Letter to the Editor
It should be noted that this letter was written on
June 24, 1998 and submitted to the journal but never published.
Letters to the Editor
CONTEMPORARY PEDIATRICS
5 Paragon Drive
Montvale, New Jersey 07645-1742
Ladies and Gentlemen,
Dr. David R. Fleisher's article on Coping with Colic in the June, 1998
issue, presents a very compassionate approach to coping with colic,
but there is more that can be done by a caring physician.
My first constipative colic "cure" came while serving as camp physician
in upstate New York in 1973. I was asked to make a "cabin call" to the
wife of a staff member with a very sore back. When I observed the severely
contorted posture the mother was utilizing for nursing her fussy three-week-old
baby, the cause of her backache was immediately obvious. When I asked
her why she nursed her baby in that position, she told me that he had
developed increasingly severe symptoms similar to those enumerated by
Dr. Fleisher, and that she had tried a variety of nursing positions
and finally was reduced to this one contorted posture for minimally-successful
nursing. Her baby was crying with feedings, clenching his fists, drawing
his legs up onto his abdomen and turning red with grunting sounds. Her
description of the baby strongly suggested constipation, and led me
to perform a simple digital rectal examination. Imagine our surprise
when the infant passed an explosive stool three feet across the floor
upon removal of my examining pinkie! He was almost instantly cured of
his fussiness, nursed heartily in normal positions, and resumed normal
post-prandial bowel movements so typical of healthy infants. The mother's
backache was gone in a day or two.
Subsequent experiences with scores of infants have never been as dramatic,
but have always been equally gratifying in terms of relief of infant
and parental suffering. My experiences with these infants has boiled
down to this: there seem to be two basic types of "rectal stenosis"
that I have witnessed and discovered by rectal examination. First, let
me point out that the normal rectal canal of a full-term infant easily
admits a 25-mm. diameter examining finger with no special discomfort
to the child. My colleagues at the former Ferguson Digestive Institute
in Grand Rapids have confirmed this concept.
In terms of rectal stenosis, the first type is a partial membranous
obstruction of the distal rectal canal. I've since learned from standard
embryological textbooks how this comes about. The obstruction and re-canalization
of the rectal canal between the fifth and eighth weeks of gestation
is often incomplete, resulting in a partial imperforate anus, which
resembles a Roman coin, with a variably-sized central opening. This
small opening allows passage of liquid stool and gas and often leads
to the misdiagnosis of "diarrhea" and the prescription of spasmolytics,
such as Levsin drops.
The second type of rectal stenosis is a simple muscular tightness, which
my health-educator wife has aptly likened to the never-inflated balloon,
which requires the stretching of that first inflation to become more
pliable. Both the membranous and muscular versions of rectal stenosis
appear to come in three categories that can be distinguished by the
experienced examiner: mild, moderate and severe. The six resulting clinical
expressions have enough clinical variations to keep us guessing -- unless
we perform the definitive rectal examination with whichever digit is
closest to 25 mm in diameter.
There seems to be an unwarranted reluctance on the part of Pediatricians
and Family Physicians to perform the appropriate rectal examination
on infants - almost a "taboo" sort of reluctance. It is true that when
stenosis of either type is encountered, the examination is momentarily
painful and a tiny amount of bleeding is noted with rupture of the partial
membrane. However, this is much to be preferred to even one night of
wailing and parental anguish (never mind the usual four months!) which
may well predispose to infant abuse, shaken baby syndrome and guilt
feelings.
This examination is both diagnostic and therapeutic if performed within
one or two weeks of onset of symptoms, hopefully before one month of
age. Delay of diagnosis and treatment often results in full-blown secondary
constipation, which then requires its own set of treatments. Of further
import, the eating-crying pattern classically pointed out by Dr. Morris
Wessel back in the 1960's seems to become behaviorally "imprinted" if
the rectal stenosis goes undetected and uncured more than approximately
a month.
It is thus paradoxical that constipative colic is more easily prevented
than cured!! In terms of supportive clinical management, I often recommend
the daily use of an adult glycerin suppository to clear up transient
constipation. I will see the baby again a week later and repeat the
rectal examination only if the improvement has been transient, as it
is in about half of the infants. In turn, those who require a second
dilatation are seen again a week later, and again, about half are now
asymptomatic. Thus, only 20 to 25% of the infants with constipative
colic will require a third dilatation. No infant has required more than
three examinations.
My plea to fellow clinicians who care for newborns is quite simple:
that we would, in addition to taking a careful and compassionate history
and performing the "thorough, gentle physical examination" recommended
by Dr. Fleisher, also take the time to explain to parents the need for
a rectal examination to make sure that rectal stenosis is not causing
the constipative colic symptoms. We should then gently but definitively
perform the rectal examination with whatever finger is closest to 25
mm. in diameter. If by this act of diagnostic and therapeutic compassion
we are able to foreshorten the infant's misery by even one night, I
believe we will also be performing a giant service to mankind and parenthood.
Sincerely,
David L. Sharp, M.D.
Board Certified - Family Medicine
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