Constipation in early childhood: patient characteristics, treatment, and longterm follow up

Review of the treatment literature for encopresis, functional constipation, and stool-toileting refusal

This review summarizes the literature on randomized, controlled, published studies involving medical, behavioral, psychological, and biofeedback treatments for encopresis/functional constipation and stool-toileting refusal in preschool-age and school-age children. Nine such studies were located in the literature involving school-age children. No randomized, controlled treatment studies involving preschool-age children have been published. This review revealed no evidence to support the routine use of psychotherapy or anal sphincter biofeedback in the treatment of pediatric fecal elimination dysfunctions, beyond those benefits derived from a comprehensive medical-behavioral intervention. Further, this review indicated that paradoxical constriction of the External Anal Sphincter does not influence the treatment outcome of either biofeedback or medical-behavioral interventions. There are remarkably few controlled treatment outcome studies in this most important clinical area. More research is needed that employs standard treatment outcome variables.

Colonic motility after surgery for Hirschsprung's disease

OBJECTIVE

Years after surgery for Hirschsprung's disease, many children continue to suffer from fecal incontinence or constipation. The purpose of the present investigation was to define the physiology underlying the persistent symptoms in children after surgery for Hirschsprung's disease, and to determine the outcome of interventions based on the results of the motility testing.

METHODS

We studied 46 symptomatic patients (5.5+/-3.3 yr old, 35 male) >10 months after surgery for Hirschsprung's disease. We performed a colonic manometry with a catheter placed with the tip in the proximal colon. We used a structured questionnaire and phone interview to follow up the patients an average of 34 months after the manometry.

RESULTS

We identified four motility patterns: 1) high-amplitude propagating contractions (HAPCs) migrating through the neorectum to the anal sphincter, associated with fecal soiling (n = 18); 2) normal colonic manometry associated with fear of defecation and retentive posturing (n = 9); 3) absence of HAPCs or persistent simultaneous contractions over two or more recording sites (n = 15), associated with constipation (n = 13); and 4) normal colonic motility and a hypertensive internal anal sphincter (>80 mm Hg) (n = 4). We based treatment on results of the motility studies. There was improvement in global health (mean score, 3.9+/-1.1 vs 2.8+/-1.3 at the time of initial evaluation, p < 0.001) and emotional health (3.8+/-1.1 vs 2.6+/-1.1, p < 0.0001). Improvement in the number of bowel movements occurred in 72% of children. Resolution or decreased abdominal pain was reported in 80%.

CONCLUSIONS

Colonic manometry clarifies the pathophysiology and directs treatment in symptomatic children after surgery for Hirschsprung's disease.

A randomised controlled study of the effect of long chain polyunsaturated fatty acid supplementation on stool hardness during formula feeding

BACKGROUND

The passage of hard stools is significantly more common in formula fed infants than breast fed infants and this might be the result of differences in fat absorption between breast and formula fed infants. Experimental studies indicate that long chain polyunsaturated fatty acids (LCPUFAs) might influence fat hydrolysis and absorption.

AIM

To investigate the relation of LCPUFA supplementation to stool frequency and consistency during the first 4 months of life.

DESIGN

Double blind, randomised, controlled study of 88 healthy infants.

RESULTS

1905 stools (858 from LCPUFA supplemented infants, 1047 non-supplemented infants) were examined. The mean (SEM) number of stools passed for each three day study period was significantly less in the LCPUFA group (5.5 (0.3) v 6.2 (0.2); p < 0.05). In both groups, there was a significant reduction in the number of stools passed with age (p < 0.001). During the first 3 months, the mean (SEM) percentage of hard stools passed by infants in the LCPUFA supplemented group was 7.7 (2.1) compared with 19.2 (2.8) for unsupplemented infants (p = 0.001).

CONCLUSION

The prevalence of hard stools is significantly reduced in infants fed a formula that is supplemented with LCPUFAs.

Constipation in school-aged children at public schools in Rio de Janeiro, Brazil

BACKGROUND

Constipation in childhood is a significant problem worldwide; however, understanding of its epidemiology is limited. Some investigators in the United States have estimated the prevalence of constipation to be 1.2% to 8.0% in the general population. In Brazil, some have found a prevalence of up to 36%.

METHODS

This cross-sectional, descriptive, observational prevalence study included 391 pupils (age range, 8-10 years) who were attending three public education centers in Rio de Janeiro. The prevalence of constipation, associated symptoms, and dietary fiber intake were evaluated by questionnaire. A child was considered to be constipated when he or she reported difficulty in defecating two or more times per week. The children were divided into constipated and nonconstipated groups, and the presence of fecal soiling, blood in the feces, and shape of the feces were assessed.

RESULTS

Twenty-eight percent of the children were constipated. There was no significant difference between the sexes. Blood in the stools was significantly more frequently reported by the constipated children (p < 0.01). There was no significant difference in the prevalence and frequency of fecal soiling or in the stool shape between the constipated and nonconstipated children (p > 0.1). Fiber content in the diet ranged from 3.4 to 4.8 g per day, which is below the range recommended.

CONCLUSIONS

The prevalence of constipation in Rio de Janeiro is similar to the rates reported in all of Brazil and in a recent study from the United Kingdom but is much higher than that in the United States. In addition, the school menu was found to contain inadequate dietary fiber content.

Rectal biopsy for diagnosis of intestinal neuronal dysplasia in children: a prospective multicentre study on interobserver variation and clinical outcome

BACKGROUND

Intestinal neuronal dysplasia (IND) of the colonic submucous plexus is considered to be a congenital malformation of the enteric nervous system causing symptoms resembling those of Hirschsprung's disease. In contrast with the established diagnosis of aganglionosis using enzyme histochemistry, controversy exists over the diagnostic criteria of IND on rectal biopsies previously defined by a consensus report and the causal relation between morphological findings and clinical symptoms.

AIMS

The interobserver variability was prospectively investigated with respect to final diagnoses and several histological features in rectal biopsy specimens from children suspected of having colonic motility disturbances.

METHODS

377 biopsy specimens from 108 children aged 4 days to 15 years were independently coded without knowledge of clinical symptoms by three experienced pathologists for 20 histological features, and a final diagnosis was given for every case. Interobserver variation for the different items and the final diagnosis were analysed using Cohen's kappa statistic. Clinical data at biopsy and outcome after 12 months were related to morphological findings.

RESULTS

The three pathologists agreed completely with respect to the diagnosis Hirschsprung's disease (kappa = 1), but in only 14% of the children without aganglionosis. In 15 (17%) of the 87 children without aganglionosis, at least one pathologist judged the case as normal, while another diagnosed IND. kappa values were close to the zero value expected by chance for the diagnoses normal and IND. Young age was related to the presence of several morphological features-for example, acetylcholine esterase staining and presence of giant ganglia. Children with chronic constipation diagnosed as having IND, given no other specific diagnosis by any of the pathologists, were significantly younger (median 8.8 months) and had a higher cure rate after one year (60%) than constipated patients considered by all observers to have no histological abnormalities (median 6.1 years, cure rate 23%).

CONCLUSIONS

In contrast with Hirschsprung's disease, there is a high interobserver variation with regard to the different morphological features and final diagnosis of IND, based on the criteria and conditions of the previous consensus report. The high frequency of histological "abnormalities" in young infants suggests that some of the features may represent a normal variant of postnatal development rather than a pathological process. Investigations using more refined and morphometric methods in rectal specimens from infants and children without bowel disease are needed to define the normal range of morphological appearance at different ages. These preliminary data indicate that, with current knowledge, rectal biopsy for diagnostic purposes should only be performed in constipated children for diagnosis of Hirschsprung's disease.

Gastrointestinal problems in the neurologically impaired child

Damage to the developing central nervous system may result in significant dysfunction in the gastrointestinal tract and is reflected in impairment in oral-motor function, rumination, gastro-oesophageal reflux, with or without aspiration, delayed gastric emptying and constipation. These problems can all potentially contribute to feeding difficulty in disabled children. Early recognition of an infant with neurological impairment that is compromising the normal feeding process is crucial. Detailed assessment of the nature of the feeding difficulties will help to predict the anticipated future nutritional needs and will allow decisions to be made about the appropriateness of input from different professionals (speech therapy, dietitians, gastroenterologists). Only when such information has been carefully assembled will rational and directed medical and surgical therapy be possible. Nutritional rehabilitation of disabled children can be associated with increased mortality and morbidity secondary to gastro-oesophageal reflux, retching, dumping syndrome or aspiration. It may also entail an increased work for care givers and increase costs of care. It is therefore necessary to document the impact of such rehabilitation on growth and quality of life for both patient and care giver.

Idiopathic constipation in childhood is associated with thickening of the internal anal sphincter

This study was undertaken to search for a rational basis for the use of anal dilatation and internal sphincterotomy as the treatment for chronic intractable constipation in children. Sixteen children, age 5 months to 13 years, who had constipation resistant to conservative treatment were compared with 39 age-matched controls. History and current symptoms were assessed using a standard questionnaire. Internal and external and sphincter morphology was assessed on clinical examination and by anal endosonography, using a 10-MHz rotating endoprobe to provide accurate measurement of the various components of the anal canal. The control group showed a linear correlation between the thickness of the internal anal sphincter and both age and weight, increasing from 0.4 mm in infancy to 0.9 mm in adolescence. Children who had constipation displayed significant thickening of the internal sphincter (range, 0.5 to 1.9 mm, P = .005) which was independent of the length of the history (P = .103). There was no difference in the morphology of the external anal sphincters between the groups. The finding of a hypertrophied internal anal sphincter could provide a rational basis for anal dilatation and internal sphincterotomy as treatment for idiopathic constipation.

The Pediatric Bowel Management Clinic: initial results of a multidisciplinary approach to functional constipation in children

The multifactorial nature of functional constipation in children suggests that a multidisciplinary management approach may be effective. The authors tested this hypothesis in a newly created pediatric Bowel Management Clinic (BMC). Detailed data were collected prospectively on all patients seen in the clinic over the first 16 months. Both quantitative and qualitative analyses were performed to describe the index population and to demonstrate the impact of the intervention. Satisfaction with care in the clinic was measured using the Measure of Processes of Care tool, then compared with a normative sample. One hundred fourteen patients, all previously treated unsuccessfully for constipation, were referred to a team comprised of a physician, nurse practitioner, nurse educator, dietitian, and psychosocial nurse specialist. The mean age was 5.4 years with equal gender distribution. Between the first and last visits recorded, several variables including stool consistency and frequency, soiling frequency, abdominal pain, rectal pain, and rectal bleeding all showed statistically significant (P < .05) improvement. Qualitative data analysis showed the significant psychosocial impact of constipation on patients and their families. In the Measures of Processes of Care questionnaire, scores for the BMC were higher than normal on all scales except in provision of information. A multidisciplinary approach to functional constipation leads to both patient and parent satisfaction and significant short-term improvement. Further studies will examine the long-term impact of the clinic.

Diagnostic dilemmas and results of treatment for chronic constipation

Chronic functional constipation (CFC) may be difficult to recognise and information regarding its long term prognosis is scarce. The records of 244 children with CFC, aged 0-18 years, were analysed for symptoms at presentation and results of treatment, and long term outcome was evaluated by means of a telephone interview in 137 patients discharged for more than one year. The patients presented with a great variety of symptoms, only 22% having infrequent defecation of increased consistency, another 22% having an obviously normal defecation pattern. The mean duration of treatment was 13 months. At the time of discharge, 69% of the patients still used laxatives. At a median of four years after discharge, 66% of the children were free of symptoms and without medication, 39% having experienced a recurrence. It is concluded that CFC may be difficult to recognise and can be alleviated by an intensive laxative regimen. Recurrence of symptoms is common, but the long term prognosis is good in most patients.

Radiological evidence of constipation in urinary tract infection

Little objective evidence has been published to support the claim that constipation is an important contributory factor in recurrent urinary tract infection (UTI) in childhood. Using a radiological scoring system, two observers assessed faecal loading from abdominal radiographs of children with proved UTIs. There was a significant increase in the degree of faecal loading in children with UTI when compared with controls (r = 0.237). This difference was mainly accounted for by girls with recurrent (greater than five) UTIs. This study confirms an association between recurrent UTI and faecal loading. Further studies are needed to establish if there is a causal relationship and benefits from treatment.

Long-term follow-up of medically treated childhood constipation

We describe the long-term (mean 6.8 years) follow-up of 43 children treated medically for chronic constipation and encopresis. Overall outcome was quite good. Thirty children (70%) were entirely asymptomatic at follow-up. Intermittent mild constipation persisted in 13 patients; only two required persistent but infrequent laxative therapy. Encopresis persisted in three of 17 children who initially reported this symptom, and was associated with significant behavioral problems.

Laparoscopic Swenson pull-through procedure for congenital megacolon

Constipation that is unresponsive to conventional remedies is the primary symptom of congenital megacolon (ie, Hirschsprung's disease). The cause of congenital megacolon is lack of ganglion cells in the bowel. The laparoscopic Swenson pull-through procedure involves removing the aganglionic segment of the colon, bringing the normally decompressed bowel through the pelvic floor, and anastomosing the bowel to the anorectal verge. Advantages of the laparoscopic approach include shorter lengths of hospital stay and fewer complications resulting from disruption of skin integrity.

Long-term anorectal function after Duhamel operation for Hirschsprung's disease

Long-term anorectal function was assessed in children operated on using Duhamel's technique for Hirschsprung's disease. The files of 75 patients (16 girls and 59 boys) operated on between 1977 and 1991 were reviewed. Questionnaires were analysed on 63 (12 girls and 51 boys) over 2 years of age. The median age at completing the questionnaire was 6.6 years. Forty-one of these 63 patients had aganglionosis of the rectosigmoid, 15 of a long colonic segment, and 7 of the total colon. Of 14 children age 4 or less, 6 had severe constipation, whereas 8 had regular spontaneous defaecation. Ten of the 49 over 4 years of age were continent without constipation, 22 had soiling and/or constipation, and 17 were incontinent, one of whom had a permanent colostomy. There was no correlation between age or sex and anorectal function. Anorectal function in children with long segment was not worse than in those with rectosigmoid aganglionosis, but only 1 of 7 with total colonic aganglionosis was continent. Because many adapt themselves to the handicap, symptoms are often underreported. A detailed questionnaire appears to be a reliable tool for elucidating the real situation. A systematic follow-up of patients with Hirschsprung's disease is proposed to anticipate the complications and to institute proper measures at an early stage.

Chronic constipation in children

The evaluation of chronic constipation with or without encopresis must begin with a careful history. The intervals between bowel movements and the size and consistency of stools deposited into the toilet should be noted. Encopresis may be manifested as dirtying the underwear. The physical examination should include a rectal and neurological examination. No specific organic cause can be found in the majority of children. One or several anorectal physiological abnormalities have been found by us and others in 95% of children with idiopathic constipation. These abnormalities include impaired rectal and sigmoid sensation and decreased rectal contractility during rectal distention. The external anal sphincter and pelvic floor muscles may be abnormally contracted during straining for defecation, and the child may be unable to defecate a rectal balloon. Most patients will benefit from a program designed to clear stools, to prevent further impaction, and promote regular bowel habits. Fifty percent of patients will be cured after 1 year and 65%-70% after 2 years.