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By Susan S. Baker

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TSH antibodies . Calcium . Lead Relapse? 15 No 16 . Wean . Observe 17 Yes Abnormal T4, TSH, Ca, Pb? 18 Evaluate further No 19 Consultation with Pediatric Gastroenterologist Has previous treatment been sufficient? 21 20 Yes to 22 No from 21 Impacted? Excess retention? 22 Abdominal x-ray 23 No Yes Excess stool? 24 . T4 . Celiac disease . TSH antibodies . Calcium . Lead Abnormal Transit time study (if not already done) 25 26 Normal Yes No Soiling? Hirschsprung disease? 27 . Behavior 28 . Reassurance .

Calcium . Lead Relapse? 15 No 16 . Wean . Observe 17 Yes Abnormal T4, TSH, Ca, Pb? 18 Evaluate further No 19 Consultation with Pediatric Gastroenterologist Has previous treatment been sufficient? 21 20 Yes to 22 No from 21 Impacted? Excess retention? 22 Abdominal x-ray 23 No Yes Excess stool? 24 . T4 . Celiac disease . TSH antibodies . Calcium . Lead Abnormal Transit time study (if not already done) 25 26 Normal Yes No Soiling? Hirschsprung disease? 27 . Behavior 28 . Reassurance . Observation modification .

23 Yes Evaluate further 24 No Yes Consultation with Pediatric Gastroenterologist Has previous treatment been sufficient? No Treat vigorously 26 Yes No . T4 . Celiac disease . TSH antibodies . Calcium . Sweat test (if not already done) 29 Hirschsprung disease? 30 Rectal manometry and/or biopsy 31 Positive for Hirschsprung disease? Yes 33 32 No Consider other tests : . Barium enema . MRI . Other metabolic tests 34 Yes No Abnormal? 35 Treat accordingly Re-evaluate 36 28 27 25 Surgical management Treatment effective?

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