ࡱ> FCDEL( `/ 0DArial00t(0(z[ 0 D-3 00000t(0(z[ 0 @ .  @n?" dd@  @@``_> WhooshWAVE 10103RIFFWAVEfmt ++data~~~~~~~~~~~~~~~~~~~~~~~~~~~|||~~~~~zvtvxz|~zvrnlrv||vtrpptz~|xvtv|~~zxvvvz|~xrlhntzzvrrpprrx~|j[QU_|bICCYn[ICY~zlnh]_r|]SUSSjz|x__l~v_]drnUb|nfd_]d]5=rrnj]jz~lMldrx[[_f|YQfWK_xh[zx[CIjzxxdSQz|_fI9WӹM;QnvK;OUx~xj]]YS~ɵlM?plM;CGpٵ[)Kh|% %;xtKQS]ɖbGr|lSnvz~nfS[nëx;Az=+AYݻ|=/1r_ ?|潄W5/Czãf)/pvbMQr|O=OtjdhjlG?G_ɊK3לdQCMppW;1SŷAMz/#?bx͖SAM[hvhYp~~zrvt[]ptWOUtxxd]v~vvxzd_xzh_nrSQltbdp~_lrQ_l][tf]W]~hWfp|fWhnhbU[hzlSCWbYbnxpdhjvjM9Ot]GQ[dpp~hhhdpx~xh]Yntnrp]dlvjQMb|vdjpzxzztljr||_[r~~jb_j|z|xpp~~v]Wh||zx|x|zzndhpxr]Yfntzjl|z||~vppnrzphrxz|~|xtrjjtv~~vz|z||xrrv~xrprtz|||vzxvx|xtx~~~~~~~zxxxx|zxz~~~rrz~|xz~~|vtx|zxz|~~~||zx|||~~zz|zz~~~~|~~||~~||zz|~||z~~~~zxzz|~~~~|~~~|~||~~~~~~~~~~~~~|||~~~~~~~~~~~~~||~~||~||~~~~|||~~~~||||~~~~~~||||~~~~~~~~~~~|~~~~|zz~~~~~~~||||~~||~~~~~|||~~~~~|||~|~|~~~~|z|~~~~~~~|||~~~~~~~~||~~~~~~I7 Screeching BrakeWAVE 201026RIFF6WAVEfmt ++data6~~~~~~~~~~~~}}}}}}}{{}}}}}~~~~~~~}{{{{{{{{{}}}{{{}~}}{}}~}}}}}~~~~}}}{yxvvuusqqppnnlnnppqsssuvvuvvxxxy{{{{}~~~~}}{{{{{~~~~~}{xxyuvxy~~}}y~~~}}{~~}y}xxuxuvvvvx{yy}yyy}~~~~~yy}xvvy}sps{{qiksuqgiqsqnlqusnpsx{{{{{yy{yxqquupnglpqpnpqsusu}}xxyy{{{~}}xxyxvqpqvunnqussssssqquusvx{~~{{}{usqkipniggkpvspsvuy{xxyy{yxy}~yx{{y}}~~{uvvvxunkqunlnpquxvy}}}vvvspnklkiilpquuvxyy{yuuqppnnquvxxuvvx}~{~}}}}{xxvpknpppuuqsslinqsusssxxyx{{vqppkilngablvupq{~{y}}vyuuqlkknpnkilllklpqplnsyy{}~}~~}xuuqqnqplfffffliklsxxxxx~~~~~~{uquupigkppu{}~~~}~}}{y{~vuvqqssv~}{~}xsspifdddfkpsv{~}xuuusuuuusvxvvxy}~~yuqifdddbaabfa^_abadfflkklsxvx~~~}}{yyvuvvvyyvvx{xyslgbgb_d_bilqy~~}{sv~}{x~~}vqqux{yxx~~}~~y}qx}sxx}yussx{{vxvupgdfkd__^ZZaa_aaZZ\W_bgbbgillns{{}y~ygabi\TTOPGGJKH=CC;CMJ>@HO^^_nqv~{{vvysnklqnfgpvniv{ulnspspgfnvqgilxyupquyysllpnklqvspsyyv{}~~xx~xxuq}qgkpxskkpqlillniggglibb_bfipppuy~~}~{xsv{xvy{}}~{~}yxvvpkilpnigdgkgd__gkkkfdfinnllkpnsvusy~~y}~{}upkklklklnqslllnnkkkidadiib\_dfiiiinvuxxyxx~{xxupipnfifdggfaffgipliiiffafddglgknpv~~unkpvysx~}~~~}{y}{nglsupnsv{{{{{{{~~yx{yxqquvyxuqqy}upqnvvx~}yyvvspxypqs{yi\^^YWPJKKMTY\^Z^ipssxqpuuusuppu{up~x~uǦqx}s^HCUP=..33+"!01+)18>JOT_nsu¾}vlf_UTWRJGJMTWRORY\UUYW^a^^bilkfadluqnusv{{xpifksld_fg\RRYbdWT^inliabgkgffdkibiqvqsx}~qnxsd\lvnYTagaYPUa^WMMRMKKPTRUW\_Yaknnls~xvy}}pilppkbdbZUZ^ZWUYZ^_a\^bdknlllqyyy}vvvqifadZY\UZURUTRYU\\UTW_d_\abipsx}}{v}}xpsxqukbgl_bgnigqqnnkflvg_d_dkdZUgyndaluliianxunpx˹ǵǾqqd_UOKC90=;03>CCJRUZYUP__UTgidpx{vx}{~}xnuuҸxdRRJ9,&!  '>;=Tlvxý½yppsxgUWWYMB=BRYTC66EJKKMMRWaa\\bgldZdqx{vv{nZ^lkWKHKJCB813==9CHC>BUYPRfnkq»{vxy{l\dnliffbgfWMMR\\Y\\^TR\dbZdqplv}{nyssy}~~}{~vquyvvuqusligZPRYUKHPWYY\abkilsux~xpuupnxqqnnnpnqkdaYWWPKKORYWZ\^^iknyua\nxupv~vy~}xgiqpkddffkiinnk_fnnq^ZnyibqsvyŶxnlvpfTKO^_WY\W\^^\\\ZW\^RP^b\WYadbbd_bigdk}~^vȶxffu_E835, '+!$9MRWdxyx~Խ~sx{xnggdWPPPH@GJHKRMGMWfaKRi~xbd{~ln¹¹}~{lbpqdRKOMC86335056BJGEG^pxux~~Ŷ}~~yps}yv~~}xu{upgbdb_\Z^ZY^bdpuu~xss~}xxv}~}vupkgaWTY_YMMZddY\gsxsu~}{~xy}xqqpvxsslpslinlafffnifpx}}~qdikbZUZYa_\inffsvssllpi_\iaMKYkpgTY~basöŽ»pn{udWOR_bJ;COYYPMMKC@MKEG;BPROU\_by}pxʾn\YOB60,$ !.8EPZdyʾy~{xuqlZOOCCORMG9=JKGJKMask^^daap}ó}x{yqy}qdWKEYRJY_TJPWRPWYafdb^anlgu~}yv{x{pln_R_iliaggafffgfblqllns{vpivui_^bg_Ublfb_ipkki_bfpnggip~}xnillf\YUJJKMPU_ag_^gu~~lfu{lTRlxiUECOYE>GGHKEMMZbZds}{Ǿugpyssifvsdddf__^^ZREMYTJGC_kPMi{kks{\yҾ}ugUEEH>'$')"'55,1=HHHKM\kx~}y~skia\adUM\YYgZEM_iaKJk~y{}gZZaaZR\b_ZZaafpkZbkgddY\nvvu~vnxy~~~ndgkknkpnklxskfkvpgfggUYssgiks}x~vy{~vy~~}npuyqlnsy}sknp}{qx}~vy~xpuxvqkqpgbbgngggkpqx{~{yupqqkad\TROUUMPRT_fZOYdspiny~lWWsbMGYqkWPTUWYZTHR\\HEWfnYRuxg{°qupaWMG8+6$"+'0356BH@CMUMUpq{xy}vxu~~silZEGOYUTYOdx{}x~y~vvxq\TfdZZ\nuigkpnnqvyyuux{v{uv}}upx~sdp{xvvnyyvqik}vbsxipubv~ysy~{{uvuq}uxuux{y}x{up{~vpqspkkllnssgW^bgqpqvu{~~yniys^JGbqaP56^iH@Y^xx~~xiuuiakqxsdgnuviTYbquiWUfZYqu^Yfafyv\iäŮͳusbldTEGE55@RUWYWTfu}qadikpdYdq_dynfnuqpk\gns~{sknvya\nnfg_akd^\ik_p{}}}y½ydfs~{nUTppbYYgnlkqpiluqvqxysyxpvy{ysl}{~vysilk_glgsuiu{plpngkpnqplpkbYTbiuqs}ys}xs{qsnklYPOfsZWdlxvi{{}{}un~{slv~qysnu}}gZ}~kqn~{pnqf_Zpxvvfv~~sY_qiRPZ\da\\\Pp}{uu}pq}}pu^aqsuniy~vs}i{~q{y~{~}}nknplld_Y^gb^Zdqv}~}{}{}y~~yxxnqkq~xx~y{yxv~y~qlxqlg_ax{snki{{}xx}sy}{ylgy}}{}~xss_lpgbZbiuulpsp}}y~svyganuyp\^pvsigu~svyv{~~vplqubqvu}pdnqs~~uvq^p{~ilqyub^fvsd\\\b_PHOTHYpsl^f{sbnvv}}ifdaaiiWbqsqlku{{qx{{v}vy{vuqdknvupqxux~~~{}{qpux{vsuqqssvu{uxyx{{vx}{}}yy}{}{vxvxsvuqqkinnkkisyvv}yvxxsnnspnqsxvuux}~}}~}~~xx{}~xnnquxvppssu{}y~~xux}}yx}~}~yxy~yyxpsvxxuqs{~}yyvyvkiffgfgiiikkfilkfkpy}}y{yuuvqlgiiggkklqpqsvxysv{{xpgkqsqvvvvsspqxx{uuy{sssp}gZ_dp{us}upk^RKd}sgvk\^ny~}qdbix~fPCMfsuslbpii\M{ykYa}dvTa}^g~lGba;>UnlkKO^{kP^akv\9HfOTlqE;C=\{G^g{bGZ¬nPikPTqUs{aTUl{¸W>KaMTx>G;Kg80TpxB)KuyqdPZxǕuglp§TllE09O^uqlfG3K^Ug}ǸsPWlZCRgvö}^PW\UbpsWWYC>Kas~W=EEqff͹bn_qTHbg_M_qxT61Hfvp”RfC6U{i^~xJKk_@CZl}ùZ^}RBRfyçisZ@Jf}xծqxiCYuP6Jlg9UxuiqbJ3HgaWk¹laidsyǹvdB)!&3WZYu~}bJ95EgZWvŹqdvbGBKi}kK@RM}vnŗ{uJYqG9K\{qgT89TRMdy~pgZGEUZkԾuB1B@asWPl\=GRig\nZJpuTERk}˸nYsg@3CayybusP9CHsv{ʶnvJ{q{R>;pKsŦv9Yl_HuGRvKYOJlplvnl_dvˍWpȩlC\xvu^d}qBHOidKJi}\ulgig~{ȳpCun\~}BWuC.Ck;=ZsG8Osn{xu}pOdbORflyfYYaZ356J_lûlMbWTduxȾ—_iROHRi}Ƚ~\dC^i^Y_Uiudzd_qu;66^~k\_y~TGGkd=)9TgžԽuEpgOTp˅Z~ÙWbZ6'1JfffJ9Jb{}b;=gpunnű_g}kKP^x͵ulxiZJ;KTp{ňxqC>;~Y5JJ~guJ+ig>HCT@avԅ{¬sskPUqʾa@6=BZixŸ{~d85KaGK^vxsPEgyPZvжiO059GZZp~ylaM+$>Uk}ŤsiPaladsŬf8CKWaB;MfnqfE3=EYbp~dBETqg_sň~yf\p}as{lR;;TTMZllM'.ZYBHT}yY@W\uv϶fBOYYJ\}\Wnu}__E8Jbu}ŮRPygOfKKgyȱgU\bp^yqB58KGMbyvP;MWnYnǜU=BaaPbpYlO!)d}=MfnHGYfϧY{vM9\E\l{WniYaPa\}xM$MiEyuygȳqdH6Gqbu}xUq96TE.Rbf{Y}Zq\u~paqv_CCUnfaTi}T9HxTgg{Ȟ\dslnU{MdxgÏOWx_{iuikRk}gOWYWqsq^=8EiMps>anU9,6Zk±^^vsxnRKfy¦lMi{d\U@0JbubJqvkxb@@OWZW}s{q~\H{yUdpWMixMPOgiJsK>Zn_}yklYabZvs_ZYH\i_k{~nP6=U}}{l~dGG_yxbõu~M=Yn{pyqZaY66G\{}qiaM>Rk{NJUg}vfW@.3C^fslkgfGuWfUlx˙ͱsUa_;>Pndsg}lYWORCayvv}dOK>Rafq©ldvaREKdp~Ⱦ_ygRKH__dxld{vnqgUEgYlaagYJnu\9OTCfyf~fdf{»n_RW_Z6EEJ_p}xkG=;ffšpB+B}saZsŸ_5PlifRdyl6=yJKWky˻qU8UpPWf{¹xfO3+@TbqvxlaJ15Rnd_{öǹ^OTubxyyʳ~l\C6Kpqu\vnW.3lkZbv~ydC5T}YpqP3@Zx^pq}siG&.E^}p}«~pMRl{GWs٦\Yqf^ZfsxJ'GM_Wql{\36q~iTiʻfH1B\p\~ùg@,;TgPl{xkM,Gi\Y{axqqqfa\T^YivkWaUluagyukf~ulUKp{ZniYKbyqHRKJguxfdaUUWb~~yypyqiYKPduödi_^^b_U_snO@EUku}~kM39;GWiuvdHUTYalpȹlHGd^\dx~kE&B}fRMkxkM9Epgký}pdYB8P~lfЩpdWG05O{abangM,Bsa^uȻxy~ZHP~kMTn~ëvv_9)dfasufuеqyRE_nxqdP8Eqgf{{gOHWYTkxq_WkgdxsisZnpfanl{{qkUkifk{g^}xqnbi\u~nHn{l\qu}u}xP@y~viuxsgqqvkuY@HKduǾ}KOk}_\TWguaYUnsOH{gffds{¤vxpfvZ\{ngbPHdqvxvd_xukWp{susdU\_RRqpdKOfÊi{iY9O}u{v}f{pW@@\lynvxupx~n@6RsUugdUWa{vß}vuO~\akg_lDZgg1Ex}KOqxuM@akx\qaa~lPYfU\v}y~}qakMPq{d_Wp}~iYksg\y{}6@s>>bqG_lqunTkp^kayaqqluvf^Tisvdqn~xiskZHk^vx}~vbqlWqq~_~qdqqaGaivn_RY^b=WiUpiR_\MYxyqgxxvuffuJBPng~Z~^8=\{{l~âuqqlkxfqqqlbqgxuu~~Zinfgdlvl{suvvsyP>;bs\ya}ZZbb^qRdyKBv{~}x{GM{kqZuf^TGEkki~xnfsMavU\yZM{palÏ_pdx~qUUdbf}~~y{udMs~dx{}}du}yxsbPfq}}ngxklnRJR{iRk}nBa{vYpWnubk_^ypk{}{i{qdvy{vfYWR~k}U5Znsxp}udapx{~~}qgfyxKTxk~uRanPOguJOdbnx}iWpuqZ_fu^~}i}sgki_pykslxuqpkxaas^\sxud_x~vW~_i{~pgxq\JZf\PqxRbqunWkiyknvsugW_vksn}{pklppa}qWf~ukGYfkdppfUk^\pnxq@;xdYvunnd\pqxsfU{qndssqyvZpvyybkkpkgau{v}xlbMCT_gppq~}\UnfYi{~}bZsnZWxiukdy{~fJasukJZbnd~qYkifi{\K^uxubTk~p\kklPJabaxaf{~~svUv{ZWis{plu~bCJ_nnvflfdv{}gM^}u}}x{~}uyWHE}xd~ZEMg}xk>B}nqupgsMnMRkskn}s_R9=OZ_\usgKJnsanfiJYdgT\Wkv~p^^lu~qkU>BP\gnivvnl^PEYddid_g~vp}x~ZRfvpsu~usvRkTP^isuiv˩yy~qgWEZba_uqfdibTEPguȰ}nqZCBWgvͶnkavYKT^yuȫfPp{kigqlq{iy^OUUfv{sTTdaUdqk^KRTn~î}lsTfxsYp{Y_{^EUWUi{uvg}d^Ydin{n_KP^iRav~udRZibi}sifaUHZnba~kTPnpy~_x\yORviYsx^YfygZf}nx}pgZP_q~nxlda\KHWgxknibfdbuydO~~iZi~nkZs{vqYan{}pdROfkxk~nPZuynl}y}v_aRYlyixq^pyU_gYiy^nqaf}_Y{WYg^\~U^pggaUssYl^Zq{fl}a^p{fx^Zni\y\Raxy_yyPTklnaTp{snZuvaxv_dysykgxy~ub\bsup~{niuylnpiqn}sb_n{qsysunvy}xp{{~~ldiky~y}kfnqqynpu{lbgy{s}kgvxp}}llpqx{lfgq{yuxyx{{qpu{vnv}skuy~vp{~vsqnv~vvssqv~y{unqyx{ss}}plv}pluy~yy}xllv}}xsss{vnqyyuux{yy{ysy}~}}yy~{vsqqsx~xxy~xqqx}xy}uppy~xsv{uv}{y{}y}~~~~{y~~yxy}~}}~~{{~{{~{xy}~~{vvy~}xy{{}~}}yxxy~yvy~}{y{{yy}~~~}{}~~~{yx{~yy{}~}{{{~~{{}~{}~~~~~~~~}}{{~~~~~}}}~~}{}~}{}~~~~}~~~}~~~~~{yy}~~~~}~~~}~~~~~}}}~~~~}}~~}}}~~~~}~~}~~~~~~~~~~~~~~~~~~~~}~~~~}~~~~~~~~~~~~~}}~~~~~~~~~~}}}~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ @G8      #$%&()*+,-./0123456789:;<=>?@ABE5F 0AA@8BCmuʚ;2Nʚ;g4IdId@z[ 0@ppp@ <4!d!dl 0s<4ddddl 0s <4BdBdl< 0h___PPT2001D<4Xm___PPTMac11jm@f   hnamd` Arial&Monotype Typography    hnamd` Arial&Monotype Typography    hnamd` Arial&Monotype Typography    hnamd` Arial&Monotype Typography    hnamd` Arial&Monotype Typography    hnamd` Arial&Monotype Typography f   hnamd` Arial&Monotype Typography  0   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  @   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography    hnamd` Arial&Monotype Typography    hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  D   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  l   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  X   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography, l   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  D   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography   0   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography      hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography   p   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography   D   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  H   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  X   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  X   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  0   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  D   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography      hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography   ,namd$ MS PGothic D   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography   0   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  !$   hnamd` Arial&Monotype Typography  "0   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  #D   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  $0   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  %D   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  &0   hnamd` Arial&Monotype Typography     hnamd` Arial&Monotype Typography  |___PPT10\ D<$4,4$  < < $, ,,$4$ !$"#$$%$&V ___PPT98 / 0 ,<<,|Ll\,lL < | | L\\\<,LlL <!L"<#L$<%L&<? %q9Chronic Constipation$Baylor Med-Peds Jennifer E. Guss, MD&%  ConstipationCommon complaint Accounts for 3% of all visits to the general pediatrician Accounts for 25% of all pediatric gastroenterology consults0:; Consipation:DefinitionxDelay or difficulty in defecation present for more than two weeks that also causes significant distress to the patient.  ConstipationDefine normal before identifying abnormal:great variation in frequency of bowel movements in healthy children Newborns breastfeeding:5-40 movements/week till 3 months 6-12 month olds:5-28/wk 1-3yo:4-21/wk >3yo:3-14/wk:ZnQ    ConstipationWhen a patient presents with the complaint of constipation, must differentiate functional(benign) from organic causes. History and Physical exam help to differentiateBwZZ0Zx/Constipation:Taking a historyFrequency and consistency of stools Pain or bleeding upon passing stools Abdominal pain Age at onset Toilet training history Fecal soiling Withholding behavior Change in appetitejZ$%  Constipation:Taking a historyN/V Wt loss Perianal fissures, dermatitis, abscess, fistula Diet Meds Any history of tx for constipation in the past: Behavioral therapy, meds/diet,success of previous tx, prior test results, parent and patient compliance with previous tx FZ0  P AQB\ RED FLAG hx findings suggest of organic cause&/#Onset in neonatal period Failure to pass meconium Significant wt loss or poor wt gain Intol to cold/low energy Polyuria/dipsia Delayed developmental milestones esp motorPZ$ *P)%" Constipation:Physical ExamAbdominal exam Neurologic exam(incl anal wink and cremasteric reflex) External exam of perineum and perianal area Digital rectal exam Stool for occult blood if h/o abdominal pain, FTT, intermittent diarrhea, fhx colon CA or colonic polyps. Infant with constipationR Z7,  t   '4-6X RED FLAG PE findings suggest organic cause&-FTT Abd distention Sacral dimpling Midline pigmentary abnormalities or hair tufts on lower spine Anteriorly displaced anus Empty rectal vault in spite of stool palpable on abdominal exam ^Z=  A>$ , Q'Organic Constipation: Physical findings&( T Occult blood in stool Absence of anal wink Decreased lower extremity tone, strength:U(   Organic Constipation:CausesDAnatomic malformations -imperforate anus -anteriorly displaced anus 0E *  Organic Constipation:CausesRMetabolic and GI disorders -hypothyroid -hypercalcemia -CF -DM -gluten enteropathyXS  ,)   Organic Constipation:CausesNeuropathic Conditions -spinal cord abnormalities/trauma Nerve disorders -Hirschprungs dz Drugs -phenobarb, antacids, anticholinergics -antidepressants, opiatesh!  'Z ?    Organic Constipation:Causes~OTHER -Botulism -lead ingestion -cow s milk protein intolerance:@  5Organic Constipation0Work up and treatment based on physical findings Functional ConstipationAka idiopathic constipation, functional fecal retention, fecal withholding When constipation presents after the neonatal period,and there is no evidence of pathology, the diagnosis functional Functional constipation is usually results from painful BM s causing children voluntarily withhold feces to avoid unpleasant defecation RIZJu  FFunctional ConstipationParents often misinterpret withholding behaviors to be efforts to pass stool Children withholding stool stiffen bodies, flush, cross legs, tighten gluteal muscles, walk on tipoes, squat, hide when the urge to defecate comesM,.6F. Constipation:typical hx: Begins after newborn period, often around time of toilet training May be intermittent periods of normal stooling Low fiber diet Poor water intake Busy child-doesn t sit for long Small amount blood on toilet tissue with wipingRZB/   0hr7%Functional Constipation:typical examStool palpable on abdominal exam Rectal vault full of stool Anal fissures/tears Normal height and weight for age Normal neurologic examD!! x Functional Constipation:CausesDiet:inadequate fiber, inadequate water intake, too much juice Behavioral:too busy toilet for adequate amount of time, negative toilet training experiences Emotional:recent psycho-social stressors2Z?]( "Functional Constipation:pathophys.&#! Whatever the reason, once a stool is hard and painful to pass, a vicious cycle begins with the child withholding stool to avoid pain. This in turn creates worse constipation, harder stools which are continually more difficult to pass Don t want to eat and drink when constipated, hindering some of the treatment methods.AZU"Functional Constipation:pathophys.&#! rWhen a large, hard bolus of stool is in the GI tract, newer liquid stool will pass around the bolus and result in involuntary anal leakage--embarrassing and damaging to a child s psyche8!Functional Constipation:Treatment]Parent Education Dietary intervention Behavioral modification Medical therapy Close follow-up:^ 9Parent EducationEDemystify constipation-explain it! If fecal soiling present, educate to keep parents from attributing negative qualities to child--understand that soiling from overflow incontinence is not willful or defiant Should expect relapses and need to tolerate them Encourage family to be supportive and positive throughout treatment ^FZ#iC  1C:Dietary InterventionBBalanced diet-whole grains, fruits, vegetables Adequate water intake Avoid foods that constipate-white rice, ripe bananas, tea Prune, pear, apple juice have been known to help or aggravate constipation depending on patient Don t force diet on child-best success when child feels in controlF"Z/:`  C; Behavioral ModificationRegular toilet habits-sit for 5-10minutes after each meal Keep stool diary of frequency, may combine with reward system to encourage time spent on toilet Bring diary to MD at follow-up visits for positive reinforcement2Z:`@ <!Behavioral ModificationModify parental behavior- no rushing in the morning to leave for school, parent and patient must be awake early enough to allow for adequate toileting time, preparation of proper morning meal No punishments or ridicule for constipation or soiling Identify psycho-social stressorsFZ7  !="Medical TherapyAlways in combination with behavioral modification Treatment with medication results in remission much sooner than without medication Laxatives should be continued until child can maintain regular toilet habits Remission usually attributed to too fast discontinuation of laxatives:Z3SMF  >#Medical Therapy)Meds may be needed for several months (lubricant)Mineral oil:1-3cc/kg/day divided QD or BID (osmotics)Milk of Magnesia(400mg/5ml):1-3cc/kg/d divided BID (PEGbased)MiraLax(polyethylene glycol):8.5-34g/d, start at 0.8g/kg and titrate for effect (stimulants)Dulcolax-one PR QD, NOT FOR PROLONGED USE!F*Z&6=Z  7>] 0=#?$ Follow-upBy phone and in office Therapy can be discontinued when regular BM, well formed are daily. Usually occurs after few months of therapy  rescue plan for when symptoms begin to occur Refer to GI when treatment fails or patient has multiple relapses:Zo/B  @%Fecal ImpactionPresence of hard mass in lower abdomen and dilated rectum filled with hard stool xray-excessive stool in colon Treat orally and/or rectally Work with patient to preserve sense of control, discuss options with patient for best outcomeDQ]  QA&Fecal ImpactionHigh dose mineral oil or milk of magnesia with a stimulant laxative or MiraLax When impaction is severe, hospitalize and administer large volume MiraLax rapidly via NG tube Rectal approach includes enemas and suppositories8O^1  ,GCG/0"#$%& ' ( ) *+,-./01234F5 ` 3fnff` fp=` !f` 3f33` fff33` ff33` 33f` f3>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PV    @ ` `p>> ^1V1P440(     BW CfDE,F6 W  Pn n /Hf  W W @`""  S @ݤ "`P  T Click to edit Master title style! !   C ߤ "   RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  C  "``b JB___PPTMac11   hnamd` Arial&Monotype Typography  \* B  C  "`b  JB___PPTMac11   hnamd` Arial&Monotype Typography  ^* B  C 0 "`8b JB___PPTMac11   hnamd` Arial&Monotype Typography  ^* B  B_ CwDE,F6  12w  _  `@`"55^   B C DE F*    FRj @`"%wT  i   " iV   BCDE`Fj3R3[J3d =xjXy.|7 sb"3324@`" Y:   BCDEF"x@`" E   B2C5DE0F: 3~25Fy+**. @`",X  BCDE F*ENEE@`"V  BCDE F*$ @`" lE  BCDEF"H@`"C  BCDE F*PWPP@`"  BC\DEF&j\+@`"  B8CDEFN8 @`"[mb  i # " ib   # "   B9CDE(F2 kr $9[CJe kk@`"Z  BC DE$F. ( G((@`"|)  BWCDE$F. $],PWt.@`" _  BCDEF"d4dd@`"L  BC(DE@FJ"BDF2Pk(x"""$@`".  BCDE(F2 [PjGaX9@`"5`Nb  iH # " iH  BCDE F*n(BPgTnn@`"'`  "BCpDEhFr?4CfcCPp(Y**.:(sk6Pg_68@`"OH  BCODE$F. tj!:^OLtt@`"ja   BCDE8FB|Q&9+Cca=wJL2 @`"  ! BCDE,F6 Lq>thc;?@`"BB> " BC DE4F> )B@  tMY)) @`"H.  # BCDE4F> _N95_}H9 @`" i $ BCDE@FJ~Bt*n Lp_55 n~~~"$@`"lT \5O % "5\O &B ZBC DEF!!T | ? s OOCi3[~d|YAdzu H  T T DH@`"\< ) 'B ZBC DEF!!T | ? s OOCi3[~d|YAdzu H  T T DH@`"5O x T 9B ( "9B b 9B )# "9B * BC&DE F*{ V&Ox{ { @`"T\ 9B + "9B , B\C]DE$F. *]\g @`"t9F - B(CDEXFb`M;Bl (TDAkl`^tZ?v.0@`"d . BC DEF" =@`"6zsn / 0B CDElFv_  5  o } 6 +   N ? T iS/x9 h  r [  u _ _ 8<@`"B 0 BCVDE F*PjV!rPP@`"iC 1 BCDE F*NT~(rFNN@`"( 2 BCDE F*N<:W6NN@`"v 3 BCDE F*X425+XX@`"iy,hB 4 s *DԔ"T0B  s *޽h ? fp=  Crayon{  +#`(    BC#DEF" y#e  @`"   <%3 Ԕ8c?"` P   T Click to edit Master title style! !  C `  " p   W#Click to edit Master subtitle style$ $  C  "``b JB___PPTMac11   hnamd` Arial&Monotype Typography  \* B  C $ "`b  JB___PPTMac11   hnamd` Arial&Monotype Typography  ^* B  C  "` b JB___PPTMac11   hnamd` Arial&Monotype Typography  ^* BT {   "{    BCDE0F: >,GS:@`"{    B2C5DE0F: 3~25Fy+**. @`"j    BCDE F*ENEE@`"X\ {    "{    BCDE F*n(BPgTnn@`"|f  (BCpDEhFr?4CfcCPp(Y**.:(sk6Pg_68@`"{   BCDEF"d4dd@`"D  BCODE$F. tj!:^OLtt@`"|  BC(DE@FJ"BDF2Pk(x"""$@`"NT z N[   " zN[   zBCDE0F: >,GS:@`" E   zB2C5DE0F: 3~25Fy+**. @`" 5   zBCDE F*ENEE@`"  \ z N[   "z N[   zBCDE F*n(BPgTnn@`"zw  f  (zBCpDEhFr?4CfcCPp(Y**.:(sk6Pg_68@`" [   zBCDEF"d4dd@`"Z!    zBCODE$F. tj!:^OLtt@`"U N   zBC(DE@FJ"BDF2Pk(x"""$@`"= L $  C BCDELF$)+,04k|w@xy( @  E@      "p 8;   B0CDE(F| fYc 0 @   " 8 B  s *޽h ? fp= 0 \Th(  h h s *t P    P*   h s *     R*  d h c $ ?   h s *  @  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S h 0 `P   P*   h 0 `   R*  H h 0޽h ? 3380___PPT10.tK°  $(  r  S Գ` P   r  S  p   H  0޽h ? 33___PPT10i.tK+D=' = @B +  @$( /@ r  S |I`P   r  S  J   H  0޽h ? 33___PPT10i.tK(+D=' = @B +  P$(    r  S O`P   r  S D   H  0޽h ? 33___PPT10i.tKvL+D=' = @B +  `$( $0 r  S R`P   r  S R   H  0޽h ? 33___PPT10i.tK)L+D=' = @B +  $$(  nobidse $r $ S d_`P   r $ S tb   H $ 0޽h ? 33___PPT10i.tKC7+D=' = @B +   D$( ?? Dr D S  o`P   r D S    H D 0޽h ? 33___PPT10i.tKNVa+D=' = @B +    H$( ɏ Hr H S $|`P   r H S |   H H 0޽h ? 33___PPT10i.tK+D=' = @B +  0$(  r  S @`P   r  S    H  0޽h ? 33___PPT10i.tK+D=' = @B +   0L$( >0x@ Lr L S \`P   r L S    H L 0޽h ? 33___PPT10i.tK+D=' = @B +   @P$( Ln Pr P S @`P   r P S    H P 0޽h ? 33___PPT10i.tK+D=' = @B +  @$(  @r @ S ̵   r @ S    H @ 0޽h ? 33___PPT10i.tK]+D=' = @B +   nf,( @ ,r , S `P    , S  <$ 0   , s *pL$D 0U 0H , 0޽h ? 33  ___PPT10 ..tK8R+D ' = @B D ' = @BA?%,( < +O%,( < +D4' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<*,%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*,%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*,)%(DA' =%(D' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+B#style.visibility<*,)D%(+8+0+,  +,$  0P( ѓ 0r 0 S `P    0 S  <$ 0  H 0 0޽h ? 33""___PPT10!..tKt+KDp!' = @B D+!' = @BA?%,( < +O%,( < +D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(/%,( < +D' =1:Bvisible*o3>+B#style.visibility<*0%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*0D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*0D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%( /%,( < +D' =1:Bvisible*o3>+B#style.visibility<*0(%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*0(D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*0(D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(/%,( < +D' =1:Bvisible*o3>+B#style.visibility<*0(7%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*0(7D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*0(7D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(/%,( < +D' =1:Bvisible*o3>+B#style.visibility<*07;%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*07;D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*07;D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(/%,( < +D' =1:Bvisible*o3>+B#style.visibility<*0;?%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*0;?D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*0;?D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(#/%,( < +D' =1:Bvisible*o3>+B#style.visibility<*0?S%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*0?SD' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*0?S+8+0+0 +  4P( 4A 4r 4 S `P    4 S  <$  0  H 4 0޽h ? 33___PPT10..tKl+rDL' = @B D' = @BA?%,( < +O%,( < +D' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*4%(D' =-6B%barn(outVertical)*<3<*4D' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*49%(D' =-6B%barn(outVertical)*<3<*49D' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*49I%(D' =-6B%barn(outVertical)*<3<*49ID' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*4IZ%(D' =-6B%barn(outVertical)*<3<*4IZD' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*4Z`%(D' =-6B%barn(outVertical)*<3<*4Z`D' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*4`%(D' =-6B%barn(outVertical)*<3<*4`D' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*4%(D' =-6B%barn(outVertical)*<3<*4+8+0+4 +b/  8(  8r 8 S `P    8 S | $  0 PH___PPT2001$  H 8 0޽h ? 33,,___PPT10,..tK\#+SD,' = @B D+' = @BA?%,( < +O%,( < +D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(/%,( < +D' =1:Bvisible*o3>+B#style.visibility<*8%(D' =+4 8?dCB1+#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*8D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*8D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%( /%,( < +D' =1:Bvisible*o3>+B#style.visibility<*8%(D' =+4 8?dCB1+#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*8D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*8D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(/%,( < +D' =1:Bvisible*o3>+B#style.visibility<*8 %(D' =+4 8?dCB1+#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*8 D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*8 D_' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(/%,( < +D' =1:Bvisible*o3>+B#style.visibility<*8 @%(D' =+4 8?dCB1+#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*8 @D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*8 @DU' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(/%,( < +D' =+4 8?`CB ppt_xBCB0-ppt_w/2B*Y3>B ppt_x<*8D ' =+4 8?XCB ppt_yBCB ppt_yB*Y3>B ppt_y<*8D' =1:Bhidden*o3>+B#style.visibility<*8%(DU' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(#/%,( < +D' =+4 8?`CB ppt_xBCB0-ppt_w/2B*Y3>B ppt_x<*8D ' =+4 8?XCB ppt_yBCB ppt_yB*Y3>B ppt_y<*8D' =1:Bhidden*o3>+B#style.visibility<*8%(DU' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%()/%,( < +D' =+4 8?`CB ppt_xBCB0-ppt_w/2B*Y3>B ppt_x<*8 D ' =+4 8?XCB ppt_yBCB ppt_yB*Y3>B ppt_y<*8 D' =1:Bhidden*o3>+B#style.visibility<*8 %(DU' =%(D' =%(D' =A@BBBB0B%(E' =4 B`BPB`B?<*%(//%,( < +D' =+4 8?`CB ppt_xBCB0-ppt_w/2B*Y3>B ppt_x<*8 @D ' =+4 8?XCB ppt_yBCB ppt_yB*Y3>B ppt_y<*8 @D' =1:Bhidden*o3>+B#style.visibility<*8 @%(+p+0+8  ++0+8  +biA  $( < r  S `P   r  S l   H  0޽h ? 33___PPT10i.tK\+D=' = @B +  ($( ܆  @ (r ( S `P   r ( S    H ( 0޽h ? 33___PPT10i.tK++D=' = @B +   $(  cA r  S t $`P  $ r  S 4 $  $ H  0޽h ? 33___PPT10i.tK5+D=' = @B +  `$(  ;% r  S $p`  $ r  S ,$  $ H  0޽h ? 33___PPT10i.tK +D=' = @B +  p$( E r  S !$`P  $ r  S L"$  $ H  0޽h ? 33___PPT10i.tKPB+D=' = @B +   p\P(  \r \ S X)$`P  $  \ S T*$ <$  0 $ H \ 0޽h ? 33  ___PPT10 ..tK;+oؤD$ ' = @B D ' = @BA?%,( < +O%,( < +D' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*\?%(D' =-6B%barn(outVertical)*<3<*\?D' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*\?%(D' =-6B%barn(outVertical)*<3<*\?D' =%(D' =%(DR' =A@BBB%B0B%(D' =1:Bvisible*o3>+B#style.visibility<*\%(D' =-6B%barn(outVertical)*<3<*\+8+0+\$ +  `$( (D `r ` S ;$`P  $ r ` S <$  $ H ` 0޽h ? 33___PPT10i.tK-+D=' = @B +  d$( GX dr d S I$`P  $ r d S pJ$  $ H d 0޽h ? 33___PPT10i.tKJ+D=' = @B +  $(  r  S Q$`P  $ r  S `R$  $ H  0޽h ? 33___PPT10i.tK/+D=' = @B +  $(  r  S lY$`P  $ r  S @Z$  $ H  0޽h ? 33___PPT10i.tKI+D=' = @B +  $(  r  S g$`P  $ r  S h$  $ H  0޽h ? 33___PPT10i.tKuE+D=' = @B +  $(    r  S u$`P  $ r  S v$  $ H  0޽h ? 33___PPT10i.tK+D=' = @B +  $(  r  S $`P  $ r  S l$  $ H  0޽h ? 33___PPT10i.tK+D=' = @B +  $( B.$ r  S ̑$`P  $ r  S p$  $ H  0޽h ? 33___PPT10i.tKj +D=' = @B +  $(  A r  S (_`P   r  S    H  0޽h ? 33___PPT10i.tKD2+D=' = @B +  $( N r  S `P  $ r  S <   H  0޽h ? 33___PPT10i.tK +D=' = @B +  $( " r  S d$`P  $ r  S 8$  $ H  0޽h ? 33___PPT10i.tK?+D=' = @B +   $(  r  S $`P  $ r  S ܺ$  $ H  0޽h ? 33___PPT10i.tK1z+D=' = @B + 0 tll(  {5 lR l 3 h   r l # h @    H l 0޽h ? 3380___PPT10.tK° 0 tlx(    xR x 3 h   $r x # $h @  $  H x 0޽h ? 3380___PPT10.tK° 0 tl|( P |R | 3 h   $r | # ܎h @  $  H | 0޽h ? 3380___PPT10.tK° 0 tl( {5 R  3 h   $r  # <$h @  $  H  0޽h ? 3380___PPT10.tK° 0 tl0(  R  3 h   $r  # $h @  $  H  0޽h ? 3380___PPT10.tK° 0 tl@( {5 R  3 h   $r  # \$h @  $  H  0޽h ? 3380___PPT10.tK° 0 tlP( {5 R  3 h   $r  # l$h @  $  H  0޽h ? 3380___PPT10.tK° 0 tl`(  R  3 h   $r  # $h @  $  H  0޽h ? 3380___PPT10.tK° 0 tl( {5 R  3 h   $r  # $h @  $  H  0޽h ? 3380___PPT10.tK°  0 tl(  R  3 h   $r  # $h @  $  H  0޽h ? 3380___PPT10.tK°  0 tl( {5 R  3 h   $r  # $h @  $  H  0޽h ? 3380___PPT10.tK°  0 tl( > R  3 h   $r  # !h @  $  H  0޽h ? 3380___PPT10.tK°  0 tl( {5 R  3 h   !r  # !h @  !  H  0޽h ? 3380___PPT10.tK° 0 tl( {5 R  3 h   !r  # D !h @  !  H  0޽h ? 3380___PPT10.tK° 0 tl( {5 R  3 h   !r  # !h @  !  H  0޽h ? 3380___PPT10.tK° 0 tl(  R  3 h   !r  # \!h @  !  H  0޽h ? 3380___PPT10.tK° 0 tl( {5 R  3 h   !r  # !h @  !  H  0޽h ? 3380___PPT10.tK° 0 tl( {5 R  3 h   !r  # L!!h @  !  H  0޽h ? 3380___PPT10.tK° 0 tl@( 0@E R  3 h   !r  # &!h @  !  H  0޽h ? 3380___PPT10.tKE 0 tlP(  k&& R  3 h   !r  # d,!h @  !  H  0޽h ? 3380___PPT10.tKEr [0]+`b `MeDwӄ@tgojo"rpV>  %Um *" ,./13579;=?ACEGIKMO4`5W"$y'T7? QC. Oh+'0 hp , L X dpxChronic ConstipationPJennifer GussaWPowerBook G4:Applications:Microsoft Office 2004:Templates:Presentations:Designs:CrayonAnoop Agrawalpp13oMicrosoft PowerPointion@@v.Z@A'@TvbG>g    x-- @ !x--'f--$Yd stY--'--$ cS< !0fcgc--'--$ MZknjm6&--'--$)@mVJ2)+)@--'--$QXcbZTQ--'--6$  #3iejcSCESc`cRFGSa-#%  --'--$( BC( --'--$1%!#.'7/9,&71--'--"$K2]5q=HqGZ>O7V?jKNFy;^0I.K2--'--$ --'p=--$ --'--$ --'--$--'--6$--'--$--'--$--'--"$     --'p=--%O136:>BGP Z#e&j(o)s*x*|***)(%#"!   !"#$(+/234454431.*'%$#"!!"# $&( *//=4D6K8R9X;^;d<i;n:s9x8}64/*(&$"! --'--:%lpstuuvuutromlkjkkln p t w z|}~--'@Arial-. %2 mChronic Constipation    .. %2 lChronic Constipation    ."Systemdi-@Arial-. 2 Baylor Med   .. 2 Baylor Med   .-@Arial-.  2 -..  2 -.-@Arial-.  2 Peds ..  2 Peds .-@Arial-. %2 Jennifer E. Guss, MD    .. %2 Jennifer E. Guss, MD    .-T՜.+,0    (On-screen Show?Jennifer Guss?R!A $ArialＭＳ ＰゴシックCrayonChronic Constipation ConstipationConsipation:Definition Constipation ConstipationConstipation:Taking a historyConstipation:Taking a history3“RED FLAG”hx findings suggest of organic cause Constipation:Physical Exam1“RED FLAG” PE findings suggest organic cause(Organic Constipation: Physical findingsOrganic Constipation:CausesOrganic Constipation:CausesOrganic Constipation:CausesOrganic Constipation:CausesOrganic ConstipationFunctional ConstipationFunctional ConstipationF. Constipation:typical hx&Functional Constipation:typical examFunctional Constipation:Causes#Functional Constipation:pathophys.#Functional Constipation:pathophys."Functional Constipation:TreatmentParent EducationDietary InterventionBehavioral ModificationBehavioral ModificationMedical TherapyMedical Therapy Follow-upFecal ImpactionFecal Impaction  Fonts UsedDesign Template Slide Titles!%_R !Anoop AgrawalAnoop Agrawal  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()+,-./012456789:<=>?@ABGRoot EntrydO)Current User;SummaryInformation(*PowerPoint Document(RDocumentSummaryInformation83