Etiology and clinical spectrum of constipation in Indian children

Rosa damascena together with brown sugar mitigate functional constipation in children over 12 months old: A double-blind randomized controlled trial

ETHNOPHARMACOLOGICAL RELEVANCE

Rosa × damascena Herrm., known as damask rose, is a bushy shrub that is found abundantly in Fars province, Iran. This species has been used in Iranian traditional practices for the treatment of abdominal pain and constipation, as gastrointestinal diseases. Brown sugar (Saccharum officinarum L.) has also shown laxative effects in pediatric patients with functional constipation.

AIM OF STUDY

This study aimed to compare the effects of Polyethylene Glycol (PEG) and a syrup made of R. damascena and brown sugar on the treatment of functional constipation in children aged above 12 months.

MATERIALS AND METHODS

This double-blind randomized clinical trial was performed on 100 patients. One group received PEG and the other received an herbal syrup containing the decocted extract of 0.1 g R. damascena petals mixed with 0.85 g brown sugar per 1 mL. The patients were followed up for two and four weeks and their progresses were recorded.

RESULTS

The cure rate was 100% in the R. damascena group and 91.7% in the control group. R. damascena and brown sugar syrup had an odds ratio of 1.09 in the treatment of functional constipation compared to PEG, but the difference was not statistically significant. The only adverse effect detected in the R. damascena group after four weeks was the bad taste of the medication that was too sweet. Nonetheless, this could be solved during the pharmaceutical processes.

CONCLUSION

The R. damascena extract and brown sugar syrup can be used as an effective, safe, and inexpensive agent in the treatment of functional constipation.

Functional constipation in Bangladeshi school aged children: A hidden misty at community

BACKGROUND

Constipation is a common problem in children and a frequent cause of hospital visit in both primary & specialized care, which needs proper evaluation & management. Presentation of constipation is variable among children. In Bangladesh there has been no published data regarding constipation in community among school aged children.

AIM

To determine the magnitude of functional constipation and its risk factors in community among Bangladeshi school children.

METHODS

This descriptive cross sectional study was conducted in different schools of Dhaka division, Bangladesh. All school aged children between 5-16 years of age who attended school were included in this study. Samples were collected randomly. Proper clinical history & physical examinations (without digital rectal examination) & available investigations (if done previously) were recorded. Diagnosis of functional constipation was done by Rome IV criteria and was compared with children without constipation. Children with any red flag sign, known chronic disease or any findings suggestive of organic disease and on treatment of constipation were excluded. Statistical analysis of the results was done by using Windows based software device with Statistical Packages for Social Science 20. For all statistical tests, P value of less than 0.05 was considered as statistically significant.

RESULTS

Total study populations were 707 and male was 443 and female 264. Among them, 134 (19%) children had constipation. In constipated children, 78 children fulfilled the Rome IV criteria for functional constipation and it was 11% of total population. Mean age of children having functional constipation was 11.24 ± 3.54 years and Male female ratio was 1:1.78. Anorexia, nausea, abdominal pain, hard stool, blood with hard stool, alternate hard and loose stool and fecal mass in left iliac fossa were analyzed between two group and all were significantly higher in children with functional constipation group. Children of school, where toilet numbers were inadequate had 2.5 times more constipation risk in comparison to children of school with adequate toilet number (OR = 2.493, 95%CI: 1.214-5.120). Children who feel embarrassed to use toilet at school, had 3.6 times higher risk of constipation (OR = 3.552, 95%CI: 1.435-8.794). Here children with H/O affected sibs and parents/grandparents had 4 and 2.6 times more chance of constipation respectively in comparison to children without H/O affected sibs (OR = 3.977, 95%CI: 1.884–8.397) and parents/grandparents (OR = 2.569, 95%CI: 1.172-5.629). Children with inadequate fluid intake had 2 times more risk of constipation in comparison to children with adequate fluid intake (OR = 1.972, 95%CI: 1.135-3.426). Children who passed electronic screen time of > 2 h/d had 2 times more chance of constipation in comparison to children who passed electronic screen time < 2 h (OR = 2.138, 95%CI: 1.063-4.301).

CONCLUSION

Constipation is not uncommon in Bangladeshi school aged children. Inadequate toilet number, family history of constipation, inadequate fluid intake, feeling embarrassed to use toilet at school, and electronic screen time for > 2 h/d were found as risk factors in the present study for functional constipation.

Polyethylene Glycol Plus Electrolytes with Stimulant Laxative in Paediatric Faecal Disimpaction: A Randomised Controlled Study

Functional constipation is common in the paediatric population all over the world. Effective disimpaction to evacuate the impacted faecal matter forms an essential initial step in the management of constipation. Though different regimens of polyethylene glycol 3350 with electrolytes (PEG+E) are accepted as the prime medication for disimpaction, response is not always satisfactory. A randomised prospective study was undertaken, in a tertiary paediatric Gastroenterology centre to find out the outcome of a 2-day disimpaction when a stimulant laxative sodium picosulphate was added to PEG3350+E (PEG+E+PS group) and comparing it with the outcome using PEG3350+E (PEG+E group) alone. Hundred and one children were randomised into two groups to receive PEG+E+PS and PEG+E. Results revealed that PEG+E+PS group proved significantly superior to PEG+E group in most of the efficacy-parameters in terms of disimpaction as well as long-term management of constipation. Though stimulant laxatives are being used for disimpaction, comparative data are lacking. This was the 1st such comparative study looking at the efficacy of these two processes of disimpaction along with long term effect on treatment.

Aetiological spectrum, clinical differentiation and efficacy of polyethylene glycol over lactulose in children with constipation: Experience of 316 cases

AIM

To find the aetiological spectrum, clinical features to differentiate organic from functional constipation (FC) and the efficacy of polyethylene glycol (PEG) over lactulose in the treatment of childhood constipation.

METHODS

From January 2007 to December 2014, 316 consecutive children (up to 18 years) with constipation were included in this study. FC was defined as per Rome III criteria. Standard treatment protocol (disimpaction with PEG followed by laxatives) was followed in FC. Lactulose was used in the first 4 years of study and PEG in the last 4 years. Success of therapy was assessed at 3 months.

RESULTS

The median age was 44 (25.00-78.00) months, and 227 (72%) were boys. The majority, 245 (77.5%), had FC, while Hirschsprung disease was the most common organic cause (39.4%). On multivariate analysis, delayed passage of meconium, growth failure, absence of retentive posturing and absent faecal impaction significantly (P < 0.05) determined an organic aetiology. In FC, successful outcome at 3 months was achieved equally with PEG and lactulose (81 vs. 76%, respectively). However, more children in lactulose group had to be switched over to PEG due to lack of efficacy (P = 0.0002).

CONCLUSIONS

FC is the most common cause of constipation in children. Presence of delayed passage of meconium, growth failure and absence of retentive posturing and absent faecal impaction raise the suspicion of an organic cause. Both lactulose and PEG are equally effective. PEG has an edge over lactulose as the need for switch over was uncommon.

Assessment of stool frequency and colonic transit time in Indian children with functional constipation and healthy controls

INTRODUCTION

Indian adults have higher stool frequency and shorter colonic transit time compared to the Western population. Colonic transit time has not been studied well in Indian children. We aimed to compare colonic transit time in normal and constipated children.

METHODS

In this prospective study, stool characteristics and colonic transit time by radio-opaque markers were studied in healthy children (group A, n = 39) and functional constipation patients (group B, n = 61). Twenty radio-opaque markers were ingested per orally at 0, 12, and 24 h followed by a single abdominal X-ray at 36 h. Total and segmental colonic transit times were calculated using the standard formula.

RESULTS

Stool frequency per week and consistency were significantly different between group A (9 [2.5-17] years) vs. group B (4.5 [2-14] years), 7 (7-14) vs.1 (1-2), and Bristol type 4 (3-5) vs. type 2 (1-3). Total colonic transit time of groups A and B was 16.2 (0.6-36) vs. 22.8 (1.8-35.4) hours; p = 0.003. Ninety-fifth percentile (upper limit of normal) cutoff derived from group A was 31.8 h. Ninety-two percent of group B had colonic transit < 95th percentile of normal healthy children. Despite 8% with colonic transit > 95th percentile, all group B patients responded well to standard therapy with laxatives.

CONCLUSION

Indian children have significantly higher stool frequency and shorter colonic transit time, which are different compared to the reported figures from the West. Most of the Indian children with functional constipation had normal colonic transit time.

ANTI-TTG AMONG CHILDREN WITH CHRONIC FUNCTIONAL CONSTIPATION UNRESPONSIVE TO 6 WEEKS OF TREATMENT OF CONSTIPATION

BACKGROUND

Celiac disease is a glutten induced enteropathy. Some authors recommended screening celiac in children with constipation. There are studies to evaluate celiac disease in children with constipation. But most of them included children regardless to treatment failure.

OBJECTIVE

The aim of this study was to evaluate frequency of elevated anti TTG in children with constipation after failure to improve during 6 week of appropriate treatment of constipation.

METHODS

In this cross sectional study, 550 children with prolonged constipation were included. Place of study was Pediatric Gastroenterology clinic of Abuzar children's hospital. Prolonged constipation was defined as a constipation which failed to resolved after 6 weeks of appropriate treatment. Constipation was defined according to ROME III criteria. After parental agreement, 5 mL of blood was obtained. Serum anti TTG level was measure using ELISA method by Orientec kit. Anti TTG>10 was considered positive if IgA was normal. SPSS version 16.0 (Chicago, IL, USA) was used for data analysis. Chi square, t-test, and Mann Whitney test used for data analysis.

RESULTS

In this study 550 children (m=277, f=273) were included. Mean age of the cases was 6.8±2.9 year. Anti TTG antibody level was 5.8±2.8 unit/mL. Of these case, 42 (7.6%) had positive anti-TTG antibody. Celiac disease was confirmed in 40 cases after histopathology examination.

CONCLUSION

Anti-TTG was positive in 7.6% children with chronic constipation who failed to respond after 6 week of treatment. Another multicenter study with longer follow up period is recommended.

Approach to Constipation in Children

PURPOSE

There is a scarcity of literature, and prevalent misconceptions about constipation in India.

METHODS

A literature search in PubMed was conducted with regard to epidemiology, clinical features, and management of constipation. Special emphasis was paid to functional constipation and refractory constipation. English language studies available full text over the last 25 years were considered and relevant information was extracted.

CONCLUSIONS

Estimated prevalence of constipation is 3% among toddlers and pre-school children worldwide and 95%, of them are considered functional. A careful history and thorough physical examination is all that is required to diagnose functional constipation. Management includes disimpaction followed by maintenance therapy with oral laxative, dietary modification and toilet training. A close and regular follow-up is necessary for successful treatment. In most of the cases laxative needs to be continued for several months and sometimes years. Early withdrawal of laxative is the commonest cause of recurrence. Refractory constipation is less common in primary care set up. Radiological colon transit study is useful in picking up Slow transit constipation. Antegrade continence enema plays an important role in the management of slow transit constipation.

Defecation-Specific Behavior in Children with Functional Defecation Issues: A Systematic Review

CONTEXT

Atypical defecation habits are common and distressing for children and families and can have a major impact on quality of life. Often, no underlying factor can be identified, and the defecation disorder is considered functional. Current interventions are not successful for up to 50% of children. We suggest this high failure rate may be caused by lack of consistency in descriptors of behavioral indicators for functional defecation problems. Most investigations and descriptors focus on general behavior. There are fewer reports concerning defecation-specific behaviors.

OBJECTIVE

To develop a thorough inventory of defecation-specific behaviors, providing a more informed foundation for assessment and intervention.

DESIGN

A systematic review of six common databases was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Reference lists of retained articles were screened for additional studies.

MAIN OUTCOME MEASURES

Content analysis was used to classify defecation-specific behaviors into 17 categories.

RESULTS

Our search yielded 2677 articles; 98 peer-reviewed publications were retained for full-text review, and 67 articles were included in the final qualitative synthesis. Although there is inconsistency in reported diagnostic criteria, stool withholding and manifesting pain on defecation are the most commonly reported defecation-specific behaviors. In the studies that included children with autism or attention-deficit/hyperactivity disorder, the defecation-specific behaviors were not unique to the diagnostic group.

CONCLUSION

Consistent use of established diagnostic criteria, along with use of behaviors identified through this review, lay a foundation for more effective interventions.

Prevalence of functional gastrointestinal disorders among adolescents in Delhi based on Rome III criteria: A school-based survey

BACKGROUND

Functional gastrointestinal diseases (FGIDs) are emerging as an important cause of morbidity in adolescents globally. The prevalence of FGIDs among Indian children or adolescents is not clear.

METHODS

A cross-sectional school-based survey conducted in 1115 children aged 10-17 years attending four semi urban government schools of National capital territory (NCT) of Delhi. Rome III questionnaire was translated into Hindi and was filled by the students under supervision. Prevalence of FGIDs was calculated.

RESULTS

Ten percent (112) adolescents had FGIDs. Out of 112, 52 % (58) were boys, and 48 % (54) were girls. 2.7 % (30) had functional dyspepsia, 1.3 % (15) had irritable bowel syndrome, 1.4 % (16) had abdominal migraine, 1.5 % (17) had aerophagia, 0.4 % (5) had functional abdominal pain syndrome, and 0.3 % (4) had functional abdominal pain. Prevalence of functional constipation, adolescent rumination syndrome, cyclical vomiting syndrome, and non-retentive fecal incontinence were 0.5 % (6), 0.3 % (4), 0.3 % (3), 0.4 % (5), respectively. Functional abdominal pain-related FGID were present in 6.3 % (70) children (35 boys and 35 girls). Functional constipation (4 vs. 2) and functional abdominal pain syndrome (4 vs. 1, p < 0.05) were significantly more in females.

CONCLUSIONS

The prevalence of functional gastrointestinal disorders in our study was 10 %. The most frequent FGID noted was functional dyspepsia.

Normal Bowel Pattern in Children and Dietary and Other Precipitating Factors in Functional Constipation

AIM

To study the bowel pattern of children in general population and children with habit constipation with respect to food habits and regarding psychosocial aspect of toileting.

MATERIALS AND METHODS

A prospective descriptive study was done in the Institute of child health and hospital for children, Chennai, with two groups, Functional constipation group and Normal bowel pattern group. The functional group included the children with the age group of 2-12 years, of either sex who fulfilled the ROME III criteria for constipation. Normal bowel pattern group had school children of age group 6-12 years of age and 2-5-year-old children attending OPD for minor ailments. The demographic profile, socioeconomic status, complaints, psychosocial aspects affecting bowel pattern and diet chart were collected and recorded from the parents in proforma. Stool frequency and type of stool passed were recorded for a week, with Bristol stool chart.

RESULTS

A total of 523 and 131 children were analysed for normal bowel pattern and functional constipation respectively. Data analysis done using SPSS version 15. The prevalence of functional constipation was noted in 13.5% with female preponderance and in the age group of 2-4 years.

CONCLUSION

Constipation continues to be a problem, mostly under recognised in older population. Psychosocial factors had a significant effect on functional constipation. Skipping breakfast, early toilet training, low intake of vegetables and fruits were other factors of significance leading to constipation.

Clinical characteristics of pediatric constipation in South jordan

PURPOSE

Constipation is a common pediatric problem worldwide. This study aims to describe the clinical characteristics of pediatric constipation in south Jordan according to gender and age group.

METHODS

All patients with constipation managed at our pediatric gastroenterology service between September 2009 and December 2012 were included. Hospital charts were reviewed. Demographic data, clinical characteristics, and final diagnosis were recorded. Data were analyzed according to gender and the following age groups: infants, pre-school, school age, and adolescents.

RESULTS

During the study period, 126 patients were enrolled. The number (percentage) of patients according to age were the following infants: 43 (34.1%), pre-school: 55 (43.7%), school age: 25 (19.8%), and adolescents: 3 (2.4%). Males made up 54.8% of the study population. There were no statistical gender differences in any age group. The most common symptom in all age groups was dry, hard stool. Infrequent defecation was found in almost one-half of the patients. Fecal incontinence was more common in school-aged children compared to pre-school-aged children and adolescents. Abdominal pain was seen in almost 40% of the constipated children. Abdominal pain was more prevalent in girls and older children. Fecal mass in the rectum was the most common physical finding, with constipated boys exhibiting higher rates. Functional constipation was the most common etiology.

CONCLUSION

Clinical characteristics of constipation in children vary according to age group and gender. Older children had less frequent bowel motions, a longer duration of symptoms, and a higher prevalence of long-standing constipation compilations (fecal incontinence and abdominal pain).

Chronic constipation

The lack of information about management of chronic constipation in children amidst general physicians has necessitated this review. A literature search in PubMed was conducted with regard to epidemiology, clinical features, investigation and management of chronic constipation in children. English language studies published over the last 20 y were considered and relevant information was extracted. Constipation is a common problem among children; the commonest cause is functional (95 %). An elaborate history and thorough physical examination are only essential things required to make a diagnosis of functional constipation. Management consists of disimpaction, followed by maintenance therapy with oral laxative, dietary modification and toilet training. A regular follow-up with slow tapering of laxative is the must for effective treatment. Early withdrawal of laxative is the commonest cause of recurrence.

Time of passage of First Stool in Newborns in a Tertiary Health Facility in Southern Nigeria

Introduction:

The first stool passed by the newborn, the meconium, is different from the ordinary stool both in its nature and its implication. Delayed or non-passage of the meconium may represent a number of clinical conditions. In this study, we sought to identify what should be considered delayed passage of meconium in our babies.

Aims and Objectives:

To investigate the timing of passage of first stool in Nigerian neonates and whether it is influenced by gender, birth weight, maternal age, and parity.

Materials and Methods:

A proforma was designed to obtain the following data: Maternal age, parity, mode of delivery, Apgar score at 1 min, birth weight, gender, and interval between delivery and passage of first stool among normal newborn babies delivered at the obstetrics department of our center in August and September 2010.

Results:

One hundred babies out of 393 delivered during the period of the study were included in the study. There were 63 (63%) males and 37 (37%) females. The interval between delivery and passage of meconium ranged from 0.5 to 54 h; mean, 16.2 (SD = 10.57). This was not influenced by gender, weight, maternal age, and parity.

Conclusion:

Non-passage of meconium beyond 48 h of life could be considered delayed. We therefore, recommend that clinicians should re-evaluate newborns, for hitherto unrecognized conditions, if after 48 h they have not passed first stool.

The physiology of human defecation

Human defecation involves integrated and coordinated sensorimotor functions, orchestrated by central, spinal, peripheral (somatic and visceral), and enteric neural activities, acting on a morphologically intact gastrointestinal tract (including the final common path, the pelvic floor, and anal sphincters). The multiple factors that ultimately result in defecation are best appreciated by describing four temporally and physiologically fairly distinct phases. This article details our current understanding of normal defecation, including recent advances, but importantly identifies those areas where knowledge or consensus is still lacking. Appreciation of normal physiology is central to directed treatment of constipation and also of fecal incontinence, which are prevalent in the general population and cause significant morbidity.

Bowel habits and toilet training in rural and urban dwelling children in a developing country

OBJECTIVES

To determine the bowel habits and toilet training of developmentally normal children ages 5 to 8 years in rural and urban areas of the province of Sindh, Pakistan.

STUDY DESIGN

We conducted a descriptive cross-sectional study, conducted at households of rural (District Khairpur) and urban (Karachi) areas of Sindh, Pakistan, which enrolled 1000 children between 5 and 8 years of age, (half from rural and half from urban areas). A questionnaire regarding age, ethnicity, and sex was completed by two separate investigators from each setting. Recall information was elicited about bowel habits for the previous 2 weeks and the frequency and quality of stools, size of stools, and dietary habit for the previous 24 hours. A constipation score that was based on modified Rome III criteria was developed for each child.

RESULTS

Functional constipation was reported 1.6 times more in the rural than the urban population (P < .001). Toilet training was initiated and completed earlier in the urban (18.6 ± 6.8 and 46 ± 12.5 months) than the rural children (28.6 ± 6.1 and 56.5 ± 6.7 months) (P < .001). The daily calorie, macronutrient, fiber, and water intake was higher in the urban population (P < .001). Functional constipation was significantly (P = .016) negatively correlated (r = -0.076) with the fiber intake.

CONCLUSIONS

Functional constipation was found more frequently in the rural area. Toilet training was initiated and completed significantly earlier in the urban population.