Constipation and Asymmetric Rectal Tone in a 10-month-old Girl

Presentation

A 10-month-old girl presents to the primary care office for follow-up of worsening constipation.

Over approximately 3 weeks, her mother reports a transition from daily soft stools to hard and round stools every other day. She had been seen for this 2 days previously in the pediatrician’s office and the night before in urgent care. An abdominal radiograph in urgent care had demonstrated a normal gas pattern and sigmoidal colonic stool burden. Rectal stimulation completed once in urgent care and one home glycerin suppository were both tried with no resultant stool by the time she presented to the pediatrician’s office. Caregivers have also attempted frequent abdominal massages, prune juice, and dark corn syrup over the previous 3 weeks.

In the pediatrician’s office now, the mother reports that the patient has been eating less than usual, is intermittently fussier, and is having night awakenings with crying. She is voiding normally and acting at baseline between episodes of fussiness. She drinks standard antireflux formula per parental choice, which they are mixing appropriately, and eats other age-appropriate infant foods.

Past medical history is significant for a full-term healthy birth with normal growth and development. At 6 months, there was parental concern that she preferred her right leg for weight bearing when held in the standing position by caregivers, with an “out-turned” left leg. Examination at that time was unremarkable, with normal Barlow and Ortolani maneuvers at that and all prior visits. A hip/pelvis radiograph was without sign of developmental hip dysplasia nor other abnormality. Approximately 2 weeks before this presentation for constipation, the parents brought up motor concerns while in a physician’s office …