mass did not extend above the level of the umbilicus, PEG 3350 at a dose of to 1.5 g/kg/day (up to a maximum of 100 g/day) given for 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 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 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 ... 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... 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