Medication Summary
Many children with anorectal malformations require medications for various reasons. Beyond perioperative medications, maintenance medications often include urinary antibiotic prophylaxis or treatment and/or laxatives.
Urinary prophylaxis is used to mitigate the risk of urinary infection and urosepsis in children with risk factors for urinary infection such as urinary fistula, vesicoureteral reflux, or continent diversion. Common agents include oral amoxicillin, oral trimethoprim/sulfamethoxazole, and gentamicin bladder irrigations. Comprehensive information on all these medications and others is available in the eMedicine pediatric topic Urinary Tract Infection.
Common laxatives include senna products, milk of magnesia, and propylene glycol solutions (eg, MiraLax, GlycoLax).
Perioperative medications
Routine pain medications for surgical procedures are warranted. Acetaminophen (15 mg/kg every 4 h) or morphine sulfate (0.05-0.1 mg/kg intravenously every 2-4 h) usually suffices.
The usual perioperative antibiotics include ampicillin (50 mg/kg every 6 h), gentamicin (2 mg/kg every 8-12 h), and clindamycin (10 mg/kg every 8 h).
Many laxatives have been used to control constipation in these patients. Senna comes in various forms and can be highly effective, although dosage must be individualized. The clinician must be personally engaged and must establish an effective dose response for each patient on a case-by-case basis.
Balanced electrolyte solutions have been used for years as a bowel preparation for surgical procedures. These solutions have only recently been made available in powdered form for mixing at home and for use as a laxative (under the name MiraLax or GlycoLax). These nonstimulant laxatives are very palatable to children because they dissolve in any beverage with minimal impact on taste.
In children who require urinary prophylaxis, standard medications include amoxicillin (first-line medication in newborns), nitrofurantoin, and trimethoprim/sulfamethoxazole (not used in babies aged < 2 mo). To ascertain a prophylaxis dose for one of these antibiotics, calculate a treatment dose based on the normal administration interval (2, 3, or 4 times per day) and then administer that same dose once per day. For example, if the amoxicillin treatment dose is 20-50 mg/kg/d divided every 8 hours and a patient weighs 10 kg, the normal dose may be 30 mg/kg/d (which falls within the recommended range). Because the patient weighs 10 kg, the dose is 100 mg every 8 hours. The prophylaxis dose would then be a once-daily dose of 100 mg.
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Pediatric imperforate anus (anorectal malformation). Distal colostogram, posteroanterior view. The initial phase of augmented-pressure distal colostography aims to determine where the colostomy was placed in the colon and how much colon is available for pull-through, without taking down the colostomy.
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Pediatric imperforate anus (anorectal malformation). Distal colostogram, lateral view. This image shows the second phase of distal colostography, in which the patient is placed in the lateral position. A radio-opaque marker is clearly visible in the lower right side of the image, marking the muscle complex on the skin. This image shows that the rectal pouch joins the urinary tract at the level of the bulbar urethra, a relatively common malformation in boys.
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Pediatric imperforate anus (anorectal malformation). Bucket-handle malformation. The appearance of a band of skin overlying the sphincteric muscle complex is a common sign in a child born with imperforate anus and perineal fistula.
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Pediatric imperforate anus (anorectal malformation). String-of-pearls malformation. This image shows white mucoid material within a perineal fistula. The fistula frequently extends anteriorly up the scrotum's median raphe.
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Pediatric imperforate anus (anorectal malformation). Cloaca. This is the classic appearance of a female infant with a cloacal malformation with a single perineal orifice. The genitals appear quite short, which is a finding consistent with cloaca.
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Pediatric imperforate anus (anorectal malformation). Fourchette fistula. This malformation is about half way between a perineal fistula and vestibular fistula. The fistula has a wet vestibular mucosal lining on its anterior half, but the posterior half is dry perineal skin.
