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Martínez-González AE, Cervin M, Pérez-Sánchez S. Assessing gastrointestinal symptoms in people with autism: Applying a new measure based on the Rome IV criteria. Dig Liver Dis 2024:S1590-8658(24)00777-1. [PMID: 38851976 DOI: 10.1016/j.dld.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 05/16/2024] [Accepted: 05/18/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND People with autism spectrum disorder (ASD) often struggle with gastrointestinal symptoms, implicating alterations of the gut-microbiota-brain axis, which has also been linked to sensory reactivity, pain, and gastro-intestinal symptoms in ASD. To better understand the prevalence and impact of gastrointestinal symptoms among individuals with ASD, a measure is needed that adhere to the Rome IV criteria of gastrointestinal symptoms and is applicable to individuals with ASD. The Gastrointestinal Symptom Severity Scale (GSSS) is a new assessment tool designed to match this need. METHODS In a diverse sample of 265 individuals with ASD (mean age = 9.44, SD = 4.99), we examined the psychometric properties of the GSSS, the prevalence of gastrointestinal symptoms and associations with ASD traits, sensory sensitivity, repetitive behaviors, and pain. RESULTS A unidimensional factor structure of the GSSS was confirmed and the measure showed good internal consistency, adequate test-retest reliability and strong convergent validity. Around a third of the participants evidenced clear difficulties with gastrointestinal symptoms and gastrointestinal symptoms were strongly associated with more pronounced ASD traits, sensory reactivity, and repetitive behaviors. CONCLUSIONS The GSSS shows promise as a useful measure to analyze the prevalence, severity, and impact of gastro-intestinal symptoms in individuals with ASD.
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Affiliation(s)
- Agustín Ernesto Martínez-González
- Department of Developmental Psychology and Didactics, University of Alicante, Spain. Postal Address: Carretera San Vicente del Raspeig, s/n-03690, San Vicente del Raspeig, Alicante, Spain.
| | - Matti Cervin
- Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - Susana Pérez-Sánchez
- Hospital Pediatric Service University General "Los Arcos", Mar Menor, Murcia. Spain; University of Murcia, Murcia, Spain
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Montoro-Pérez N, Martínez-González AE, Infante-Cañete L, de Los Ángeles Martínez-González M, Hidalgo-Berutich S, Andreo-Martínez P. Development and validation of the Gastrointestinal Symptom Severity Scale in Spanish children and adolescents. Eur J Pediatr 2024; 183:2703-2715. [PMID: 38526598 PMCID: PMC11098890 DOI: 10.1007/s00431-024-05504-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/26/2024]
Abstract
Functional gastrointestinal disorders (FGIDs) are characterized by chronic or recurrent gastrointestinal symptoms (GS) that are not explained by structural or biochemical abnormalities. FGIDs are related to lower quality of life, increased demands on medical resources, and greater somatization and emotional instability. Furthermore, GS appears to be an indicator of dysbiosis in gut-microbiota, affecting the gut-microbiota-brain relationship. To develop and evaluate the psychometric properties of a new instrument called the Gastrointestinal Symptom Severity Scale (GSSS) using a web-based survey in a sample of neurotypical children and adolescents from Spain. Instrument development and validation processes were applied to the GSSS following its administration as part of an online survey. The sample included 1242 neurotypical children and adolescents. The mean age of participants was 13.95 years, with a standard deviation of 1.37 years. Overall, 13.8% suffered infectious diarrhea, 12.6% suffered abdominal pain, 5% suffered dyspepsia and 2.6% suffered gastro-esophageal reflux. A single-factor model produced good fit indices. Furthermore, internal consistency and test-retest reliability outcomes were acceptable. The GSSS was found to have acceptable metric measurement invariance. Significant correlations with other instruments were produced and were of expected direction and magnitude, confirming scale validity for hypothesis testing. Conclusions: The GSSS shows promising psychometric properties for assessing GS in neurotypical Spanish adolescents and children. What is Known: • To the best of our knowledge, instruments assessing the severity of gastrointestinal symptoms in children and adolescents are still too few. What is New: • The GSSS shows promising psychometric properties for assessing GS in neurotypical adolescents and children. The GSSS may help improve understanding of GS involvement in the gut-brain microbiota axis in children and adolescents.
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Affiliation(s)
- Néstor Montoro-Pérez
- Department of Nursing, Faculty of Health Sciences, Person-Centred Care and Health Outcomes Innovation Group, University of Alicante, San Vicente del Raspeig, Spain
- GREIACC Research Group, La Fe Health Research Institute, Valencia, Spain
| | | | - Lidia Infante-Cañete
- Department of Developmental and Educational Psychology, Faculty of Psychology, University of Malaga, Malaga, Spain
| | | | - Silvia Hidalgo-Berutich
- Department of Developmental and Educational Psychology, Faculty of Psychology, University of Malaga, Malaga, Spain
| | - Pedro Andreo-Martínez
- Department of Agricultural Chemistry, Faculty of Chemistry, University of Murcia, Murcia, Spain
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Djurijanto F, Lin SH, Vo NP, Le NQK, Nguyen-Hoang A, Shen SC, Wu CH, Chen JY, Nguyen NTK. Prevalence and determinants of constipation in children in Asia: a systematic review and meta-analysis. EClinicalMedicine 2024; 71:102578. [PMID: 38606167 PMCID: PMC11007433 DOI: 10.1016/j.eclinm.2024.102578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024] Open
Abstract
Background Constipation is prevalent worldwide, significantly increasing healthcare costs and diminishing the quality of life in children affected. Current studies have yielded mixed results regarding the factors associated with constipation, and mainly focusing on patients outside of Asia. Moreover, most of these studies lack focus on the paediatric population. This study aimed to identify the prevalence and associated factors of constipation among children in Asia. Methods In this systematic review and meta-analysis, we systematically searched PubMed, Scopus, and Cochrane for cohort and cross-sectional studies published from database inception up to October 12, 2022, and continued with manual searching until September 2, 2023. Eligible studies were those that included children in Asia aged 0-18 years old suffering from idiopathic constipation, with prevalence value provided in the English abstract. The analysis included clinical and general population. Children with organic constipation, who had undergone gastrointestinal surgery, or with congenital defects were excluded, as these factors affect the incidence of constipation. Data included in the analysis were extracted from published reports only. The extracted data were pooled using random-effects model to analyse the prevalence of constipation in children in Asia. This study is registered with PROSPERO, CRD42022367122. Findings Out of 4410 systematically searched studies and 36 manually searched ones, a total of 50 studies were included in the final analysis, encompassing data from 311,660 children residing in Asia. The pooled prevalence of constipation was 12.0% (95% CI 9.3-14.6%, I2 = 99.8%). There was no significant difference in constipation prevalence observed by sex and geographical location. Nonetheless, adolescents and children aged 1-9 years exhibited a significantly higher prevalence constipation compared to infants (p < 0.0001) Additionally, significant differences in constipation rates were observed across various diagnostic methods, population sources, and mental health conditions. Interpretation Despite the high heterogeneity resulting from varying diagnostic tools or definitions used among studies, our review adds to the literature on constipation among children in Asia. It reveals a notably high prevalence of constipation in this demographic. Diagnostic methods, age, and compromised mental health emerged as significant influencers of constipation among children in Asia, highlighting potential strategies to mitigate constipation prevalence in children in Asia. Funding The National Science and Technology Council, Taiwan.
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Affiliation(s)
- Felicia Djurijanto
- Programs of Nutrition Science, National Taiwan Normal University, Taipei, 106, Taiwan
| | - Shyh-Hsiang Lin
- School of Nutrition and Health Sciences, Taipei Medical University, Taipei, 110, Taiwan
- School of Food Safety, Taipei Medical University, Taipei, 110, Taiwan
| | - Nguyen-Phong Vo
- Department of Hepatobiliary and Pancreatic Surgery, Cho Ray Hospital, Vietnam
| | - Nguyen Quoc Khanh Le
- Research Centre for Artificial Intelligence in Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Translational Imaging Research Centre, Taipei Medical University, Taipei, 110, Taiwan
| | - Anh Nguyen-Hoang
- Faculty of Health Sciences and Sport, University of Stirling, Scotland, UK
| | - Szu-Chuan Shen
- Programs of Nutrition Science, National Taiwan Normal University, Taipei, 106, Taiwan
| | - Chung-Hsin Wu
- School of Life Science, National Taiwan Normal University, Taipei, 106, Taiwan
| | - Jian-Yu Chen
- Programs of Nutrition Science, National Taiwan Normal University, Taipei, 106, Taiwan
| | - Ngan Thi Kim Nguyen
- Programs of Nutrition Science, National Taiwan Normal University, Taipei, 106, Taiwan
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Di Lorenzo C, Nurko S, Hyams JS, Rodriguez-Araujo G, Shakhnovich V, Saps M, Simon M. Safety and efficacy of linaclotide in children aged 7-17 years with irritable bowel syndrome with constipation. J Pediatr Gastroenterol Nutr 2024; 78:539-547. [PMID: 38504394 DOI: 10.1002/jpn3.12103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Linaclotide, a guanylate cyclase-C agonist, was recently approved in the United States for the treatment of children 6-17 years old with functional constipation. This study evaluated the safety and efficacy of various linaclotide doses in children 7-17 years old with irritable bowel syndrome with constipation (IBS-C). METHODS In this 4-week, randomized, double-blind, placebo-controlled, parallel-group, Phase 2 study, children with IBS-C were randomized to once-daily placebo or linaclotide (Dose A: 18 or 36 µg, B: 36 or 72 µg, and C: 72 µg or 145 µg, or 290 µg); those aged 7-11 years in a 1:1:1:1 allocation based on weight (18 to <35 kg:18 µg, 36 µg, or 72 µg; or ≥35 kg: 36 µg, 72 µg, or 145 µg), and those aged 12-17 years in a 1:1:1:1:1 allocation (the higher option of Doses A-C or 290 µg). The primary efficacy endpoint was a change from baseline in 4-week overall spontaneous bowel movement (SBM) frequency rate over the treatment period. Adverse events and clinical laboratory measures were also assessed. RESULTS Efficacy, safety, and tolerability were assessed in 101 patients. In the intent-to-treat population, numerical improvement was observed in overall SBM frequency rate with increasing linaclotide doses (A: 1.62, B: 1.52, and C: 2.30, 290 µg: 3.26) compared with placebo. The most reported treatment-emergent adverse events were diarrhea and pain, with most cases being mild and none being severe. CONCLUSIONS Linaclotide was tolerated well in this pediatric population, showing numerical improvement in SBM frequency compared with placebo.
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Affiliation(s)
- Carlo Di Lorenzo
- Department of Gastroenterology & Hepatology & Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Samuel Nurko
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jeffrey S Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
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van Engelenburg-van Lonkhuyzen ML, Bols EMJ, Bastiaenen CHG, de Bie RA. Measurement properties of the childhood bladder and bowel dysfunction questionnaire. J Pediatr Gastroenterol Nutr 2024; 78:592-600. [PMID: 38314913 DOI: 10.1002/jpn3.12152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVES The childhood bladder and bowel dysfunction questionnaire (CBBDQ) was previously found feasible, structurally valid, with good internal consistency. The purpose of this study was to evaluate the remaining measurement properties according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). METHODS A prospective cohort study among parents of children aged 5-12 years was conducted. Calculated were the area under the curve (AUC) (criterion validity, responsiveness, interpretability) and intra-class correlation coefficients (ICCagreement ) (construct validity and test-retest reliability). RESULTS One hundred and seventy-two parents were included from March 2019 to April 2021. Correlating the bladder subscales of the CBBDQ with the Vancouver symptom score for dysfunctional elimination (VSSDES) and proxy-reported pediatric incontinence quality of life (p-PinQ) showed convergent validity (ICCsagreement : 0.76 and 0.74). Divergent validity was found when correlating the bowel subscales of the CBBDQ with the VSSDES (ICCagreement : 0.52). Excellent criterion validity (AUC: 0.98); excellent test-retest reliability (ICCagreement : 0.94) and, at 6 months, fair responsiveness (AUC: 0.74) were found. The minimal important change was 4.5, with cut-off value of 11. CONCLUSION The CBBDQ has been developed according to COSMIN standards. The items were defined using the consensus-based ICCS standards and Rome-III criteria. The measurement properties were identified using enough participants. Although interpretability is not considered a measurement property, interpretability aspects are reported here as they refer to what instrument scores mean. The 18-item-CBBDQ met the measurement properties of validity, reliability, and responsiveness, as defined by COSMIN. The CBBDQ is suitable for self-administration by parents, and completion takes little time.
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Affiliation(s)
- Marieke L van Engelenburg-van Lonkhuyzen
- Department of Epidemiology, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
- Departmentof Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Esther M J Bols
- Research Group Autonomy and Participation for Persons with a Chronic Illness and Academy of Physiotherapy, Zuyd University, Heerlen, The Netherlands
| | - Caroline H G Bastiaenen
- Department of Epidemiology, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
- Departmentof Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Rob A de Bie
- Department of Epidemiology, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
- Departmentof Epidemiology, Maastricht University, Maastricht, The Netherlands
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Zhao J, Zhang Y, Xiong Y, Du J, Chen Y, Guo W, Huang J. Three dimension high definition manometry evaluated postoperative anal canal functions in children with congenital anorectal malformations. Front Pediatr 2023; 11:1126373. [PMID: 37397140 PMCID: PMC10311638 DOI: 10.3389/fped.2023.1126373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Background We aimed to evaluate the function of the reconstructed anal canal in postoperative anorectal malformations (ARMs) patients through three dimension (3D) high-definition anorectal manometry. Methods From January 2015 to December 2019, 3D manometry was performed as a postoperative functional assessment of patients with ARMs divided into age subgroups based on the time of manometry. Manometric parameters, such as the length of the anorectal high-pressure zone (HPZ-length), the mean resting and squeeze pressure of HPZ (HPZ-rest and HPZ-sqze), recto-anal inhibitory reflex (RAIR), and strength distribution of the anal canal, were collected and compared with age-matched controls. Their functional outcomes were analyzed with SPSS 23.0 software for statistical analysis. Results 171 manometric measurements were performed on 142 postoperative patients (3 months∼15 years). The HPZ-rest in all patients was significantly lower than in age-matched controls (p < 0.05). HPZ-sqze was notably decreased in patients older than 4 years, whereas other age groups were comparable to controls (p < 0.05). The proportions of asymmetric strength distribution and negative RAIR were higher in ARMs patients. The type of anorectal malformations and lower HPZ-rest were the impact factors affecting postoperative functional outcomes. Conclusions The majority of the ARMs patients had acceptable functional outcomes. 3D manometry can objectively assess the reconstructed anal canal function. The patients with fecal incontinence had a high proportion of extremely low HPZ-rest and HPZ-sqze, negative RAIR, and asymmetric strength distribution. The manometric details will help the clinicians explore the causes of defecation complications and guide further management.
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Park JS. Disorders of Gut-Brain Interaction in Children With Down Syndrome. J Neurogastroenterol Motil 2023; 29:3-4. [PMID: 36606430 PMCID: PMC9837546 DOI: 10.5056/jnm22205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
- Ji Sook Park
- Department of Pediatrics, Gyeongsang National University College of Medicine, Jinju, Gyeongsangnam-do, Korea
Institute of Health Sciences, Gyeongsang National University, Jinju, Gyeongsangnam-do, Korea,Correspondence: Ji Sook Park, MD, PhD, Institute of Health Sciences, Gyeongsang National University, 15 Jinju-daero 816beon-gil, Jinju, Gyeongsangnam-do 52727, Korea, Tel: +82-55-750-8156, Fax: +82-55-752-9339, E-mail:
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Demirören K, Güney B, Bostancı M, Ekici D, Ekici D. A Comparison Between Rome III and Rome IV Criteria in Children with Chronic Abdominal Pain: A Prospective Observational Cohort Study. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2022; 33:979-984. [PMID: 35946891 PMCID: PMC9797798 DOI: 10.5152/tjg.2022.21893] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The Rome IV includes a redefinition of functional gastrointestinal disorders and diagnostic criteria. The present study aimed to compare the Rome III and Rome IV classification results and to reveal their differences in children with chronic abdominal pain. METHODS The present study is a prospective observational cohort study. Three hundred forty-four children, who were admitted to the pediatric gastroenterology clinic, had abdominal pain for more than 2 months, and were not diagnosed with an organic disease, were included in our study. RESULTS In children with chronic abdominal pain, Rome IV criteria did not cause a change in the number of patients diagnosed with functional abdominal pain disorders according to Rome III (89.8% vs 89.2%, P >.05). Functional abdominal pain and functional abdominal pain syndrome were the most common diagnoses in Rome III and functional abdominal pain, not otherwise specified in Rome IV. When compared to Rome III, while the diagnosis of functional dyspepsia increased in Rome IV, irritable bowel syndrome decreased. CONCLUSION In children with chronic abdominal pain, Rome IV criteria did not cause a change in the number of patients diagnosed with functional abdominal pain disorders according to Rome III, but it caused a diagnostic shift. It was seen that some of the children diagnosed with irritable bowel syndrome in Rome III shifted to functional dyspepsia diagnosis in Rome IV.
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Affiliation(s)
- Kaan Demirören
- Department of Pediatric Gastroenterology, Yüksek İhtisas Teaching Hospital, University of Health Sciences, Bursa, Turkey,Corresponding author: Kaan Demirören, e-mail: ;
| | - Bünyamin Güney
- Department of Pediatrics, Yüksek İhtisas Teaching Hospital, University of Health Sciences, Bursa, Turkey
| | - Muharrem Bostancı
- Department of Pediatrics, Yüksek İhtisas Teaching Hospital, University of Health Sciences, Bursa, Turkey
| | - Deniz Ekici
- Department of Pediatrics, Yüksek İhtisas Teaching Hospital, University of Health Sciences, Bursa, Turkey
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Zhao J, Zhang Y, Xiong Y, Du J, Chen Y, Guo W, Huang J. Three dimension high-definition manometry in evaluation of anorectal function in 104 normal infants and children: A clinical study from China. Neurogastroenterol Motil 2022; 34:e14395. [PMID: 35578443 DOI: 10.1111/nmo.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/15/2022] [Accepted: 04/11/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND We aimed to evaluate anorectal function of normal infants and children through three dimension high-definition anorectal manometry (3D ARM) to fill the research blank in this area. METHODS From November 2014 to January 2019, 104 normal infants and children among patients who underwent 3D ARM were divided into four groups according to age (≤1 month; >1 month to ≤1 year; >1 year to ≤4 years and >4 years) and reviewed. The following parameters were performed: the length of anorectal high-pressure zone (HPZ), the resting pressure of HPZ (HPZ-rest), the squeezing pressure of HPZ (HPZ-sqze), recto-anal inhibitory reflex (RAIR), and pressure distribution of the anal canal. Graphpad Prism 7.0 software was used for statistical analysis. RESULTS HPZ, HPZ-rest, and HPZ-sqze increased with age. There were differences in HPZ-rest and HPZ-sqze between the groups (p < 0.05). Sex had a significant effect on HPZ, but not on HPZ-rest and HPZ-sqze. The HPZ of males was higher than that of females among those ≤1 month old (p < 0.05). RAIR (-) was found in 17 patients (16%) for whom Hirschsprung's disease were excluded by biopsy, and these patients had regular defecation during follow-up. Most of the patients (85%) older than 1 year had a symmetric anal pressure distribution during the contracting period (p < 0.05). CONCLUSIONS Anal canal function parameters gradually increased with age in normal infants and children which demonstrated the important role of age in evaluation, and these parameters can provide a reference for postoperative evaluation of anal canal function.
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Affiliation(s)
- Jiawei Zhao
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yanan Zhang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yu Xiong
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingbin Du
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yongwei Chen
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Weihong Guo
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jinshi Huang
- Department of Neonatal Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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