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• Anal Fissure
• Constipation
• Pinworms
• Vomiting ( Viral Gastritis )

An anal fissure is a shallow tear or crack in the skin at the opening of the anus. More than 90% of children with blood in their stools have anal fissure. The main symptoms are as follows:

• The blood is bright red.
• The blood is only a few streaks or flecks.
• The blood is on the surface of the stool or on the toilet tissue after wiping.
• Your child usually passes a large or hard bowel movement just before the bleeding starts.
• You may see a shallow tear at the opening of the anus when the buttocks are spread apart, usually at 6 or 12 o'clock. ( A tear cannot always be seen. )
• Touching the tear causes mild pain.

Trauma to the anal canal during constipation is the usual cause of anal fissures.

Bleeding from a fissure stops on its own in 5 or 10 minutes.

Warm Saline Baths

Give your child warm baths for 20 minutes, 3 times each day. Have them sit in a basin or tub of warm water with about 2 ounces of table salt or baking soda added. Do not use any soap on the irritated area. Then gently dry the anal area.

Ointments

If the anus seems irritated, you can apply 1% hydrocortisone ointment
( nonprescription ). If the pain is severe, apply 2% Xylocaine or 1% Nupercainal ointment
( no prescription needed ) 3 times each day for a few days to numb the area.

Diet

The most important aspect of treatment is to keep your child on a non constipating diet. Increase the amounts of fresh fruits and vegetables, beans, and bran products that your child eats. Reduce the amounts of milk products your child eats or drinks.
Occasionally, a stool softener ( such as mineral oil ) is needed temporarily.

During regular hours if :

• The bleeding increases in amount.
• The bleeding occurs more than two times after treatment begins.
• You have other concerns or questions.

• Painful passage of stools: The most reliable sign of constipation is discomfort with the passage of a bowel movement.
  
• Inability to pass stools: These children feel a desperate urge to have a bowel movement (BM), have discomfort in the anal area, and strain, but they are unable to pass anything.
  
• Infrequent movements: Going 4 or more days without a BM can be considered constipation , even though this may cause no pain in some children, and even be normal for a few. ( Exception: After the second month or so of life, many breast-fed babies pass normal large, soft BM’s at infrequent intervals [ up to 7 days is not abnormal ] without pain ).

Common Misconceptions in Defining Constipation

Large or hard BM’s unaccompanied by any of the conditions just described are usually
normal variations in BM’s. Some normal people have hard BM’s daily without any pain.
Babies less than 6 months of age commonly grunt, push, strain, draw up the legs, and
become flushed in the face during passage of BM’s. However, they don’t cry. These behaviors are normal and should remind us that it is difficult to have a BM while lying down.

Constipation is often due to a diet that does not include enough fiber. Drinking or eating
too many milk products can cause constipation. It’s also caused by repeatedly waiting too
long to go to the bathroom. If constipation begins during toilet training, usually the parent
is applying too much psychological pressure.

Changes in the diet usually relieve constipation. After your child is better, be sure to keep him on a non constipating diet so that it doesn't happen again. Sometimes the trauma to the anal canal during constipation causes an anal fissure (a small tear). This is confirmed
by finding small amounts of bright red blood on the toilet tissue or the stool surface.

Diet Treatment for Infants (Less than 1 year old)

• Give fruit juices (such as grape or prune juice) twice each day to babies less than 4 months old. Switching to soy formula may also result in looser stools.
  
• If your baby is over 4 months old, add strained foods with a high fiber content, such as cereals, apricots, prunes, peaches, pears, plums, beans, peas, or spinach twice daily. Avoid strained carrots, squash, bananas, and apples.

Diet Treatment for Older Children (More than 1 year old)

• 
  Make sure that your child eats fruits or vegetable at least three times each day (raw unpeeled fruits and vegetables are best). Some examples are prunes, figs, dates, raisins, peaches, pears, apricots, beans, celery, peas, cauliflower, broccoli, and cabbage.
  ( Warning: Avoid any foods your child can’t chew easily. )
  
• Increase bran. Bran is an excellent natural stool softener because it has a high fiber content. Make sure that your child’s daily diet includes a source of bran, such as one of the new “natural” cereals, un milked bran, bran flakes, bran muffins, shredded wheat, graham crackers, oatmeal, high-fiber cookies, brown rice, or whole wheat bread. Pop-corn is one of the best high-fiber foods.
  
• Decrease consumption of constipating foods, such as milk, ice cream, yogurt, cheese, and cooked carrots.
  
• Increase the amount of water your child drinks.
  ( Exception: Orange juice is not as helpful as others. )

Sitting on the Toilet (Children who are Toilet Trained)

Encourage your child to establish a regular bowel pattern by sitting on the toilet for 10 minutes after meals, especially breakfast. Some children and adults repeatedly get blocked up if they don’t do this. If your child is resisting toilet training by holding back, stop the toilet training for a while and put him in diapers or Pull-ups.

Stool Softeners.
If a change in diet doesn't’t relieve the constipation, give your child a stool softener with dinner every night for 1 week. Stool softeners (unlike laxatives) are not habit-forming. They work 8 to 12 hours after they are taken. Examples of stools softeners that you can
buy at your drugstore without a prescription are Maltsupex (2 tablets), Haley’s M-O (1 tablespoon), Metamucil or Citrucel (1 tablespoon), or plain mineral oil (1 tablespoon).

Measures for Acute Rectal Pain.
If your child has acute rectal pain needing immediate relief, one of the following will usually provide quick relief : sitting in a warm bath to relax the anal sphincter, a glycerine suppository, gentle rectal stimulation for 10 seconds using a thermometer, or a gentle rectal dilation with a lubricated finger (covered with plastic wrap).

Immediately for advice about and enema if :

• Your child develops extreme pain.

During regular hours if :

• Your child does not have a bowel movement after 3 days on a non constipating diet.
• You have other concerns or questions.

A pinworm is a white, very thin worm about 1/4 inch long that moves. If it does not wiggle it is probably lint or a thread. Pinworms usually are seen in the anal and buttock area, especially at night or early in the morning. Occasionally one is found on the surface of a bowel movement. More than 10% of children have them. They do not cause any serious health problems, but they can cause considerable itching and irritation of the anal area and buttocks.

Anti pinworm Medicine

If you have definitely seen a pinworm, your child needs to be treated.

Treatment of Other Family Members for Pinworm

Children are usually infected by children outside the family. If anyone else in your family has anal symptoms or anyone sleeps with your child, call our office during office hours for instructions. Physicians do not agree on whether to treat everyone in the family or only those with symptoms. If any of your child's friends have similar symptoms, be sure to tell their parents to get them tested. Dogs and cats do not carry pinworms.

If your child has itching or irritation of the anal area, they could have pinworms. Keep in mind that many children get itching in this area just from washing their anal area too frequently or vigorously with soap.
Check your child for pinworms as follows: First, look for a 1/2 inch, white, threadlike worm that moves. Examine the area around the anus using a flashlight. Do this for a few hours after your child goes to bed and first thing in the morning for two consecutive nights. If no adult pinworm is seen, do a cellophane tape test for pinworm eggs.

Instructions for Cellophane Tape Test.
Pick up glass slides at our office ( two for each child ) and mark your child's name on the slides. Touch the sticky side of a piece of clear cellophane tape to the skin on both sides of the anus. Do this in the morning soon after your child has awakened and definitely before any bath or shower. Do this two mornings in a row. Apply one piece of tape to each side. Bring the slides to our office for examination with a microscope. We will call you to give you the results. If the pinworm eggs are seen, we will prescribe a medication.

If your child has had recent contact with a child who has pinworms but has no symptoms, your child probably will not get them. Pinworms are harmless and are never present very long without causing some anal itching. If you want to be sure your child does not have them, wait for at least 1 month. The swallowed egg will not mature into an adult pinworm for 3 to 4 weeks. Then contact our office about doing a cellophane tape test for pinworm eggs.

Infection is caused by swallowing pinworm eggs. Your children can get pinworms no matter how carefully you keep them and your house clean. The following hygiene measures, however, can help to reduce the chances of re infection of your child or new infections in other people.

• Have your child scrub their hands and fingernails thoroughly before each meal and after each use of the toilet. Keep the fingernails cut short because eggs can collect their. Thumb sucking and nail biting should be discouraged.
• Vacuum or wet mop your child's entire room once every week because any eggs scattered on the floor are infectious for 1 to 2 weeks.
• Machine washing at regular temperature will kill any eggs present in clothing or bedding.

During regular hours if :

• The skin around the anus becomes red or tender. ( Streptococcus bacteria and infections have a special affinity for this site. )
• The anal itching is not resolved within 1 week after treatment.
• You have other concerns or questions.

Vomiting is the forceful ejection of a large portion of the stomach's contents through the mouth. The mechanism is strong stomach contractions against a closed stomach outlet. By contrast, regurgitation is the effortless spitting up of one or two mouthfuls of stomach contents that is commonly seen in babies under 1 year of age.

Most vomiting is caused by a viral infection of the stomach (viral gastritis) or eating something that disagrees with your child. Often, the viral type is associated with diarrhea.

The vomiting usually stops in 6 to 24 hours. Dietary changes usually speed recovery. If diarrhea is present, it usually continues for several days.

Special Diet for Vomiting
For Bottle-Fed Infants (less than 1 year old)
Offer oral re hydration solutions (ORS) for 8 hours.

• ORS includes Infalyte, Kao-Lectrolyte and Pedialyte (over-the-counter products).
• For vomiting once, offer half-strength formula.
• For vomiting two or more times, offer ORS.
• Give small amounts (1 teaspoon) every 10 minutes.
• After 4 hours without vomiting, increase the amount.
• After 8 hours without vomiting, return to formula.
• For infants more than 4 months old, also return to cereal, strained bananas, etc.
• A normal diet is okay in 24 to 48 hours.

For Breast-Fed Infants
Reduce the amount per feeding.

• Provide breast milk in smaller amounts. Your goal is to avoid filling the stomach.
• If your baby vomits twice, nurse on only one side every 1 to 2 hours.
• If he vomits more than two times, nurse for 4 to 5 minutes ever 30 to 60 minutes
• After 8 hours without vomiting, return to regular breast-feeding.

For Older Children (more than 1 year old)
Offer clear fluids in small amounts for 8 hours.

• Water or ice chips are best for vomiting without diarrhea because water is directly absorbed across the stomach wall (ORS is unnecessary).
• Other options: Half-strength flat lemon-lime soda, ginger ale or popsicles. Stir soda until the fizz is gone because the bubbles can inflate the stomach.
• Give small amounts (1 tablespoon) every 10 minutes.
• After 4 hours without vomiting, increase the amount.
• For severe vomiting, rest the stomach completely for 1 hour, then start over with smaller amounts.
• For older children (more than 1 year old), add bland foods after 8 hours without vomiting.
• Stay on bland, starchy foods (any complex carbohydrates) for 24 hours.
• Start with saltine crackers, white bread, rice, mashed potatoes, etc.
• A normal diet is okay in 24 to 48 hours.

Medicines
Discontinue all medicines for 8 hours. Oral medicines can irritate the stomach and make vomiting worse. If your child has a fever over 102 degrees, use acetaminophen suppositories. Call our office if your child needs to be taking prescription medicine.

Common Mistakes in Treatment of Vomiting
A common error is to either give as much clear fluids as your child wants rather than gradually increasing the amount. This almost always leads to continuous vomiting. Keep in mind that there is no effective drug or suppository for vomiting and that diet therapy is the answer. Vomiting alone rarely causes dehydration unless you give drugs by mouth, milk, or too much clear fluid.

IMMEDIATELY if :

• Any signs of dehydration occur (no urine in over 8 hours, very dry mouth, etc).
• Any blood appears in the vomited material.
• Abdominal pain develops and lasts more than 4 hours.
• Your child starts acting very sick.

Within 24 hours if :

• The vomiting continues for more than 24 hours in children under age 2 or for more than 48 hours if over age 2.
• You have other questions or concerns.