My baby is constipated, exhibits pain in his abdomen, and looks pale to me. Can I give him a laxative?

 
One recent night when I was on call I received a phone call from a mom regarding her one year old son. With no sense of urgency in her voice she apologized for calling after hours. “Normally I would have waited until tomorrow but I am sure he is constipated. I wanted to see if it was OK to give him a suppository.” In my initial questioning I was able to ascertain that he had no fever, no vomiting or diarrhea. Mom continued, “I don’t want to waste your time but I just switched him to cow’s milk. He has been eating more people food but has not had a bowel movement for two days. Would it be OK to use a suppository?”.
 
I heard her son crying in the background, sounding very uncomfortable. As she described him to me, he would draw his legs up almost as if there were spasms that come and go. I asked if he looked particularly pale. “As a matter of fact, he does look a bit pale and he looks really distressed when these spasms come.” Although he did not have a bowel movement for two days the urine output was good and there were never any bloody stools.
 
When I told her to take him to the emergency room ASAP there was a long quiet pause. Slowly, and in a skeptical voice she said, “Okay…but the ER, really? I just wanted to know if I could use a suppository.” I explained that I was concerned her son may have a condition called intussusception. We needed to rule this out immediately. She was to go directly to the ER. I would call ahead and let them know she was coming. They would most likely do an ultrasound to make the diagnosis. She was a good sport and said, “We’re on our way!” The ER doctor called me 45 minutes later with the information that the ultrasound did show an intussusception. The radiologist was on her way in.
 

Intussusception is not an uncommon condition in pediatrics. It mostly occurs in children from two months to three years of age. 80% of cases are under three years.

 
The peak age is between 5-9 months. It can also occur in older children and adults as well but is very uncommon. Intussusception occurs when one portion of the intestines slides into an adjacent part of intestines, causing a ”telescoping” effect which leads to a bowel obstruction. By far the most common site for this is where the small intestines join the large intestines, or colon, in the lower right section of the abdomen. This is known as an ileo-colic intussusception. Less commonly, a portion of the small intestines can “intussuscept” on itself and is known as an ileo-ileal intussusception.
 
Intussusception can cause nausea, vomiting and severe abdominal cramps. This pain can cause a younger child to draw his legs up to find relief, or an older child to squat down and double over. In classic presentations a clinician can palpate a “sausage shaped mass” in the abdomen. Some children may have a bloodystool that is described a “current jelly”. This occurs if there has been compromise to the blood supply of the intestines which can lead to a sloughing of the lining. Fever is not typically a sign of intussusception and would cause concern that there may be severe damage to the intestines with possible perforation of the intestinal wall. There is no known cause of intussusception in over 90% of the cases. However, things like a lymph node, polyp or diverticulum may be implicated and would serve as the leading point for the telescoping of the intestines.
 

The most common test for diagnosing intussusception is an abdominal ultrasound.

 
The radiologist would report a donut sign, or bull’s eye which is exactly what it looks like. There are concentric rings which form a target-like structure in the affected area. Once diagnosed, the patient will be given an IV for fluids, and not allowed to eat or drink. If the diagnosis is an oleo-colic intussusception, a trained radiologist will perform an enema using either barium, water soluble contract,or air. They will watch with fluoroscopy while carefully doing the enema. In over 80% of cases this will resolve the intussusception. This MUST be done in experienced hands for there is a risk of perforating the bowel. If this procedure is not successful the pediatric surgeon should be on standby to take the child to the operating room for a laparoscopic procedure.
 
If the intussusception is successfully reduced by enema, there can be a recurrence rate of up to 10%. This will occur in the first 24 hours and it is not uncommon to keep the patient in the hospital for this time period watching for any recurrence. This will allow the medical team to be sure the patient is able to tolerate a regular diet.
 
If there is an ileo-ileal intussusception the radiological enema will be of no use because of the location of the obstruction. Luckily, this is not nearly as common as the ileo-colic type, and many willresolve with conservative measures. The patient would be admitted, given IV fluids, not allowed to eat, and surgery would be on board to follow them closely until it resolved.
 

In the case of our patient, the pediatric radiologist came in and was able to reduce the intussusception without incident.

 
He tolerated the procedure quite well. By morning he was eating jello and clear liquids, and by lunchtime he ate a regular meal. The stipulation was that if he ate dinner and was continuing to be his normal self, we would let him go home that night. Mom was eager to go home and knew exactly what to look for should it recur. He went home in the evening and did just fine.