Cover article

Managing constipation:
Evidence put to practice

By Samuel Nurko, MD, MPH, Susan S. Baker, MD, PhD, Richard B. Colletti, MD, Joseph M. Croffie, MD, MPH, Carlo Di Lorenzo, MD, Walton Ector, MD, and Gregory S. Liptak, MD, MPH

Most children with constipation don't have an underlying organic disorder. The history and physical exam are usually sufficient to diagnose functional constipation. Behavioral modification, education, and oral laxatives are mainstays of treatment.

Approximately 3% of general pediatric outpatient visits and 25% of pediatric gastroenterology consultations are the result of a perceived defecation disorder.¹ Constipation accounts for the great majority of these physician visits. A special committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), comprising primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, recently published evidence-based guidelines for the management of constipation² (also available at www.naspghan.org). This article discusses how pediatricians can put these constipation guidelines into practice, with a particular focus on managing this condition in children 1 year of age and older.

LEARNING OBJECTIVES

After reviewing this article the physician should be able to

Presentation and initial evaluation

A frustrated mother brings her 5-year-old son, Kevin, to the pediatrician's office. She says he had been having normal bowel movements until about 2 years of age, when, after passing a very hard stool, he became "afraid of going." He took to crossing and stiffening his legs when he felt the urge to have a bowel movement.

At first, Kevin's mother thought he was trying to push the stool out, but later realized that he was actually trying to hold it in. He then started to go to "special" places to withhold (corners of the room, behind the sofa) and, since then, has been having fewer movements. He now moves his bowels once a week. The mother can tell from his facial expression that it hurts to hold it in and, when he does have a movement, the stool is large and hard. He is soiling a lot, and children make fun of him. The mother has also noticed some blood in his stool, which she assumes is coming from a rectal tear.

Constipation is a delay or difficulty in defecation that has been present for longer than two weeks and is causing significant distress. The frequency of bowel movements can vary in healthy children: from five to 40 bowel movements a week in breastfed infants until 3 months of age, to five to 28 in 6- to 12-month-olds, to four to 21 in children age 1 to 3 years. Healthy children older than 3 years have three to 14 bowel movements a week.³

Parents may be worried that a serious disease is causing the constipation. After the neonatal period, however, constipation in children is usually functional: no objective evidence of underlying pathology can be found, and the constipation is caused by painful bowel movements, which result in voluntary withholding of feces to avoid unpleasant defecation.

When these children get the urge to defecate, they may stiffen their bodies, cross their legs, tighten their gluteal muscles, walk on tiptoes, or hold on to furniture. They often are flushed. Some squat or hide in certain areas of the house. Such behavior often is misinterpreted by parents as an effort to push and pass stool.

A complete evaluation of the child with constipation is important (Figure [top]). In most cases, a thorough history and physical exam is sufficient to distinguish functional constipation (also called idiopathic constipation, functional fecal retention, and fecal withholding) from organic constipation. A thorough history includes asking the time of the first bowel movement after birth, finding out how the family or child defines "constipation," and inquiring about aspects of the constipation history listed in Table 1. In addition, the clinician should obtain information about the patient's medical, nutritional, developmental, psychosocial, and family background.

TABLE 1
Components of the constipation history

Frequency and consistency of stools

Pain or bleeding upon passing stools

Abdominal pain

Change in stooling pattern over time

Age at onset

Toilet training

Fecal soiling

Withholding behavior

Change in appetite

Nausea or vomiting

Weight loss

Perianal fissures, dermatitis, abscess,
or fistula

Current treatment
  • Diet
  • Medications (for all conditions)

Previous treatment
  • Diet
  • Medications
  • Behavioral therapy
  • Success of any of these or other treatments
  • Results of prior tests
  • Estimate of parent and patient adherence

The physical exam should include abdominal and neurologic examinations as well as an external exam of the perineum and perianal area and at least one digital exam of the anorectum. A stool test for occult blood is recommended when abdominal pain, failure to thrive, intermittent diarrhea, or a family history of colon cancer or colonic polyps is reported, or when the patient is an infant with constipation. An abdominal radiograph to assess the degree of stool retention is only necessary when there is doubt about the diagnosis.

Clinical diagnosis

Kevin's history is unremarkable. He takes no medication and exhibits no thyromegaly. An abdominal exam shows large amounts of stool. There are no sacral dimples or other spinal abnormalities. The cremasteric reflex and anal wink are normal. Rectal examination reveals a moderately dilated rectum filled with hard stool. Stool is guaiac-negative for occult blood.

The differential diagnosis of constipation is extensive. In this case, the absence of "red flags"—that is, observations from the history or physical findings that suggest an underlying organic pathology (Tables 2 and 3)—leads to a clinical diagnosis of functional constipation.

TABLE 2
Examples of organic causes of constipation

TABLE 3
Physical findings that suggest organic constipation

The presence of a hard mass in the lower abdomen, together with a dilated rectum filled with hard stool, indicates fecal impaction, which should be treated promptly. Fecal impaction may also be detected by abdominal radiography (with the finding of excessive stool in the colon). A barium enema is usually unnecessary except in a newborn.

Fecal disimpaction

When fecal impaction is present, it can be treated with oral or rectal medication (Figure [center]). The oral approach is noninvasive and gives the child a sense of power, but it may be difficult for him (or her) to adhere to the treatment regimen. The rectal approach is faster but invasive. The choice of treatment is best determined by discussing options with the family and child.

If an oral approach is selected, a number of medications, used alone or in combination, are recommended (Table 4). A high dosage of mineral oil or magnesium hydroxide (milk of magnesia), together with a stimulant laxative, or a polyethylene glycol (PEG)-electrolyte solution is effective for disimpaction.^4­6 When impaction is severe, the patient may need to be admitted to the hospital, where a PEG solution can be administered by nasogastric (NG) intubation.

With a rectal approach, the options are a phosphate soda enema, saline enema, or mineral oil enema followed by phosphate soda enema (Table 5). Soapsuds, tap water, and magnesium enemas are not recommended because they are potentially toxic. In children older than 1 year, bisacodyl suppositories have been used successfully; in infants, glycerin suppositories have been effective.

TABLE 4
Options for oral disimpaction

TABLE 5
Options for rectal disimpaction

At times, it is necessary to use a combined approach, in which an oral laxative and rectal medication are used. If disimpaction is unsuccessful, or if hospitalization for disimpaction is necessary, consider consultation with a pediatric gastroenterologist. Once the stool has been disimpacted, begin maintenance treatment to prevent recurrence.

Kevin is given a diagnosis of fecal impaction secondary to functional constipation. He is treated with one pediatric Fleet enema followed by milk of magnesia, 2 mL/kg/d, and one teaspoon of Senokot (extract of senna concentrate) syrup daily for three days. During the visit, the pediatrician makes the effort to explain the cause of the problem and discusses behavioral interventions (use of a calendar and reward stickers to encourage regular sitting on the toilet). The impaction is removed, and maintenance therapy is begun.

Treatment of functional constipation

Therapy for functional constipation comprises:

• parent education

• measures to help ensure that bowel movements occur at normal intervals with good evacuation (dietary intervention, behavioral modification, a laxative)

• close follow-up

• adjustment of medications as necessary.

Educating the parents. Part of this first step is demystification of constipation, including an explanation of its pathogenesis. If fecal soiling is present, an important goal of education is to keep parents from attributing any negative qualities to their child: They must understand that soiling from overflow incontinence is not a willful, defiant maneuver.

Successful treatment of constipation, particularly when it occurs with overflow incontinence, requires that the family be well organized, able to complete time-consuming interventions, and patient enough to tolerate gradual improvement and relapses. Encourage parents to maintain a positive and supportive attitude through all aspects of treatment.

Dietary changes. Absorbable and nonabsorbable carbohydrates may help soften stools. Carbohydrates, especially sorbitol, found in some juices (prune, pear, apple) can increase the frequency and water content of stools. A balanced diet that includes whole grains, fruits, and vegetables is recommended as part of treatment. Forceful implementation of diet is undesirable.

Behavioral modification and regular toilet habits are important.^7,8 Recommend unhurried time on the toilet—sitting for five to 10 minutes—after meals. It is often helpful to have children and their caregivers keep a diary of stool frequency, which can be combined with a reward system. A child can use a calendar with stickers, for example, to record each stool passed in the toilet. Small prizes can be given after a predetermined number of successful evacuations in the toilet. The patient can bring the calendar on visits to the pediatrician, where it serves as positive reinforcement.

Oral medication. The use of medications in combination with behavioral management has been shown to benefit children with functional constipation: Children receiving medications achieve remission significantly sooner than those who are not.⁹ A laxative is most beneficial until a child is able to maintain regular toilet habits.

Mineral oil and osmotic laxatives, alone or in combination, are recommended for daily treatment of constipation (Table 6). Long-term studies have demonstrated the efficacy and safety of mineral oil, magnesium hydroxide, lactulose, and sorbitol.^10,11 Because these agents seem to be equally efficacious, the choice should be based on consideration of safety, cost, the child's preference, ease of administration, and the clinician's experience.

TABLE 6
Maintenance treatment for functional constipation

The recent introduction of PEG­ based solutions, such as MiraLax, may provide a satisfactory alternative to other commonly used medications. These agents are tasteless and, therefore, may be easier to administer. Prospective studies to assess their efficacy and safety in the pediatric population are still needed, however.

Prolonged use of a stimulant laxative such as senna or bisacodyl should generally be avoided, particularly at this stage of treatment. (Stimulant laxatives may cause dependency, and should not be prescribed for long periods by the primary care practitioner alone.) One of these agents may be used intermittently as "rescue therapy," to avoid recurrence of impaction.¹²

Maintenance therapy should be discontinued only after the patient has consistently had regular bowel movements without difficulty. Maintenance therapy may therefore be necessary for many months. Relapse is common, and close follow-up by telephone and office visits is recommended.

To help Kevin establish regular toilet habits, he is encouraged to start a diary of his stool frequency. To prevent a recurrence of impaction, the doctor recommends a liquid preparation of milk of magnesia, 2 mL/kg/d. A follow-up visit is scheduled in a month's time. In the interim, Kevin's parents are encouraged to call the pediatrician's office if a question or problem arises.

Refractory constipation

About two weeks later, Kevin's mother calls the office. His bowel habits improved for a week, but now his movements are becoming less frequent, and he is still soiling his underwear.

Reassessment of the diagnosis is appropriate (Figure [bottom]). The pediatrician also needs to determine whether the patient has been adhering to the regimen. Lack of adherence is a common cause of treatment failure. Often, children refuse to take medication because it tastes bad, and parents struggle to administer it.

It is worthwhile to schedule an office visit and ask the patient to bring his stool diary. The visit also affords an opportunity to reinforce information about constipation and share tips on how to improve adherence. The effort to educate parents about constipation and demystify this condition may need to be repeated several times.¹³ A change of medication may be beneficial as well.

If a motivational or behavioral problem is interfering with successful treatment, consider referring the patient to a mental health-care provider.

During the office visit, the pediatrician again finds fecal impaction on physical exam. He recommends an addition to the milk of magnesia regimen: Senokot syrup, 5 mL/d for three days, and mineral oil, 2 mL/kg/d for the same three days. He also reinforces the importance of a balanced diet, behavioral changes, and maintaining the stool diary.

Disimpaction is successful. The maintenance regimen now includes mineral oil, 2 mL/kg/d, in addition to the milk of magnesia. At the one-month follow-up, Kevin is asymptomatic and his bowel habits have improved. A few weeks later, however, the pediatrician again must treat him for impaction.

Referral

Consultation with a pediatric gastroenterologist or other specialist becomes necessary when treatment fails, the patient has multiple relapses, or management is complex. A consultant, reevaluating the child with refractory constipation, can exclude an underlying organic disorder, perform specialized tests, and offer counseling.

Before making a referral, you should:

• determine whether the patient has adhered to the medical regimen

• review the differential diagnosis

• consider whether laboratory tests are indicated to establish the presence of conditions such as hypothyroidism, hypercalcemia, celiac disease, and lead toxicity. After thyroid function testing, for example, a child with a positive result can be referred directly to a pediatric endocrinologist.

The abdominal radiograph and transit time. If the diagnosis of constipation is in doubt, the pediatric gastroenterologist can order additional tests. A plain abdominal radiograph can detect fecal retention in a child who is obese or refuses a rectal exam. Measurement of colonic transit time with radiopaque markers may be helpful in a patient with a history of infrequent bowel movements but without objective findings of constipation.¹⁴

Hirschsprung disease. When there is objective evidence of constipation and it is refractory to treatment, Hirschsprung disease—the absence of ganglion cells in the myenteric and submucous plexuses of the distal colon—should be considered. This condition is a rare cause of intractable constipation in toddlers and school-age children, although it is the most common cause of lower intestinal obstruction in newborns. It occurs in about one in 5,000 live births. In 8% to 20% of affected children, Hirschsprung disease remains unrecognized after the age of 3 years.^15,16

Symptoms vary with age and extent of disease. In the newborn, bilious emesis, abdominal distention, failure to pass meconium, and abnormal stool frequency are common. Complete intestinal obstruction may occur. Unless the diagnosis is established during the neonatal period, the affected infant may exhibit mild constipation followed by acute obstruction, frequent episodes of fecal impaction, or acute life-threatening enterocolitis. From infancy through adulthood, mild to severe constipation may be the only symptom.

Children with Hirschsprung disease usually have a history of delayed passage of meconium and rarely report the presence of fecal soiling. Because clinical features do not allow a complete differentiation of Hirschsprung disease and functional constipation, the former diagnosis must always be considered in any child, adolescent, or adult with severe, intractable constipation.

When Hirschsprung disease is suspected, the patient should be evaluated at a medical center where a pediatric gastroenterologist and pediatric surgeon are available. Rectal suction biopsy with histopathologic analysis and rectal manometry can reliably exclude Hirschsprung disease.

Once the disease has been excluded, the pediatric gastroenterologist can review previous management, consider changes in treatment, or perform other evaluations. Time-limited treatment with a stimulant laxative, prokinetic medication, or PEG solution is an option. Biofeedback, bowel training, and psychotherapy also may be considered.

Additional testing. The pediatric gastroenterologist might order magnetic resonance imaging (MRI) to identify intraspinal problems; colonic manometry to exclude underlying neuropathy or myopathy; barium enema to exclude an anatomic abnormality; and full-thickness rectal biopsy to detect a myenteric disorder. Blood tests such as antiendomysial antibody, thyroid function, and serum calcium, if not performed previously, can detect other causes of constipation.

When further evaluation is needed or changes in therapy are undertaken, the pediatrician may have to communicate to the patient and the family, on more than one occasion, that constipation can resolve but maintenance therapy may be necessary for many months. Relapse is common, and difficulty with bowel movements may continue into adolescence. For many children, regular bowel movements can be maintained only with long-term drug treatment, under the care of the primary care pediatrician or the pediatric gastroenterologist.^17,18

Kevin is referred to a pediatric gastroenterologist, who confirms the absence of red flags on physical exam and finds a hard mass of palpable stool in the lower abdomen and hard stool in the rectum. Because of the impaction and the intractability of the constipation, the patient is admitted to the hospital for a clean-out. An NG tube is placed and Golytely is administered. Anorectal manometry reveals normal internal anal sphincter relaxation and normal defecation dynamics. An MRI of the spine is normal, as are a sweat test and tests of calcium, thyroid function, and antiendomysial antibody. After the clean-out, MiraLax, 17 g/d, is begun. Kevin's response is good.

As this case illustrates, constipation is generally benign—even though it may recur frequently and disrupt the patient's and family's lives. The natural history of constipation has not been well studied, but clinical experience suggests that children with functional constipation can be managed with the expectation that most will outgrow the condition or, at least, have a favorable long-term prognosis. Nevertheless, vigilance and further evaluation are warranted in patients who repeatedly do not respond to standard treatments.

At the time Kevin was being evaluated, Jennifer, a 13-month-old girl with infrequent defecation, was referred by the pediatrician to a pediatric gastroenterologist. She has had difficulty with bowel movements since early in life. By reports, she did not pass her first meconium stool until 72 hours after being born. She was not breastfed, and the mother reported that Jennifer had explosive bowel movements every three or four days, usually after rectal stimulation. Jennifer often showed signs of abdominal distention and had difficulty gaining weight.

Physical exam revealed a very distended abdomen and a tight anal opening, without any stool in the vault. On withdrawal of the examining finger, explosive loose stool was produced. An abdominal radiograph showed a very distended colon. Anorectal manometry revealed a lack of internal anal sphincter relaxation. Rectal biopsy showed a lack of ganglion cells and an abnormal acetylcholinesterase stain, confirming the diagnosis of Hirschsprung disease.

The patient was taken to the operating room, where a short segment of aganglionic bowel was found and resected and a pull-through procedure performed.

Jennifer's story is different from Kevin's. Red flags on the initial presentation and physical exam—delayed passage of meconium, history of infrequent explosive stool after rectal stimulation, difficulty gaining weight, very distended abdomen with colonic dilatation, an empty vault with a tight anal sphincter, and an explosive stool after the exam—prompted early referral. Both cases, however, illustrate the critical role of the pediatrician in managing constipation and identifying patients who require specialized evaluation.

References

1. Molnar D, Taitz LS, Urwin OM, et al: Anorectal manometry results in defecation disorders. Arch Dis Child 1983;58:257

2. Baker SS, Liptak GS, Colletti RB, Croffie JM, Di Lorenzo C, Ector W, Nurko S: Constipation in infants and children: Evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 1999;29:612

3. Fontana M, Bianchi C, Cataldo F, et al: Bowel frequency in healthy children. Acta Paediatr Scand 1989;78:682

4. Tolia V, Lin CH, Elitsur Y: A prospective randomized study with mineral oil and oral lavage solution for treatment of faecal impaction in children. Aliment Pharmacol Ther 1993;7:523

5. Gleghorn EE, Heyman MB, Rudolph CD: No-enema therapy for idiopathic constipation and encopresis. Clin Pediatr 1991;30:669

6. Ingebo KB, Heyman MB: Polyethylene glycol-electrolyte solution for intestinal clearance in children with refractory encopresis: A safe and effective therapeutic program. Am J Dis Child 1988;142:340

7. Lowery SP, Srour JW, Whitehead WE, et al: Habit training as treatment of encopresis secondary to chronic constipation. J Pediatr Gastroenterol Nutr 1985;4:397

8. Howe AC, Walker CE: Behavioral management of toilet training, enuresis, and encopresis. Pediatr Clin North Am 1992;39:413

9. Nolan T, Debelle G, Oberklaid F, et al: Randomised trial of laxatives in treatment of childhood encopresis. Lancet 1991;338:523

10. McClung HJ, Boyne LJ, Linsheid T, et al: Is combination therapy for encopresis nutritionally safe? Pediatrics 1993;91:591

11. Loening-Baucke V: Chronic constipation in children. Gastroenterology 1993;105:1557

12. Nurko SS: Constipation, in Walker-Smith J, Hamilton D, Walker AW (eds): Practical Pediatric Gastroenterology, ed 2. Hamilton, Ontario, BC Decker, 1996, p 95

13. Rappaport LA, Levine MD: The prevention of constipation and encopresis: A developmental model and approach. Pediatr Clin North Am 1986;33:859

14. Papadopoulou A, Clayden GS, Booth IW: The clinical value of solid marker transit studies in childhood constipation and soiling. Eur J Pediatr 1994;153:560

15. Klein MD, Philippart AI: Hirschsprung's disease: Three decades' experience at a single institution. J Pediatr Surg 1993;28:1291

16. Swenson O, Sherman JO, Fisher JH: Diagnosis of congenital megacolon: An analysis of 501 patients. J Pediatr Surg 1973;8:587

17. Staiano A, Andreotti MR, Greco L, et al: Long-term follow-up of children with chronic idiopathic constipation. Dig Dis Sci 1994;39:561

18. Loening-Baucke V: Constipation in children. Curr Opin Pediatr 1994;6:556

DR. NURKO is director of the Motility Program, Children's Hospital, Boston, and assistant professor of pediatrics, department of pediatrics, Harvard Medical School, Boston. He receives research grants from Braintree Laboratories.

DR. BAKER is chair, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Constipation Guidelines Committee; co-director, Digestive Diseases and Nutrition Center, Children's Hospital of Buffalo, N.Y.; and professor of pediatrics, State University of New York, Buffalo.

DR. COLLETTI is professor of pediatrics, department of pediatrics, University of Vermont College of Medicine, Burlington.

DR. CROFFIE is clinical associate professor of pediatrics and director of GI Motility, department of pediatrics, J. Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis.

DR. DI LORENZO is professor of pediatrics, department of pediatrics, and director of Motility Center, Children's Hospital of Pittsburgh, University of Pittsburgh. He receives research grants from Braintree Laboratories and Janssen Pharmaceutica.

DR. ECTOR is associate professor of pediatrics, division of general pediatrics, Medical University of South Carolina, Charleston.

DR. LIPTAK is associate professor of pediatrics, department of pediatrics, University of Rochester, N.Y.

For more information on the guidelines discussed in this article, the authors may be contacted at naspghan@naspghan.org or via the Web site www.naspghan.org.

ACCREDITATION

This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Jefferson Medical College and Medical Economics, Inc.

Jefferson Medical College of Thomas Jefferson University, as a member of the Consortium for Academic Continuing Medical Education, is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. All faculty/authors participating in continuing medical education activities sponsored by Jefferson Medical College are expected to disclose to the activity audience any real or apparent conflict(s) of interest related to the content of their article(s). Full disclosure of these relationships, if any, appears with the author affiliations in the beginning of the article.

CONTINUING MEDICAL EDUCATION CREDIT

This CME activity is designed for practicing pediatricians and other health-care professionals as a review of the latest information in the field. Its goal is to increase participants' ability to prevent, diagnose, and treat important pediatric problems.

Jefferson Medical College designates this continuing medical educational activity for a maximum of one hour of Category 1 credit towards the Physician's Recognition Award (PRA) of the American Medical Association. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

This credit is available for the period of December 15, 2001, to December 15, 2002. Forms received after December 15, 2002, cannot be processed.

Although forms will be processed when received, certificates for CME credits will be issued every four months, in March, July, and November. Interim requests for certificates can be made by contacting the Jefferson Office of Continuing Medical Education at 215-955-6992.

HOW TO APPLY FOR CME CREDIT

1. Each CME article is prefaced by learning objectives for participants to use to determine if the article relates to their individual learning needs.

2. Read the article carefully, paying particular attention to the tables and other illustrative materials.

3. Complete the CME Registration and Evaluation Form below. Type or print your full name and address in the space provided, and provide an evaluation of the activity as requested. In order for the form to be processed, all information must be complete and legible.

4. Send the completed form, with $20 payment if required (see Payment below), to:
Office of Continuing Medical Education/JMC
Jefferson Alumni Hall
1020 Locust Street, Suite M32
Philadelphia, PA 19107-6799

5. Be sure to mail the Registration and Evaluation Form on or before December 15, 2002. After that date, this article will no longer be designated for credit and forms cannot be processed.

FACULTY DISCLOSURES

Jefferson Medical College, in accordance with accreditation requirements, asks the authors of CME articles to disclose any affiliations or financial interests they may have in any organization that may have an interest in any part of their article. The following information was received from the author of "Managing constipation: Evidence put to practice."

Samuel Nurko, MD, MPH, receives research grants from Braintree Laboratories; Susan S. Baker, MD, PhD, has nothing to disclose; Richard B. Colletti, MD, has nothing to disclose; Joseph M. Croffie, MD, MPH, has nothing to disclose; Carlo Di Lorenzo, MD, receives research grants from Braintree Laboratories and Janssen Pharmaceutica; Walton Ector, MD, has nothing to disclose; and Gregory S. Liptak, MD, MPH, has nothing to disclose.

CME REGISTRATION AND EVALUATION FORM

Date of publication: December 2001
Title: Managing constipation: Evidence put to practice
Author: Samuel Nurko, MD, MPH; Susan S. Baker, MD, PhD; Richard B. Colletti, MD; Joseph M. Croffie, MD, MPH; Carlo Di Lorenzo, MD; Walton Ector, MD; and Gregory S. Liptak, MD, MPH
MP Code: CP1201

Registration

Name: _______________________________________________   Degree: _______________

Street address: ____________________________   Institutional affiliation: ______________

City: _____________________   State: __________   ZIP: ___________   Telephone: __________

Specialty: [ ] Pediatrics   [ ] Other _________________ Years in practice: _________   Resident? ___

Time needed to complete this CME activity: [  ] <1 hr [  ] 1 hr [  ] 1.5 hr [  ] 2 hr

Certification: I attest to having completed this CME activity.

______________________________________
            Signature (required)   

Evaluation

1. Rate the overall effectiveness of this CME activity. 5 (very effective) 4  3  2  1 (not at all effective)

2. Circle "Yes" or "No"

3. Which of the following best describes a change you might consider making in your practice as a result of something you learned from this activity? (Please circle only one response.)

A. Slightly modify what I currently do.
B. Make a major change in what I currently do.
C. Follow a procedure; use a technique/technology that is completely new to me.
D. Follow a procedure; use a technique/technology that I currently use but for a different purpose.
E. None of the above, but some change.
F. Not considering any changes.

4. Please describe any change(s) you plan to make in your practice as a result of this activity: ________

_________________________________________________________________________________

_________________________________________________________________________________

5. How committed are you to making these changes? 5 (very committed) 4   3   2   1  (not at all committed)

6. Other comments __________________________________________________________________

Payment

Circle A or B, and enclose payment if required.

A. I am a paid subscriber to Contemporary Pediatrics, so no payment is due.

The subscriber number above my name on the mailing label is: ___ ___ ___ ___ ___ ___ ___ ___

(Example: _1_ _2_ _3_ _4_ _5_ _6_ _7_ _8_ ).

If you do not know your subscriber number, please call 1-800-432-4570.

B. I am not yet a paid subscriber, so I am enclosing $20 to cover the cost of processing my CME application.

[ ] I am enclosing a check (payable to JMC/CME).

[ ] Please charge my Mastercard or Visa (circle type of card),

account number: ___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___ ,

expiration date: ___ ___ /___ ___

                                          _____________________________________________
                                                              Signature (required)

 

Samuel Nurko. CME: Managing constipation: Evidence put to practice. Contemporary Pediatrics 2001;12:56.