evid 2015;2015:0303.
Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of
functional constipation in infants and children: evidence-based
recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol
Nutr 2014;58:258–274.


CHAPTER 19 ■ COUGH
TODD A. FLORIN

INTRODUCTION

Cough is a common pediatric complaint with a variety of causes. Although cough
is usually a self-limited symptom associated with upper respiratory illnesses, it
occasionally indicates a more serious process. Under most circumstances, history
and physical examination can accurately determine the cause.

PATHOPHYSIOLOGY
Cough is a reflex designed to clear the airway. Although a cough can be initiated
voluntarily, it is usually elicited by stimulation of receptors located throughout the
respiratory tract, from the pharynx to the bronchioles, in addition to the paranasal
sinuses, stomach, and external auditory canal. Receptors may be triggered by
inflammatory, chemical, mechanical, and thermal stimuli. Direct (central)
stimulation of a cough center in the brain occurs more rarely. The reflex consists
of a forced expiration and sudden opening of the glottis, which rapidly forces air
through the airway to expel any mucus or foreign material.

DIFFERENTIAL DIAGNOSIS
The causes of cough differ in the type of stimulus and the site of involvement in
the respiratory tract ( Table 19.1 ). The common causes of cough are listed in
Table 19.2 . Potentially life-threatening causes are listed in Table 19.3 .
In distinguishing the etiologies of cough, the clinician must consider features
that are atypical for simple upper respiratory infections (URIs) or routine asthma.
Although pertussis exists as a URI in the catarrhal phase, infants with paroxysms
of coughing, color change, significant posttussive emesis, or apneic episodes
should be tested and managed as possible pertussis. Similarly, toddlers and young
children with new-onset wheezing following a choking episode, those infants
with wheezing unresponsive to usual therapy, and those with persistent lobar
pneumonia should be evaluated for foreign body aspiration. Cough associated
with expectoration of blood (hemoptysis) should prompt evaluation for infection,
vasculitis, pulmonary vascular disorders, trauma, congenital heart defects,
neoplasm, or coagulopathy. Finally, children who present with cough and

associated stridor may have croup, but those with recurrent stridor, associated
dysphagia, or chronic hoarseness must be evaluated for a foreign body, extrinsic