VEGETATIVE DISORDERS

Definition
abnormalities of vegetative functions like eating, evacuation or sleep, either due to delayed maturation of bodily functions or abnormal psychosocial development vegetative state is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal than true awareness.

Rumination Disorder
Rumination disorder is an eating disorder in which an infant or young child -- brings back up and re-chews partially digested food that has already been swallowed Weightloss or failure to gain at expected level male affection more commonly , 3-14 months of age

Symptoms of rumination disorder in babies and young kids include

Repeated regurgitation of food Repeated re-chewing of food Weight loss Bad breath and tooth decay Repeated stomach aches and indigestion Raw and chapped lips unusual movements typical include straining and arching the back, holding the head back, tightening the abdominal muscles, and making sucking movements with the mouth..

Two types 1)psycogenic 2)self stimulating To be considered this behavior must occur in children who had previously been eating normally, it must occur on a regular basis usually daily for at least one month, during feeding or right after eating.

Treatment of rumination disorder

mainly focuses on changing the child's behavior. Changing the child's posture during and right after eating Encouraging more interaction between mother and child during feeding; giving the child more attention Reducing distractions during feeding Making feeding a more relaxing and pleasurable experience Distracting the child when he or she begins the rumination behavior

 Psychotherapy for the mother and/or family may be helpful to improve communication and address any negative feelings toward the child due to the behavior. no medications used to treat rumination disorder.

Complications Are Associated With Rumination Disorder

Malnutrition Lowered resistance to infections and diseases Failure to grow and thrive Weight loss Gastric ulcers Dehydration Bad breath and tooth decay Aspiration pneumonia and other respiratory problems Choking &Death

Pica

Definition of Pica
an eating disorder typically defined as the persistent eating of non nutritive& non edible substances for a period of at least one month at an age in which the behavior is developed mentally in appropriate (>1824month) include plaster, charcoal, clay, wool, ashes, paint, and earth .

predisposing factors
Mental retardation and lack of parental nurturing (psychologic and nutritional) are predisposing factors Pica appears to be more common in children with autism and other brain-behavior disorders such as Kleine-Levin syndrome

Persistent pica
Is often associated with : * Family disorganization * Poor supervision * Psychologic neglect Pica appears to be more prevalent in the lower socioeconomic classes

Geophagia
Pica usually remits in childhood but can continue into adolescence and adulthood. In particular, geophagia (eating of earth) is associated with pregnancy and is not seen as abnormal in some cultures

Risks
Children with pica are at an increased risk for: * Iron-deficiency anemia Lead poisoning * Parasitic infections

Screening
for * iron-deficiency anemia * parasitic infestation * lead intoxication is always indicated.

Enuresis

NORMAL VOIDING AND TOILET TRAINING

The infant has coordinated, reflex voiding as often as 15 to 20 times per day

At 2-4 yr, toilet training begins When grow up;

Average bladder capacity (Ounces) = Age (yr)+ 2 ( Up to the age of 12-14 yr )

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NORMAL VOIDING AND TOILET TRAINING (Cont.)

Girls typically acquire bladder control before boys, and bowel control is typically achieved before urinary control. By 5 yr of age, 90-95% are nearly completely continent during the day and 80-85% are continent at night

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NORMAL VOIDING AND TOILET TRAINING (Cont.)

The transitional phase of voiding refers to: The period when children are acquiring bladder control.

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Steps of normal conscious bladder control

To achieve normal conscious bladder control, several steps must occur: 1.Awareness of bladder filling 2.Cortical inhibition of reflex (unstable) bladder contractions

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Steps of normal conscious bladder control (cont.)

3.Ability to consciously tighten the external sphincter to prevent incontinence 4.Normal bladder growth 5.Motivation by the child to stay dry.

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Enuresis
Voluntary or involuntary repeated discharge of urine into clothes or bed after developmental age when bladder control should be established . Diagnosis made when urine is voided twice a week for atleast 3 consecutive months or when clinically significant distress ocuurs in areas of child life as a result of wetting

 5yr -7%males ,3%females 10yr -3%males , 2%females 18 yr 1%males ,rare

Enuresis may be 1. Primary (90%) Nocturnal urinary control never achieved 2. Secondary (10%) The child was dry at night for aminimum period of 6 months and then enuresis occurs .

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Epidemiology
Approximately 60% of children with nocturnal enuresis are boys. Family history positive in 50% of cases. Although primary nocturnal enuresis may be polygenetic, candidate genes localized to chromosomes 12 and 13.

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Pathogenesis of primary nocturnal enuresis

Is multifactorial and includes the following:
1. 2. , Maturational delay . Sleep factors enuretic children described as being deep sleepers with inadequate arousal impair vasopressin secretion

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Pathogenesis of primary nocturnal enuresis

(cont.)

3 Antidiuretic hormone lack of circadian rhythm /impaired response 4.Genetic factors, ; family history with 40% single parent 70%both parents ;with chromosomes8, 12 13q,22 the likely sites of the gene for enuresis mode of inheritance autosomal dominant

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ProfSaad S AlAni Khorfakkan Hospital

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Pathogenesis of primary nocturnal enuresis (cont.)

5. Psychologic factors, often implicated in secondary enuresis. 6. Organic factors-urinary tract infection (UTI) or obstructive uropathy, which is an uncommon cause of enuresis. 7. Bladder capacity . <2 yr wt in kg X 7 ml >2yr ( age in yr +2)X30ml

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Clinical Manifestations and Diagnosis

(cont.)

A complete physical examination including palpation of the abdomen and rectal examination after voiding to assess the possibility of a chronically distended bladder. Uncomplicated enuresis no further evaluation The family whether the child snores loudly at night.

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Clinical Manifestations and Diagnosis (cont.)

The child with nocturnal enuresis should be

examined carefully for neurologic and spinal abnormalities. There is an increased incidence of bacteriuria in enuretic girls, and, if found, it should be investigated and treated

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Clinical Manifestations and Diagnosis

(cont.)

Urinalysis should be obtained after an overnight fast and evaluated for specific gravity or osmolality, or both, to exclude polyuria as a cause of frequency and incontinence and to ascertain that the concentrating ability is normal.

The absence of glycosuria should be confirmed.

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Clinical Manifestations and Diagnosis

(cont.)

If there are no daytime symptoms and if the physical examination and urinalysis are normal, and culture is negative, further evaluation for urinary tract pathology generally is not warranted. A renal ultrasonogram is reasonable in an older child with enuresis or in children who do not respond appropriately to therapy.

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Treatment ( Factors to consider)

Age of child Medical cause has been ruled out Rate of spontaneous remission (approximately 14%16% per year) Behavioral conditioning with bell and pad or similar methodology
Equally effective as pharmacological treatment Lower rate of relapse than with pharmacological treatment Safer than pharmacological treatment

Most commonly used pharmacological intervention is Desmopressin acetate (DDAVP) Most serious side effect (rare) is hyponatremia, leading to seizures Imipramine can be used for refractory individuals Combination of behavioral and pharmacological treatment for refractory enuresis

Treatment
Fluid management Bladder training exercises Motivational therapy behavioral and psychopharmacologic methods Behavioral treatment attempted first . The bell and pad method of conditioning is a reasonable first approach. success rate of 75%,

Behavioral Treatment
Bladder capacity alarm: results were comparable with those obtained with the traditional bell and pad technique. Other procedures include reward systems, such as star charts, nighttime awakening to urinate, retention-control training, and fluid restriction.

Pharmacologic therapy
Is intended to treat the symptom of enuresis and is not curative.

One form of treatment is desmopressin acetate, synthetic analog of antidiuretic hormone and reduces urine production overnight.
It is available as a tablet, with a dosage of 0.2-0.6 mg at bedtime.

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Desmopressin acetate, (cont.)

used as a nasal spray, with a dosage of 10 g (1 spray) to 40 g (4 sprays total) at bedtime.

reduce evening fluid intake, not used if the child has a systemic illness with vomiting or diarrhea. Hyponatremia ,nasal stuffiness ,head ache,epistaxsis -the nasal spray

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Desmopressin acetate, (cont.)

used for 3-6 mo, and then tapered off If tapering results in recurrent enuresis, the medication ,started again at the higher dosage. No adverse events with the long-term

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Pharmacologic therapy (cont.)

other pharmacologic agent is Imipramine, tricyclic antidepressant. mild anticholinergic and -adrenergic effects ,alter the sleep pattern The dosage of imipramine is - 25 mg in children age 6-8 yr - 50 mg in children age 9-12 yr, and - 75 mg in teenagers.

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Pharmacologic therapy (cont.)

Reported success rates are 30-60%. Side effects - anxiety, insomnia, and dry mouth.. Oxybutynin chloride, a pure anticholinergic agent, Ind uninhibited bladder contractions , above 6 yrs Dose 5 mg max 20 mg per day SE constipation , blurring of vision , dryness of mouth ,palpitations

has been used in some children with primary nocturnal enuresis, but the response rate is low.
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Encopresis
Refers to the passage of feces into inappropriate places after a chronologic age of 4 yr (or equivalent developmental level). Subtypes include: 1. Retentive encopresis: Encopresis with constipation and overflow incontinence 2. Nonretentive encopresis: Encopresis without constipation and overflow incontinence
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Encopresis (cont.)
Encopresis may be: 1.Primary: persist from infancy onward 2.Secondary : may appear after successful toilet training two thirds of encopresis cases are of the retentive type and associated with chronic constipation;

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Encopresis (cont.)
younger than 4 yr of age, the male: female ratio for chronic constipation is 1:1. school-aged child, however, encopresis is more common in males

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Clinical Manifestations
The first consideration in management assessment of fecal retention. Rectal examination * A positive rectal examination is sufficient to document fecal retention * A negative rectal examination in the presence of encopresis requires plain abdominal roentgenograms. The presence of fecal retention is evidence of chronic constipation
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Clinical Manifestations (cont.)

Many children with encopresis present with abnormal anal sphincter physiology as documented either by electromyography or difficulty in defecating a rectal balloon. The inability to defecate a balloon at presentation is associated with poorer response to treatment

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Clinical Manifestations (cont.)

Abnormal anal sphincter function is a marker for chronic constipation; children with this pathology do not appear to have a higher incidence of behavioral or psychiatric disorders review study suggests that Primary encopresis in boys is associated with global developmental delays and enuresis, Secondary encopresis is associated with high levels of psychosocial stressors and conduct disorder

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Clinical Manifestations (cont.)

Associated behavioral or psychiatric problems obviously may complicate the treatment of encopresis,especially when parents respond to soiling with retaliatory, punitive measures and children become angry, ashamed, and resistant to intervention. School performance and attendance secondarily affected as the child becomes the target of scorn and derision from schoolmates because of the offensive odor

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Treatment
The standard treatment approach to encopresis begins with 1. Clearance of impacted fecal material 2. Short-term use of mineral oil or laxatives to prevent further constipation. Concomitant behavioral management is also indicated. The focus of behavioral treatment should be on compliance with: 1. Regular postprandial toilet sitting and 2. adoption of a high-fiber diet.

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Treatment (cont.)
manual disimpaction is required before the treatment can begin; rarely megacolon is observed and referral to a gastroenterologist is required. Once impacted stool is removed, the combination of constipation management and simple behavior therapy done

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Treatment (cont.)
Encouragement to issue rewards for compliance to the child from the outset of treatment and to avoid power struggles with the child. Keeping records of the child's progress Long-term laxative use is contraindicated.

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Treatment (cont.)
tricyclic antidepressants tried with varying success Tricyclic antidepressants often cause or exacerbate constipation ,avoided in children with retentive encopresis Encopresis eventually resolves in most children, regardless of treatment approach.

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Summary
Encopresis refers to the passage of feces into inappropriate places after a chronologic age of 4 yr Subtypes include: Retentive encopresis and Nonretentive encopresis Encopresis may be: Primary or Secondary The first consideration in managing encopresis is assessment of fecal retention.
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Summary (cont.)
Primary encopresis in boys is associated with global developmental delays and enuresis, Secondary encopresis is associated with high levels of psychosocial stressors and conduct disorder the combination of constipation management and simple behavior therapy is successful in the majority of cases

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Clinical Manifestations and Diagnosis

history should be obtained, with respect to fluid intake at night and pattern of nocturnal enuresis. Children with diabetes insipidus, diabetes mellitus, and chronic renal disease may have a high obligatory urinary output and a compensatory polydipsia.

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