Management of Functional Constipation in Children: Therapy in Practice

Efficacy of Probiotics Compared With Pharmacological Treatments for Maintenance Therapy for Functional Constipation in Children: A Systematic Review and Network Meta-analysis

CONTEXT

There has been an increase in randomized controlled trials (RCTs) comparing probiotics with various maintenance therapies, such as polyethylene glycol, lactulose, and mineral oil, to treat functional constipation in children.

OBJECTIVE

The aim was to compare probiotics with all other oral maintenance therapies for functional constipation in children and rank all treatments in terms of effectiveness in a network meta-analysis.

METHODS

RCTs were identified through systematically searching the MEDLINE, Scopus, EMBASE, and Cochrane Library databases, trial registries, and forward and backward citation searching. Within-study risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and confidence in the estimates was assessed using the CINeMA (Confidence in Network Meta-Analysis) framework. Random-effects network meta-analyses were conducted.

RESULTS

Data were pooled from 41 and 29 RCTs for network meta-analysis of defecation frequency and treatment success, respectively. Probiotics did not significantly increase the number of bowel movements per week when compared with any conventional treatment or placebo. A combination of mineral oil and probiotics was the most effective treatment for increasing defecation frequency (mean difference: 3.13; 95% confidence interval [CI]: 0.64, 5.63). The most effective treatments for increasing the risk of treatment success as compared with placebo were mineral oil (relative risk [RR]: 2.41; 95% CI: 1.53, 3.81) and a combined treatment of polyethylene glycol and lactulose (RR: 2.45; 95% CI: 1.21, 4.97). Confidence in the estimates ranged from very low to moderate.

CONCLUSION

Currently, there is no evidence to suggest that probiotics should be used as a standalone treatment for functional constipation in children. More high-quality studies are needed to evaluate different strains of probiotics and their potential benefit as an additional treatment component to conventional treatments. Mineral oil and polyethylene glycol were the most effective treatments to increase defecation frequency and treatment success rates and should remain the first line of treatment for children with functional constipation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no.

CRD42022360977 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=360977).

Exploring Community Perspectives on Functional Paediatric Habitual Constipation

(1) Background: Functional habitual constipation (FC) in children is a common gastrointestinal problem. This study aimed to explore the local community's view on this problem, emphasising the challenges that parents face in managing the condition and its impact on the child's quality of life. (2) Methods: A prospective, cross-sectional, community-based study was conducted between March and July 2023. The survey received 933 responses. The target population was adults over 18 years of age living in the Eastern Province of Saudi Arabia. An electronically distributed questionnaire was designed in the Arabic language. (3) Results: The mean knowledge scores were significantly higher in females than males, with t (931) = -2.701 and p = 0.007. The Bonferroni post hoc test results indicated that participants between 20 and 29 years exhibited significantly higher levels of knowledge scores compared to those between 30 and 39 years. Furthermore, the results revealed that those with three or more children had significantly higher knowledge scores compared to those with only one child. (4) Conclusions: This study demonstrated that parents in the local community have a good perceived knowledge of FC, but it needs to be linked with practice. They tended to report high levels of perception and demonstrated better practices. These results emphasise the importance of exploring the local community's view on constipation among children.

Laxative Weaning Protocol for Patients With Functional Constipation: A Pilot Study

BACKGROUND

Children with functional constipation require prolonged laxative administration for proper emptying. Whether these laxatives can be weaned after better functioning is achieved is unknown. We aim to describe a standardized protocol for stimulant laxative weaning and its early outcomes.

METHODS

Patients were candidates for weaning if they had been on a stable laxative dose for six months, defined as one bowel movement per day with no soiling, impaction, or enemas. Laxative dose was decreased by 10-25% with re-evaluation every two weeks. If patients remained well without constipation, dose was weaned further by 10-25%. If there were worsening of symptoms, lower dose was maintained for 3-6 months until re-evaluation.

RESULTS

There were a total of sixteen patients evaluated. Median age was 12.7 years [IQR: 11.7-15.3] with laxative duration of 8.0 years [IQR: 5.4-10.7]. All patients were on senna; some were on fiber. Median starting senna dose was 71.3 mg [IQR: 54.3-75.0] and median fiber dose was 5.5 g [IQR: 4.0-6.0]. As of most recent follow up, nine patients (56.3%) had weaned off laxatives in 3.7 months [IQR: 1.3-11.6]. For those still on laxatives, median reduction in dose was 41.4 mg [30.0-75.0], and over half weaned their dose by >50%. Almost all (90.9%) of those on high doses were able to wean.

CONCLUSION

A standardized laxative weaning process can be successful in patients with functional constipation, especially on high doses. Further prospective studies will be necessary to confirm the success of this protocol.

LEVEL OF EVIDENCE

III.

EFFECT OF VISCERAL MANIPULATION ON CHILDREN WITH REFRACTORY CHRONIC FUNCTIONAL CONSTIPATION: A RANDOMIZED CONTROLLED TRIAL

BACKGROUND

Functional constipation (FC) is a common global high prevalence issue in children.

OBJECTIVE

The purpose of the present study is to evaluate the effect of visceral manipulation (VM) on children with chronic interacble FC unresponsive to the standard treatment.

METHODS

This study was conducted as a randomized, single-blind controlled trial. Fifty-two children with refractory chronic functional constipation unresponsive to the standard medical treatment were randomly allocated to two groups of 26 control (standard medical care (SMC)) and 26 intervention (SMC with VM) for 4 weeks. Abdominal pain, painful defecation, stool consistency, defecation frequency, and the dose of oral laxative were evaluated before and after the treatment period using the Pain Rating Scale, Bristol stool form scale, and patient/parents report.

RESULTS

At the end of treatment, except for the dose of oral laxative in the control group, all of the results showed a significant difference in both groups (P<0.05). The dose of oral laxative in the intervention group decreased significantly (P<0.05), however, no significant change was observed in the control group (P>0.05). In the intervention group comparison, statistically significant differences were found in all va-riables except the Bristol stool form scale (P<0.05). The Bristol stool form scale after treatments was not different when the groups were compared (P=0.32), but the number of subjects who had normal stool consistency was significantly increased in the intervention group than in the control group (P<0.05).

CONCLUSION

VM can be considered as a possible treatment without side effects besides SMC for the management of chronic FC. Further studies are needed to investigate the long-term effect of VM.

Recent advances in treating constipation in children

INTRODUCTION

Functional constipation (FC) is a common childhood condition, diagnosed via the Rome IV criteria. Standard therapy includes lifestyle and dietary modification followed by initiation of osmotic laxative therapy. About 30% of children continue to experience symptoms related to FC despite appropriate management. New pharmacologic, surgical, and neuromodulatory therapies for FC are now available for use in adult and pediatric populations. In 2023, the first pharmacologic agent, linaclotide, obtained FDA approval for treatment of FC in children 6-17 years old.

AREAS COVERED

This article reviews current and emerging pharmacologic, surgical, and neuromodulation therapies for the management of FC in pediatric patients. Efficacy and safety data regarding each of these modalities was reviewed and discussed.

EXPERT OPINION

Advancements in therapeutics available for the management of FC necessitate further investigation on safety and efficacy in pediatric populations. Careful consideration should be taken in choosing an available treatment with limited pediatric evidence as adult and pediatric FC have different underlying pathophysiology and require a different therapeutic approach. Standardization of methodology and pediatric endpoints are needed to optimize ability to compare efficacy of different treatments. We predict the future of pediatric FC management will include a personalized approach to care, resulting in improved outcomes.

Effectiveness of physiotherapy in children with functional constipation

PURPOSE

The objective was to compare the immediate effects of pharmacological versus physiotherapy intervention versus a combination of physiotherapy and pharmacological treatment, as well as the quality of life and the recurrence of symptoms in children with functional constipation after 3 months.

METHODS

A total of 69 children with functional constipation between the ages of 5 and 14 years of either gender were assessed and randomly assigned to one of three groups: Group A, B, and C. Visual Analogue Scale, Bristol Stool Form Scale, frequency of defecation, PedsQL GI symptom scale, and PedsQL Generic Core Scale were used as outcome measures. Pharmacology was used to treat Group A, physiotherapy was used to treat Group B, and a combination of both was used to treat Group C.

RESULTS

The study revealed statistically significant results on Visual Analogue Scale, Bristol Stool Form Scale, and frequency of defecation in all groups. However, no significant changes were observed on the PedsQL GI symptom scale and the Generic Core scale in Group A, whereas significant changes were observed in Groups B and C.

CONCLUSION

In this study, we found that there were significant differences in the short- and long-term effects across all groups. More changes occurred in Group C than in Groups A and B.

Randomized controlled trial of linaclotide in children aged 6-17 years with functional constipation

OBJECTIVES

Linaclotide, a guanylate cyclase-C agonist, was recently approved in the United States for treatment of children 6-17 years old with functional constipation (FC). This study evaluated the safety and efficacy of several linaclotide doses in children 6-17 years old with FC.

METHODS

In this multicenter, randomized, double-blind, placebo-controlled phase 2 study, 173 children with FC (based on Rome III criteria) were randomized to once-daily linaclotide (A: 9 or 18 μg, B: 18 or 36 μg, or C: 36 or 72 μg) or placebo in a 1:1:1:1 ratio for 6- to 11-year-olds (dosage determined by weight: 18 to <35 or ≥35 kg) and linaclotide (18, 36, 72, or 145 μg) or placebo in a 1:1:1:1:1 ratio for 12- to 17-year-olds. The primary efficacy endpoint was change from baseline in weekly spontaneous bowel movement (SBM) frequency throughout the 4-week treatment period. Adverse events (AE), clinical laboratory values, and electrocardiograms were monitored.

RESULTS

Efficacy and safety were assessed in 173 patients (52.0% aged 6-11 years; 48.0% aged 12-17 years); 162 (93.6%) completed the treatment period. A numerical improvement in mean SBM frequency was observed with increasing linaclotide doses (1.90 in 6- to 11-year-olds [36 or 72 μg] and 2.86 in 12- to 17-year-olds [72 μg]). The most reported treatment-emergent AE was diarrhea, with most cases being mild; none were severe.

CONCLUSIONS

Linaclotide was well tolerated in this pediatric population, with a trend toward efficacy in the higher doses, warranting further evaluation.

Position paper on transanal irrigation in chronic non-organic constipation

The practice of recto-colonic water irrigation to treat constipation has been used since ancient times with different, uncontrolled, and variably performing methods which have been considered interchangeably all alike. The use of better-performing devices with a standardized methodology is relatively recent, and the term Trans Anal Irrigation (TAI) defines a methodology performed with devices able to control the timing, volume, and pressure of the water introduced into the rectum and colon utilizing a catheter or a cone through the anus. Such practice has been implemented with favorable responses in patients with refractory chronic constipation secondary to neurological diseases. However, since the role of Trans Anal Irrigation as a therapeutic aid in chronic functional constipation and functional evacuation disorders is not yet fully clarified and standardized, a group of clinical investigators with recognized expertise in these clinical conditions intends to clarify the elements that characterize a TAI procedure that can benefit patients with functional constipation and functional defecation disorders defined according to the lastly updated Rome Diagnostic Criteria. Finally, the paper deals with adherence and practical implementation of TAI.

Prevalence and determinants of constipation in children in Asia: a systematic review and meta-analysis

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.

The ten "hard" questions in pediatric functional constipation

Functional constipation is a common problem in childhood and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. No organic cause of the constipation can be found in approximately 95% of children, defining the "so-called" chronic functional constipation. Its prevalence has been reported to range from 0.7 to 29.6%, with a median of 12%. The diagnosis of functional constipation is exclusively clinical based on the pediatric diagnostic Rome criteria for functional gastrointestinal disorders and does not routinely require laboratory and/or radiological investigations. In case of alarm signs and symptoms that may suggest organic diseases, further investigations can be required. The therapeutic management is based on non-pharmacological and pharmacological approaches. Education, demystification of constipation and reward-based toilet training represent the cornerstones of nonpharmacological management. Disimpaction, maintenance treatment and weaning of medication are all elements of pharmacological treatment. Osmotic laxatives, mainly polyethylene glycol (PEG), are considered the first-choice laxative for both disimpaction and maintenance treatment. The aim of this review is to provide pediatric gastroenterologists with a practical tool to support the clinical and therapeutic management of children and adolescents affected by chronic functional constipation.

Effect of prebiotic oligosaccharides on bowel habit and the gut microbiota in children with functional constipation (Inside study): study protocol for a randomised, placebo-controlled, multi-centre trial

BACKGROUND

Functional constipation (FC) in children is a common gastrointestinal disorder with a worldwide-pooled prevalence of 9.5%. Complaints include infrequent bowel movements, painful defecation due to hard and/or large stools, faecal incontinence, and abdominal pain. Prebiotic oligosaccharides have been shown to relieve constipation symptoms in young adults and elderly. However, sufficient evidence is lacking linking additional prebiotic intake to improve symptoms in children with FC. We hypothesise that prebiotic oligosaccharides are able to relieve symptoms of constipation in young children as well.

METHODS

In the present randomised, double-blind, placebo-controlled, multi-centre study, we will study the effects of two prebiotic oligosaccharides in comparison to placebo on constipation symptoms in children of 1-5 years (12 to 72 months) of age diagnosed with FC according to the Rome IV criteria for functional gastrointestinal disorders. The primary outcome measure will be change in stool consistency. Secondary outcomes include stool frequency and stool consistency in a number of cases (%). Tertiary outcomes include among others painful defecation, use of rescue medication, and quality of life. In addition, the impact on gut microbiome outcomes such as faecal microbiota composition and metabolites will be investigated. Participants start with a run-in period, after which they will receive supplements delivered in tins with scoops for 8 weeks, containing one of the two prebiotic oligosaccharides or placebo, followed by a 4-week wash-out period.

DISCUSSION

This randomised double-blind, placebo-controlled multi-centre study will investigate the effectiveness of prebiotic oligosaccharides in children aged 1-5 years with FC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04282551. Registered on 24 February 2020.

Diagnostic and therapeutic approach to children with chronic refractory constipation: Consensus report by the SIGENP motility working group

Constipation is a common problem in children, accounting for about 3% of all primary care visits and up to 25% of referrals to paediatric gastroenterologists. Although polyethylene glycol often proves effective, most children require prolonged treatment and about 50% of them have at least one relapse within the first 5 years after initial recovery. When conventional treatment fails, children are considered to have refractory constipation. Children with refractory constipation deserve specialist management and guidance. Over the last decades, there has been a remarkable increase in our knowledge of normal and abnormal colonic and anorectal motility in children, and a number of different techniques to measure transit and motility have been developed. The present review analyses the possible diagnostic investigations for children with refractory constipation, focusing on their actual indications and their utility in clinical practice. Moreover, we have also analytically reviewed medical and surgical therapeutic options, which should be considered in selected patients in order to achieve the best clinical outcome.

The synergistic effect of herbal medicine and probiotics in pediatric functional constipation: A systematic review and meta-analysis

BACKGROUND

Pediatric functional constipation (PFC) is a prevalent and persistent gastrointestinal disorder, that requires various treatments, including alternative approaches. This review assessed the synergistic efficacy of herbal medicine (HM) and probiotics for PFC.

METHODS

We conducted a comprehensive search of 11 databases, including English, Chinese, and Korean databases, until June 29, 2023. The inclusion criteria were randomized clinical trials (RCTs) comparing the intervention of HM with probiotics to that of the same probiotics. Statistical analyses included calculation of the mean difference (MD), standardized MD, risk ratio (RR) with a 95% confidence interval (CI), and assessment of risk of bias using Review Manager Version 5.4 software. The Grading of Recommendations Assessment, Development, and Evaluation rating system was used to evaluate evidence quality. Potential publication bias was assessed using funnel plots, Egger test, the fail-safe N test, and Duval and Tweedie trim and fill method.

RESULTS

A total of 22 RCTs involving 2228 patients were included in the meta-analysis. The HM and probiotics group exhibited superior outcomes compared to the probiotics alone group in various parameters: total effective rate (RR: 1.24, 95% CI: 1.19-1.29, P < .001), Bristol fecal Score (MD: 0.80, 95% CI: 0.71-0.89, P < .001), gastrointestinal peptide hormone (motilin) (MD: 35.37, 95% CI: 24.64-64.10, P < .001), inflammation indicator (nitrous oxide) (MD: -12.45, 95% CI: -15.12 to -9.77, P < .001), minimal sensitive volume of the rectum (MD: -8.7, 95% CI: -10.91 to -6.49, P < .001), and recurrence rate (RR: 0.30, 95% CI: 0.21-0.43, P < .001).

CONCLUSION

The combination of HM and probiotics may exhibit a synergistic effect on PFC. Nevertheless, it is imperative to undertake rigorously planned RCTs to comprehensively evaluate the synergistic efficacy of HM and probiotics.

Transcutaneous Posterior Tibial Nerve Stimulation: An Adjuvant Treatment for Intractable Constipation in Children

BACKGROUND

Functional constipation can lead to painful defecations, fecal incontinence, and abdominal pain, significantly affecting a child's quality of life. Treatment options include non-pharmacological and pharmacological approaches, but some cases are intractable and require alternative interventions like neuromodulation. A subtype of neuromodulation, called Transcutaneous Posterior Tibial Nerve Stimulation (TPTNS), comprises electrical stimulation at the ankle level, by means of electrodes fixed to the skin. TPTNS is a minimally invasive, easy-to-apply technique that can potentially improve constipation symptoms in the pediatric population by stimulating the sacral nerves.

AIM

To evaluate the clinical results and applicability of TPTNS as an adjuvant treatment for children and adolescents with functional constipation.

METHODS

Between April 2019 and October 2021, 36 patients diagnosed with functional constipation according to the Rome IV Criteria were invited to participate in the study. The study followed a single-center, uncontrolled, prospective cohort design. Patients received TPTNS for 4 or 8 weeks, with assessments conducted immediately after the periods of TPTNS and 4 weeks after the end of the intervention period. The data normality distribution was determined by the Shapiro-Wilk test. The Wilcoxon test and Student's t-test for paired samples were used to compare quantitative variables, and the McNemar test was used to compare categorical variables.

RESULTS

Of the 36 enrolled patients, 28 children and adolescents with intractable function constipation completed the study, receiving TPTNS for 4 weeks. Sixteen patients (57.1%) extended the intervention period for 4 extra weeks, receiving 8 weeks of intervention. TPTNS led to significant improvements in stool consistency, frequency of defecation, and bowel function scores, with a reduction in abdominal pain. Quality of life across physical and psychosocial domains showed substantial enhancements. The quality of life-related to bowel habits also improved significantly, particularly in lifestyle, behavior, and embarrassment domains. The positive effects of this intervention are seen relatively early, detected after 4 weeks of intervention, and even 4 weeks after the end of the intervention. TPTNS was well-tolerated, with an adherence rate of approximately 78%, and no adverse effects were reported.

CONCLUSIONS

TPTNS is an adjuvant treatment for intractable functional constipation, improving bowel function and quality of life. The effects of TPTNS were observed relatively early and sustained even after treatment cessation.

Effectiveness of structured physiotherapy in constipation in children with neurodevelopmental disorders-a randomized trial

INTRODUCTION

Constipation is one of the major issues faced by children with neuro-developmental disorder (NDD). The aims of the study were to: 1) examine the effectiveness of a structured physiotherapy program on constipation in children with NDD; and 2) compare if conventional physiotherapy along with structured physiotherapy intervention has any combined effect on constipation in children with NDD.

METHOD

Thirty-five children with neurodevelopmental disorder were assessed and randomly allotted into two groups. Twenty-two completed the intervention for 2 weeks and were statistically analyzed at baseline and post 4 weeks at a single tertiary center. The outcome measures used were Pediatric quality of life inventory (PedsQL), Peds QL Gastrointestinal symptoms scale, Bristol stool form scale, and defecation frequency. Group A received the conventional treatment, whereas group B received structured physiotherapy along with the conventional treatment.

RESULTS

Group A had no significant outcomes, whereas in group B there were statistically significant differences for all outcome measures. Comparatively, a statistically significant change was noted for PedsQL GI symptoms scale (p = .045) and its constipation sub-scale (p = .002) in group B along with change in the Bristol stool form.

CONCLUSION

Combined effect of structured along with conventional physiotherapy was better in terms of form of stool, constipation, and its associated quality of life factors as compared to conventional physiotherapy alone.

Constipation: A Pristine Universal Pediatric Health Delinquent

Constipation suffered by children is a global public health problem. Functional constipation (FC) brings about deteriorating effects in the children's lives who suffer from it. The risk factors for the development of constipation include the consumption of a diet low in fiber and high in calories (such as the consumption of fast food), a sedentary lifestyle with a lack of exercise, a family history of constipation, and emotional and psychological stress endured by children in their families. It is one of the most common causes of stomachaches in children. FC may lead to fecal incontinence (FI), anal fissures, recurrent urinary tract infections (RUTI), and enuresis in children. Severe constipation may result in stool becoming rock-hard and inflexible in the rectum, which is clinically identified as fecal impaction. It is imperative to perform clinical evaluation and treatment, including pharmacological (the use of stimulant and osmotic laxatives) and non-pharmacological (education, changes in diet, intervention to promote positive behavior and address any emotional issues, toilet training, and physiotherapy for the pelvic floor) interventions. In the case of refractory patients, neuromodulation, the irrigation of the anal canal, and surgical management may be needed. It is essential to lead a healthy, stress-free lifestyle with plenty of exercise and a balanced diet rich in fiber (such as fruits and vegetables) so children can have regular bowel habits and thrive.

Application of non-invasive neuromodulation in children with neurodevelopmental disorders to improve their sleep quality and constipation

BACKGROUND

Children with neurodevelopmental disorders have a very wide clinical variability. A common prevalent factor is problems with stool and sleep quality. Currently, there are multiple studies related to their evaluation, but not so much related to a specific intervention. The aim was to evaluate the effectiveness and safety of the application of non-invasive neuromodulation as a treatment in children with neurodevelopmental disorders to improve constipation and quality of sleep.

METHODS

A total of 23 minors aged between 2 and 16 were included in this cross-sectional study. All participants were applied the microcurrent device for 60 min, 3 times per week for a total of 4 weeks. The technique was based on non-invasive neuromodulation using a surface-applied microcurrent electrostimulation device that administers an external, imperceptible, pulsed electrical stimulation. It is applied to the extremities, in a coordinated manner, using gloves and anklets connected with electrodes to a control console. Sleep latency and microarousals were evaluated through a sleep diary. To assess the evolution and type of defecation, the adapted and validated version in Spanish of the Bristol Stool Form Scale was used.

RESULTS

No adverse events occurred during the study and no incidences were registered. Clinically relevant improvements were registered in defecation frequency and type as well as in sleep related parameters. An increase in the hours of sleep was registered, from 7,35 (0,83) to 9,09 (1,35), and sleep interruptions decreased from 3,83 (1,95) to 1,17 (1,11), (p < .001).

CONCLUSION

Microcurrents can be used as an effective and safe treatment to improve quality of sleep and constipation in children with neurodevelopmental disorders. More studies are needed in order to obtain statistically significant results.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05265702.

FIRST REGISTRATION

03/03/2022 PROTOCOL: https://clinicaltrials.gov/ct2/show/NCT05265702?term=baez+suarez&draw=2&rank=4.

Application of non-invasive neuromodulation in children with neurodevelopmental disorders to improve their sleep quality and constipation

BACKGROUND

Children with neurodevelopmental disorders have a very wide clinical variability. A common prevalent factor is problems with stool and sleep quality. Currently, there are multiple studies related to their evaluation, but not so much related to a specific intervention. The aim was to evaluate the effectiveness and safety of the application of non-invasive neuromodulation as a treatment in children with neurodevelopmental disorders to improve constipation and quality of sleep.

METHODS

A total of 23 minors aged between 2 and 16 were included in this cross-sectional study. All participants were applied the microcurrent device for 60 min, 3 times per week for a total of 4 weeks. The technique was based on non-invasive neuromodulation using a surface-applied microcurrent electrostimulation device that administers an external, imperceptible, pulsed electrical stimulation. It is applied to the extremities, in a coordinated manner, using gloves and anklets connected with electrodes to a control console. Sleep latency and microarousals were evaluated through a sleep diary. To assess the evolution and type of defecation, the adapted and validated version in Spanish of the Bristol Stool Form Scale was used.

RESULTS

No adverse events occurred during the study and no incidences were registered. Clinically relevant improvements were registered in defecation frequency and type as well as in sleep related parameters. An increase in the hours of sleep was registered, from 7,35 (0,83) to 9,09 (1,35), and sleep interruptions decreased from 3,83 (1,95) to 1,17 (1,11), (p < .001).

CONCLUSION

Microcurrents can be used as an effective and safe treatment to improve quality of sleep and constipation in children with neurodevelopmental disorders. More studies are needed in order to obtain statistically significant results.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05265702.

FIRST REGISTRATION

03/03/2022 PROTOCOL: https://clinicaltrials.gov/ct2/show/NCT05265702?term=baez+suarez&draw=2&rank=4.

The Prevalence of Bowel and Bladder Function During Early Childhood: A Population-Based Study

OBJECTIVES

Our primary aim was to determine bowel and bladder function in children aged 1 month to 7 years in the general Dutch population. Second, we aimed to identify demographic factors associated with the presence of bowel and bladder dysfunction, and their coexistence.

METHODS

For this cross-sectional, population-based study, parents/caregivers of children aged from 1 month to 7 years were asked to complete the Early Pediatric Groningen Defecation and Fecal Continence questionnaire. Different parameters of bowel and bladder function were assessed using validated scoring systems such as the Rome IV criteria.

RESULTS

The mean age of the study population (N = 791) was 3.9 ± 2.2 years. The mean age at which parents/caregivers considered their child fully toilet-trained was 5.1 ± 1.5 years. Prevalence of fecal incontinence among toilet-trained children was 12%. Overall prevalence of constipation was 14%, with a constant probability and severity at all ages. We found significant associations between fecal incontinence and constipation [odds ratio (OR) = 3.88, 95% CI: 2.06-7.30], fecal incontinence and urinary incontinence (OR = 5.26, 95% CI: 2.78-9.98), and constipation and urinary incontinence (OR = 2.06, 95% CI: 1.24-3.42).

CONCLUSIONS

Even though most children are fully toilet-trained at 5 years, fecal incontinence is common. Constipation appears to be common in infants, toddlers, and older children. Fecal incontinence and constipation frequently coexist and are often accompanied by urinary incontinence. Increased awareness of bowel and bladder dysfunction in infants, toddlers, and young children is required to prevent these problems from continuing at older ages.

A narrative review on the diagnosis and management of constipation in infants

INTRODUCTION

Functional constipation is one of the common disorders of gut-brain interaction in infancy, and decreases the quality of life of infants and parents.

AREAS COVERED

Relevant articles up to November 2022 were reviewed. We searched in PubMed, Google Scholar, and MEDLINE for guidelines, position papers, reviews, and randomized controlled trials on infant constipation.

EXPERT OPINION

Randomized controlled trials in this specific age group are mostly limited to trials with infant formula. The prevalence of infant constipation in formula-fed infants is decreasing, and can be associated with adaptations in formula composition. While the supplementation of infant formula with pro-, pre- and/or synbiotics decreases the prevalence of constipation, their efficacy in constipated infants is disappointing. There is limited evidence to support the addition of magnesium to infant formula to treat constipation. The evidence for the efficacy and safety of polyethylene glycol in children < 2 years has expanded over the past years. The administration of lactulose or polyethylene glycol is the preferred medical management, in case nutritional management does result in insufficient improvement.

Design of a phase 3, randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of prucalopride in pediatric patients with functional constipation

Background

A previous phase 3 trial of prucalopride in pediatric patients (6 months-18 years old) with functional constipation (FC) demonstrated no efficacy versus placebo. We designed an additional phase 3 trial to further assess the efficacy, long-term safety and tolerability of prucalopride in children and adolescents.

Methods

This multicenter trial (ClinicalTrials.gov identifier: NCT04759833; EudraCT number: 2022-003221-22) comprises a 12-week, randomized, double-blind, placebo-controlled phase, followed by a 36-week, double-blind, safety extension phase. Approximately 240 toilet-trained patients aged 3-17 years will be randomized 1:1:1 to receive low- (0.04 mg/kg) or high-dose (0.08 mg/kg) prucalopride, or placebo once daily. Fifteen non-toilet-trained patients ≥6 months old with FC will be included in an exploratory efficacy and safety analysis.

Discussion

The efficacy endpoints used in this study will differ from those used in adults and in the previous pediatric phase 3 trial; they have been adapted to be more suitable for a wider age range of pediatric patients. Both study phases will be longer than in the previous pediatric study, providing a longer time period in which to assess the efficacy and safety of prucalopride. Study participants will be identified using the modified Rome IV criteria for FC, instead of the Rome III criteria, and non-toilet-trained patients will be included, which will broaden the population of pediatric patients assessed. Patients will undergo fecal disimpaction before randomization and undergo standardized continuous behavioral therapy throughout the trial. This pediatric study of prucalopride will aim to demonstrate the efficacy and long-term safety of this treatment.

An Update of Pharmacological Management in Children with Functional Constipation

Functional constipation is a common problem in childhood worldwide and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. It is a clinical diagnosis based on the Rome IV criteria. Non-pharmacological treatment involves education, demystification, lifestyle advice, and toilet training. Pharmacological treatment consists of disimpaction, maintenance treatment, and eventually weaning if possible. Polyethylene glycol is considered as the first choice of laxative for both disimpaction and maintenance treatment. Different osmotic laxatives, stimulant laxatives, lubricants, and enemas are available as alternative pharmacological treatment options. Novel drugs are emerging but evidence to support the widespread application of these drugs in the pediatric population is often lacking and more high-quality research is needed in this field. If children remain symptomatic despite optimal pharmacological treatment, botulinum toxin injections in the anal sphincter can be considered as an alternative, more invasive treatment option. This review provides an update on currently available literature concerning the pharmacologic treatment of functional constipation in children.

Gut dysmotility in children with neurological impairment: the nutritional management

Intestinal motility disorders represent a frequent problem in children with neurological impairment. These conditions are characterized by abnormal movements of the gut, which can result in symptoms such as constipation, diarrhea, reflux, and vomiting. The underlying mechanisms leading to dysmotility are various, and the clinical manifestations are often nonspecific. Nutritional management is an important aspect of care for children with gut dysmotility, as it can help to improve their quality of life. Oral feeding, when safe and in the absence of risk of ingestion or severe dysphagia, should always be encouraged. When oral nutrition is insufficient or potentially harmful, it is necessary to switch to an enteral by tube or parenteral nutrition before the onset of malnutrition. In most cases, children with severe gut dysmotility may require feeding via a permanent gastrostomy tube to ensure adequate nutrition and hydration. Drugs may be necessary to help manage gut dysmotility, such as laxatives, anticholinergics and prokinetic agents. Nutritional management of patients with neurological impairment often requires an individualized care plan to optimize growth and nutrition and to improve overall health outcomes. This review tries to sum up most significant neurogenetic and neurometabolic disorders associated with gut dysmotility that may require a specific multidisciplinary care, identifying a proposal of nutritional and medical management.

Efficacy of non-pharmacological treatment for adult patients with chronic constipation

BACKGROUND

Functional constipation is defined as a delay or difficulty in defecation that lasts two weeks or more which history and physical examination have ruled out its organic causes. In this study, we aimed to evaluate the efficacy of non-pharmacological treatments (dietary changes and increased physical activity) for adult patients with chronic constipation.

METHODS

This prospective randomized clinical trial was performed in 2020-2021 on 64 patients with functional constipation with the Iranian Registry of Clinical Trials (IRCT) code IRCT20200601047621N2 (https://en.irct.ir/trial/48798). The demographic data and constipation severity were collected by checklist. The diet was designed by a nutritionist containing 25 to 30 grams of fiber and eight glasses of water or liquids other than tea daily for 12 weeks. The amount of sufficient physical activity was defined as doing half an hour of brisk walking daily to increase the heart rate by 50%. All cases were visited during the study and the constipation severity questionnaire was completed at baseline and after 2, 4, 8 and 12 weeks after the beginning of the study.

RESULTS

Patients had significantly improved defecation frequencies after 12 weeks (P = 0.03 compared to baseline). We also observed that patients had improvements in having a hard stool (P = 0.001 compared to baseline), painful defecation (P = 0.03 compared to baseline), use of a finger to defecate (P = 0.04 compared to baseline), and straining while defecation (P < 0.001 compared to baseline). Patients with age groups 30-40 and 40-50 significantly improved defecation frequencies, painful defecation, and straining while defecating compared to other age groups.

CONCLUSION

Non-pharmacological treatments could significantly improve functional constipation in patients. Significant improvements were observed in patients between 30-50 years of age.

Intra and inter: Alterations in functional brain resting-state networks in patients with functional constipation

Background

Functional constipation (FCon), is a symptom-based functional gastrointestinal disorder without an organic etiology and altering brain structure and function. However, previous studies mainly focused on isolated brain regions involved in brain plasticity. Therefore, little is known about the altered large-scale interaction of brain networks in FCon.

Methods

For this study, we recruited 20 patients with FCon and 20 healthy controls. We used group independent component analysis to identify resting-state networks (RSNs) and documented intra- and inter-network alterations in the RSNs of the patients with FCon.

Results

We found 14 independent RSNs. Differences in the intra-networks included decreased activities in the bilateral caudate of RSN 3 (strongly related to emotional and autonomic processes) and decreased activities in the left precuneus of RSN 10 (default mode network). Notably, the patients with FCon exhibited significantly decreased interactive connectivity between RSNs, mostly involving the connections to the visual perception network (RSN 7–9).

Conclusion

Compared with healthy controls, patients with FCon had extensive brain plastic changes within and across related RSNs. Furthermore, the macroscopic brain alterations in FCon were associated with interoceptive abilities, emotion processing, and sensorimotor control. These insights could therefore lead to the development of new treatment strategies for FCon.

White-matter microstructural alterations in patients with functional constipation: A tract-based spatial statistics study

BACKGROUND

Highly prevalent functional constipation (FC) belongs to the category of functional gastrointestinal disorders. Neuroimaging studies have demonstrated brain functional and morphometric changes in patients with FC. However, whether FC is associated with white-matter (WM) microstructural alterations remains unclear.

METHODS

Diffusion tensor imaging (DTI) and tract-based spatial statistics (TBSS) were introduced to investigate WM microstructural changes as calculated by fractional anisotropy (FA), mean (MD), axial (AD), and radial diffusivity (RD) in 26 FC patients and 31 healthy controls.

KEY RESULTS

Patients with FC relative to healthy controls had significantly decreased FA with increased MD/RD in the genu (GCC) and body (BCC) of the corpus callosum, right cingulum (Cing), bilateral anterior corona radiata (ACR), bilateral superior corona radiata (SCR), and left posterior corona radiata (PCR) (p_FWE  < 0.05). Between-group difference was only in the left SCR and PCR when regressing out anxiety and depression as covariates.

CONCLUSIONS AND INFERENCES

These WM tracts are mainly responsible for sensory and emotional information communication and corresponding functional integration; thus, our findings indicate an association between FC and WM microstructural abnormalities in regions involved with visceral afferent and emotional-arousal processing. Alterations in WM microstructures including the CC, cingulum, and ACR are more related to psychological symptoms than constipation, which might have greater impact on brain structures.

Development of a Bowel Management Scoring Tool in Pediatric Patients with Constipation

OBJECTIVE

To develop a reliable and valid scoring tool, the Pediatric Bowel Management Scoring Tool (PBMST), to better guide management of constipation in pediatric patients.

STUDY DESIGN

The project comprised 2 stages, development of the questionnaire and construction of the bowel management score. Two questionnaires were created, one for children aged 8-18 years to self-report and one parent proxy-report for children aged 4-8 years. Questions regarding physical symptoms (n = 6), emotional aspects (n = 2), social activities/school (n = 1), and treatment (n = 1) were included. Patients (or parents of patients) with symptoms of constipation completed the questionnaire. The reproducibility of each question was computed using the Cohen weighted kappa coefficient (κ). A bowel management score was developed using logistic regression analysis, assessing the associations between the questions and impact on self-reported quality of life (QoL). Questions with adequate reproducibility and significantly associated with QoL were incorporated into the score.

RESULTS

The questionnaire was completed by 385 patients. Six questions met the inclusion criteria and were incorporated into the score: stool shape (range, 0-3 points), anorectal pain (0-4 points), abdominal pain (0-3 points), frequency of fecal incontinence (0-3 points), assistance of caregivers (0-3 points), and interference with social activities (0-6 points). Differences in bowel management scores among patients reporting no, little, some, or major impact on QoL were statistically significant (P < .001).

CONCLUSIONS

The newly developed and validated PBMST is a reliable tool for evaluating bowel management strategies in children with constipation.

Management of children with functional constipation referred to tertiary care

OBJECTIVES

To describe the management, to compare treatment at initial referral vs. during specialized follow-up, and to describe outcomes of children with functional constipation (FC) referred to a Brazilian tertiary care center.

METHODS

Retrospective study, including children (4-18 years) with FC followed at a single center from 2006 to 2019. Demographics, treatments, time of follow-up, and outcomes were analyzed. The management of FC followed an institutional protocol.

RESULTS

104 patients were identified, 79 were eligible and included in the analysis: 59% male, mean age at referral was 6.4 years, and mean duration of symptoms was 4.4 years. There were significant changes in the therapy(ies) used at the time of referral compared to during follow-up, with a noticeable increase in the frequency of the use of polyethylene glycol, enemas, magnesium hydroxide, and bisacodyl; 5.1% received trans-anal irrigation, and 3.8% underwent surgery. Outcomes were favorable in more than half of the cases: 31% improved; 19.5% had complete resolution and 2.5% were transferred back to primary care. Symptoms remained unchanged in 30.4%, and no patients experienced worsening of symptoms. The mean duration of follow-up was 2.8 years. When comparing patients with favorable vs. unfavorable outcomes, the authors did not identify significant differences in gender, age, therapies used, duration of symptoms, or length of follow-up.

CONCLUSIONS

Children with FC are often referred to specialized care not receiving optimal therapy. Many patients whose FC was labeled "refractory" may be treated successfully with a well-established plan of care, and do not truly present intractable constipation.

Can Lactose Intolerance Be a Cause of Constipation? A Narrative Review

Lactose intolerance and constipation are common in children and impact everyday life, not only for patients but also their families. Both conditions can be comorbid with other diseases or form a part of their clinical presentation, but constipation is not usually associated with lactose intolerance. The typical symptoms of lactose intolerance include abdominal pain, bloating, flatus, diarrhoea, borborygmi, and less frequently nausea and vomiting. In approximately 30% of cases, constipation can be a symptom of lactose intolerance. Constipation is characterized by infrequent bowel movements, hard and/or large stools, painful defecation, and faecal incontinence, and is often accompanied by abdominal pain. This paper provides a narrative review on lactose intolerance, its epidemiology, pathogenesis, the correlation between lactose intolerance and constipation in children, and potential mechanisms of such association.

Diagnosing and managing acute abdominal pain in children

ABSTRACT

Acute abdominal pain is a common complaint in children. The care of these patients is challenging for clinicians because presentation, diagnosis, and treatment are different in children than adults. This article describes the presentation, physical examination, diagnosis, and treatment of common causes of acute abdominal pain in children and discusses emerging trends in diagnosis and treatment.

Nonpharmacologic Treatment for Children with Functional Constipation: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the effectiveness and safety of nonpharmacologic interventions for the treatment of childhood functional constipation.

STUDY DESIGN

Randomized controlled trials (RCTs) evaluating nonpharmacologic treatments in children with functional constipation which reported at least 1 outcome of the core outcome set for children with functional constipation.

RESULTS

We included 52 RCTs with 4668 children, aged between 2 weeks and 18 years, of whom 47% were females. Studied interventions included gut microbiome-directed interventions, other dietary interventions, oral supplements, pelvic floor-directed interventions, electrical stimulation, dry cupping, and massage therapy. An overall high risk of bias was found across the majority of studies. Meta-analyses for treatment success and/or defecation frequency, including 20 RCTs, showed abdominal electrical stimulation (n = 3), Cassia Fistula emulsion (n = 2), and a cow's milk exclusion diet (n = 2 in a subpopulation with constipation as a possible manifestation of cow's milk allergy) may be effective. Evidence from RCTs not included in the meta-analyses, indicated that some prebiotic and fiber mixtures, Chinese herbal medicine (Xiao'er Biantong granules), and abdominal massage are promising therapies. In contrast, studies showed no benefit for the use of probiotics, synbiotics, an increase in water intake, dry cupping, or additional biofeedback or behavioral therapy. We found no RCTs on physical movement or acupuncture.

CONCLUSIONS

More well-designed high quality RCTs concerning nonpharmacologic treatments for children with functional constipation are needed before changes in current guidelines are indicated.

Functional constipation is associated with alterations in thalamo-limbic/parietal structural connectivity

BACKGROUND

Functional constipation (FCon) is a common functional gastrointestinal disorder (FGID) with a high prevalence in clinical practice. Previous studies have identified that FCon is associated with functional and structural alterations in the primary brain regions involved in emotional arousal processing, sensory processing, somatic/motor-control, and self-referential processing. However, whether FCon is associated with abnormal structural connectivity (SC) among these brain regions remains unclear.

METHODS

We selected the brain regions with functional and structural abnormalities as seed regions and employed diffusion tensor imaging (DTI) with probabilistic tractography to investigate SC changes in 29 patients with FCon and 31 healthy controls (HC).

KEY RESULTS

Results showed lower fractional anisotropy (FA) in the fibers connecting the thalamus, a region involved in sensory processing, with the amygdala (AMY), hippocampal gyrus (HIPP), precentral (PreCen) and postcentral gyrus (PostCen), supplementary motor area (SMA) and precuneus in patients with FCon compared with HC. FCon had higher mean diffusivity (MD) and radial diffusivity (RD) in the thalamus connected to the AMY and HIPP. In addition, FCon had significantly increased RD of the thalamus-SMA tract. Sensation of incomplete evacuation was negatively correlated with FA of the thalamus-PostCen and thalamus-HIPP tracts, and there was a negative correlation between difficulty of defecation and FA of the thalamus-SMA tract.

CONCLUSIONS AND INFERENCES

These findings reflected that FCon is associated with alterations in SC between the thalamus and limbic/parietal cortex, highlighting the integrative role of the thalamus in brain structural network.

Effectiveness of Viola Flower Syrup Compared with Polyethylene Glycol in Children with Functional Constipation: A Randomized, Active-Controlled Clinical Trial

Background

Functional constipation (FC) is a health concern that is prevalent in the pediatric population. It lowers the quality of life and increases the probability of comorbidities. As a complementary modality, herbal medicine has been considered useful in a variety of conditions. Persian medicine (PM) resources mention the Viola flower as an effective herb in treating constipation. The purpose of the current trial was to evaluate the efficacy of Viola flower syrup (VFS) compared with polyethylene glycol (PEG) in children with functional constipation.

Methods

This randomized, active-controlled, single-center trial was conducted on 140 children aged between 4 and 10 years with confirmed FC according to Rome III criteria. Participants were randomly assigned to receive either VFS or PEG for four weeks. Independent t-test and general linear model (GLM) repeated measures analysis of variance were used to determine the intergroup difference, and paired sample t-test was used to evaluate the intragroup difference.

Results

After four weeks of intervention, 133 individuals (66 in VFS and 67 in the PEG group) were analyzed. Results of both groups demonstrated significant improvement in all measured criteria at the end of the study compared to baseline (P < 0.001). No significant difference was observed between the two groups at baseline or at the end of the study (P > 0.05), except for fecal retention at baseline (P=0.028). Participants in the PEG group experienced more side effects compared to the VFS group.

Conclusion

The findings of this investigation indicated that VFS is an effective and relatively safe medication to be used in the treatment of pediatric FC.

Clinical Efficacy of Infantile Massage in the Treatment of Infant Functional Constipation: A Meta-Analysis

Background: Functional constipation in children is a common disease that causes a psychological burden on infants and young children across the world. It will greatly affect infant quality of life in early childhood and even affect their psychological and physical health. At present, infant functional constipation is treated with western drugs alone, but this can produce drug dependency. In recent years, Traditional Chinese Medicine (TCM) infant massage has been used as a complementary and alternative therapy, and its effectiveness and safety have been proven, attracting the attention of numerous researchers.

Objective: Our study aimed to compare the influence of infant massage intervention on defecation frequency and consistency, determine the effectiveness, and safety of infant massage in the treatment of infant functional constipation, and obtain high-quality clinical evidence.

Methods: Based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement, inclusion, and exclusion criteria were formulated. Randomized controlled trials (RCTs) on TCM infant massage for the treatment of infant functional constipation were found following a search of four mainstream medical databases. RCTs found to meet the study's requirement were included; data information was then extracted, and the quality was assessed using the Cochrane bias risk assessment tool. Through RevMan software, a meta-analysis was carried out for overall effective rate, stool form, defecation frequency, defecation difficulty, and constipation symptom scoring index. The relative risk (RR) and 95% confidence interval (95% CI) were calculated, heterogeneity was tested and its source was found, and publication bias was assessed through the Egger's and Begg's tests and by means of funnel plots.

Results: A total of 23 RCTs and 2,005 patients were included. The results of the meta-analysis showed that compared to drug therapy alone, TCM infant massage had a superior effect on the treatment of infant functional constipation. This difference was statistically significant (p < 0.05) and evaluated according to the overall effective rate (RR = 1.25; 95% CI = 1.17, 1.33), defecation frequency [mean difference (MD) = −0.72; 95% CI = −0.80, −0.65], and constipation symptom score (MD = −0.81; 95% CI = −1.20, −0.43), showing that TCM infant massage is indeed superior to drug therapy alone in the treatment of infant functional constipation. TCM infant massage was found to be equivalent to drug therapy alone in terms of the stool form score [−0.30 (−0.38, −0.22)] and the defecation difficulty score [−0.73 (−0.81, −0.65)], since the difference was not statistically significant (p > 0.05). The source of heterogeneity might be related to the state of patient, manipulation of the massages, efficacy of drugs in the control group, and difference in judgment criteria for efficacy. The Egger's test and Begg's test showed that publication bias did not occur in our study.

Conclusion: TCM infant massage can increase defecation frequency and reduce the symptoms of constipation in children suffering from functional constipation; in addition, the clinical trial showed beneficial effects. Since some of the RCTs featured a very small sample size, the reliability and validity of our study's conclusion may have been affected as well; therefore, the explanation should be treated with some caution. In the future, a large number of higher-quality RCTs are still needed to confirm the results of our study.

Utilisation and Safety of Polyethylene Glycol 3350 With Electrolytes in Children Under 2 Years: A Retrospective Cohort

OBJECTIVES

In the UK, Movicol paediatric plain (polyethylene glycol 3350 with electrolytes [PEG 3350+E], Norgine, UK), is licensed for chronic constipation in children 2 -11 years of age and faecal impaction (FI) from 5 years. This study aimed to investigate usage and characterise the risk profile in children under 2 years of age using PEG 3350+E in the UK.

METHODS

Retrospective, single exposure cohort study, with patients identified from Clinical Practice Research Datalink (CPRD) GOLD. Patients first prescribed PEG 3350+E under 2 years of age for the treatment of constipation or FI, between September 2003 and July 2019, were included.

RESULTS

There were 13,235 patients with a constipation indication and 40 patients with FI. For the constipation cohort: median age of PEG 3350+E first prescription was 1.2 years [interquartile range (IQR) 0.9, 1.6] and 68.4% had one treatment episode (TE). The mean duration of exposure, in the first TE, was 88.9 days. The most common total daily dose was one sachet (6.9 g).In terms of incident events on treatment, 0.5% of patients had abdominal pain, 3.0% had diarrhoea (may be attributed to treatment) and 4.1% had vomiting. 2.0% had signs/symptoms which could (in extreme cases) be associated with electrolyte disturbance, however, none had abnormal electrolyte values.

DISCUSSION

The safety aspect of this study did not identify any signals of concern in the constipation cohort. The number of patients in the FI cohort were too small for robust conclusions. If information were available, then a safety study would ideally assess treatment intake per kilogram, including electrolyte intake, before reaching safety conclusions. Nevertheless, these data contribute to real-world evidence on the use of PEG 3350+E in this population.

Abnormalities in the thalamo-cortical network in patients with functional constipation

Functional constipation (FCon) is a common functional gastrointestinal disorder (FGID); neuroimaging studies have shown brain functional abnormalities in thalamo-cortical regions in patients with FGID. However, association between FCon and topological characteristics of brain networks remains largely unknown. We employed resting-state functional magnetic resonance imaging (RS-fMRI) and graph theory approach to investigate functional brain topological organization in 42 patients with FCon and 41 healthy controls (HC) from perspectives of global, regional and modular levels. Results showed patients with FCon had a significantly lower normalized clustering coefficient and small-worldness, implying decreased brain functional connectivity. Regions showed altered nodal degree and efficiency mainly located in the thalamus, rostral anterior cingulate cortex (rACC), and supplementary motor area (SMA), which are involved in somatic/sensory, emotional processing and motor-control. For the modular analysis, thalamus, rACC and SMA had an aberrant within-module nodal degree and nodal efficiency, and thalamus-related network exhibited abnormal interaction with the limbic network (amygdala and hippocampal gyrus). Nodal degree in the thalamus was negatively correlated with difficulty of defecation, and nodal degree in the rACC was negatively correlated with sensation of incomplete evacuation. These findings indicated that FCon was associated with abnormalities in the thalamo-cortical network.

Cortical morphometry alterations in brain regions involved in emotional, motor-control and self-referential processing in patients with functional constipation

Functional constipation (FC) is a common functional gastrointestinal disorder (FGID). Neuroimaging studies on patients with FC showed brain functional abnormalities in regions involved in emotional process modulation, somatic and sensory processing and motor control. Brain structural imaging studies in patients with FGID have also shown disease-related alterations in cortical morphometry, but whether and how FC affects brain structure remains unclear. Structural Magnetic Resonance Imaging and surface-based morphometry analysis were used to investigate the impact of FC on cortical morphometry in 29 patients with FC and 29 healthy controls (HC). Results showed that patients with FC compared to HC had significantly decreased cortical thickness in the left middle frontal gyrus (MFG), dorsomedial (DMPFC) and ventromedial prefrontal gyrus (VMPFC), right dorsal anterior cingulate cortex (dACC), left orbitofrontal cortex (OFC), posterior cingulate cortex (PCC)/precuneus, middle temporal gyrus (MTG), and supplementary motor area (SMA) (P < 0.01). Correlation analysis showed that sensation of incomplete evacuation was negatively correlated with cortical thickness in the SMA (P < 0.0001). In addition, patients with FC also had decreased cortical volume than HC in the MTG, precentral gyrus (PreCen) and precuneus/cuneus (P < 0.01), as well as decreased cortical surface area in the PreCen (P < 0.01). No correlation was found between cortical volume/surface area and behavioral measures. These findings suggest that patients with FC are associated with cortical morphometric abnormalities in brain regions implicated in somatic/motor-control, emotional processing and self-referential processing.

Dietary habits in Greek children with functional constipation based on Rome III criteria: a school-based, cross-sectional multivariate analysis

Background

Functional constipation (FC) is the most common gastrointestinal disorder of childhood and has a multifactorial etiology. We aimed to assess dietary habits in Greek children with FC compared to the general population (control group, CG).

Methods

This was a subgroup analysis of a school-based, cross-sectional study carried out in children 6-18 years of age, between January and June 2014, using the Rome III criteria for the diagnosis of FC. Dietary parameters, as well as socioeconomic and demographic data and their association with the likelihood of FC, were analyzed through multivariate logistic regression analysis and expressed as odds ratios (OR).

Results

A total of 1439 children (1218 CG, 221 FC) were included in the analysis. The final model showed that consumption of was the only dietary parameter significantly related to FC; higher frequency of consumption was inversely related to the likelihood of FC (OR: 0.98, 95% CI: 0.96, 0.99, P=0.048). Significant socioeconomic confounders with a positive association with FC were: parental educational level, victimization, physical activity and number of adults at home.

Conclusions

Increased frequency of fiber consumption is significantly associated with higher odds of FC irrespective of socioeconomic background and lifestyle parameters. Interventional studies are required to validate these cross-sectional observations.

Efficacy of polyethylene glycol 3350 as compared to lactulose in treatment of ROME IV criteria-defined pediatric functional constipation: A randomized controlled trial

BACKGROUND AND AIMS

Functional constipation is a common childhood problem, with a prevalence of approximately 3% worldwide. The aim of the study was to compare the efficacy of polyethylene glycol (PEG) 3350 and lactulose in the treatment of pediatric functional constipation.

METHODS

A total of 100 subjects with functional constipation were enrolled and centrally randomized to receive PEG 3350 (0.7-1.5 mg/kg/day) or lactulose (0.7-2.0 g/kg/day).

RESULTS

There was a significant increase in median (min, max) stool frequency within 1 week in the PEG 3350 group as compared to the lactulose group (1 [0, 3] to 8 [3, 39] vs. 1 [0, 3] to 7 [1, 17]) (p-value < 0.01). The trend was maintained at week 2, week 3 (p-value < 0.01), and week 4 (p-value = 0.05) with the PEG 3350 group reporting higher weekly median stool frequency than the lactulose group. The PEG group reported significant reduction in painful bowel movements from 68.8% subjects at baseline to 43.8% at the end of first week, whereas the lactulose group reported an increase from 48.9% to 73.3% (p-value = 0.05). Other parameters of constipation, i.e. straining, large diameter stool, and large fecal mass as reported subjectively by parents, significantly decreased from baseline to the end of the study in the PEG 3350 arm compared to those in the lactulose arm. At the end of week 4, there was a statistically significant reduction in all the ROME IV-defined criteria between the two groups.

CONCLUSION

This study proved that the PEG 3350 treatment group had early symptom relief and significant improvement compared to the lactulose group in pediatric functional constipation.

TRIAL REGISTRATION

Clinical Trials Registry India (CTRI/2018/01/011061).

Paediatrics: how to manage functional constipation

BACKGROUND

Despite being a common problem in childhood, functional constipation is often difficult to manage. This article provides a narrative updated review on the evaluation, diagnosis and management of childhood functional constipation.

METHODS

A PubMed search was performed with Clinical Queries using the key term 'functional constipation'. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and to the paediatric population. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

A detailed history and thorough physical examination are important in the evaluation of a child with constipation to establish the diagnosis of functional constipation as per the Rome IV criteria and to catch 'red flags' suggestive of organic causes of constipation. These 'red flags' include delayed passage of meconium, ribbon stool, rectal bleeding/blood in the stool unless attributable to an anal fissure, failure to thrive, severe abdominal distension, absent anal wink/cremasteric reflex, tight and empty rectum on digital examination and explosive expulsion of liquid stool and gas on withdrawal of the finger, hair tuft/dimple/lipoma/haemangioma in the lumbosacral area, and an anteriorly displaced anus. For functional constipation, pharmacological therapy consists of faecal disimpaction and maintenance therapy. This can be effectively accomplished with oral medications, rectal medications or a combination of both. The most commonly used and most effective laxative is polyethylene glycol. Non-pharmacological management consists of education, behavioural modification and dietary interventions. The combination of pharmacological therapy and non-pharmacological management increases the chance of success.

CONCLUSION

Polyethylene glycol is the medication of first choice for both disimpaction and maintenance therapy. If polyethylene glycol is not available or is poorly tolerated, lactulose is the preferred alternative. Other laxatives may be considered as second-line therapy if treatment with osmotic laxatives fails or is insufficient. Maintenance treatment should be continued for at least 2 months. Early treatment will result in a faster and shorter treatment course.

Altered Functional Connectivity Within and Between Salience and Sensorimotor Networks in Patients With Functional Constipation

Functional constipation (FCon) is a common functional gastrointestinal disorder. A considerable portion of patients with FCon is associated with anxiety/depressive status (FCAD). Previous neuroimaging studies mainly focused on patients with FCon without distinguishing FCAD from FCon patients without anxiety/depressive status (FCNAD). Differences in brain functions between these two subtypes remain unclear. Thus, we employed resting-state functional magnetic resonance imaging (RS-fMRI) and graph theory method to investigate differences in brain network connectivity and topology in 41 FCAD, 42 FCNAD, and 43 age- and gender-matched healthy controls (HCs). FCAD/FCNAD showed significantly lower normalized clustering coefficient and small-world-ness. Both groups showed altered nodal degree/efficiency mainly in the rostral anterior cingulate cortex (rACC), precentral gyrus (PreCen), supplementary motor area (SMA), and thalamus. In the FCAD group, nodal degree in the SMA was negatively correlated with difficulty of defecation, and abdominal pain was positively correlated with nodal degree/efficiency in the rACC, which had a lower within-module nodal degree. The salience network (SN) exhibited higher functional connectivity (FC) with the sensorimotor network (SMN) in FCAD/FCNAD, and FC between these two networks was negatively correlated with anxiety ratings in FCAD group. Additionally, FC of anterior insula (aINS)-rACC was only correlated with constipation symptom (i.e., abdominal pain) in the FCNAD group. In the FCAD group, FCs of dorsomedial prefrontal cortex-rACC, PreCen-aINS showed correlations with both constipation symptom (i.e., difficulty of defecation) and depressive status. These findings indicate the differences in FC of the SN-SMN between FCAD and FCNAD and provide neuroimaging evidence based on brain function, which portrays important clues for improving new treatment strategies.

Understanding Parents' Experiences When Caring for a Child With Functional Constipation: Interpretive Description Study

BACKGROUND

Pediatric functional constipation (FC) is a common but serious medical condition. Despite significant effects on children, families, and the health care system, the condition is typically undertreated. Parents carry the primary responsibility for complex treatment programs; therefore, understanding their experiences and needs may offer a critical perspective toward improving clinical care.

OBJECTIVE

The aim of this study is to understand and give voice to parents' experiences and information needs when caring for a child with FC. The ultimate objective is to build an evidence base suitable for creating a digital knowledge translation tool to better support parents caring for a child with FC.

METHODS

This qualitative design used an interpretive description methodology to generate findings aimed at improving clinical care. One-on-one, in-depth interviews were completed either in person or through web-based teleconferencing to explore parents' perspectives. Data collection and analysis occurred concurrently.

RESULTS

Analysis of 16 interviews generated 4 major themes: living in the shadows; not taken seriously, with a subtheme of persevering and advocating; missing information and misinformation; and self-doubt and strained relationships. One minor theme of affirmative influences that foster resilience and hope was identified.

CONCLUSIONS

Parents have unmet needs for support and information related to pediatric FC. To address gaps in current care provision, decision makers may consider interventions for clinicians, resources for parents, and shifting care models to better meet parents' needs.

Promelaxin Microenemas Are Non-inferior to Oral Polyethylene Glycol for the Treatment of Functional Constipation in Young Children: A Randomized Clinical Trial

Background: Polyethylene glycol (PEG) is recommended as first-line treatment of pediatric functional constipation. However, the oral route of administration is often poorly feasible in children mostly due to poor palatability. Promelaxin microenemas exert a topical evacuative action and may offer a valuable option in pediatric FC. Aim: To assess whether Promelaxin microenemas would be non-inferior to PEG 4000 in young children with FC. Methods: This is a randomized, open-label, multi-centric, non-inferiority trial enrolling infants and young children aged 6-48 months, with FC according to Rome III criteria. After 1 week of run in, children were randomized to 2 weeks of Promelaxin or PEG, followed by a 6-week on-demand treatment period. Primary endpoint was response rate to randomized treatment, with "response" defined as at least 3 evacuations per week and an average increase of at least one evacuation per week as compared to baseline. Safety, stool consistency and the analysis of fecal microbiota were secondary endpoints. Results: Out of the 158 patients who entered the trial, 153 patients were treated (77 and 76, PEG and Promelaxin arm, respectively). In the primary analysis, the 95% confidence interval (CI) for the treatment's effect lay entirely above the non-inferiority margin in both Full Set (FAS) and Per Protocol (PP) analyses, providing evidence of the non-inferiority of Promelaxin vs. PEG 4000 [response rate difference: 16.5% (CI 1.55-31.49%) and 11.03% (CI -5.58 to 27.64%), FAS and PP analyses, respectively]. Mean compliance to the randomized treatment was >80% in both arms. Secondary endpoints did not significantly differ between the two arms, except for the average number of total days of on-demand treatment that was significantly lower in the Promelaxin arm [14.6 (12.7) vs. 9.8 (9.1), mean (SD); primary endpoint responders in PEG and Promelaxin arm, respectively; p = 0.027]. Microbiota evenness significantly increased in the PEG 4000 arm at V4 as compared to the Promelaxin arm (p < 0.05). In addition, at V5, patients treated with PEG showed a significantly decreased microbiota density as compared to patients treated with Promelaxin (p = 0.036). Conclusions: Promelaxin microenemas are non-inferior to oral PEG in children with FC. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02751411.

A protocol for an interventional study on the impact of transcutaneous parasacral nerve stimulation in children with functional constipation

INTRODUCTION

Transcutaneous parasacral nerve stimulation (TPNS) via electrodes placed over the sacrum can activate afferent neuronal networks noninvasively, leading to sacral reflexes that may improve colonic motility. Thus, TPNS can be considered a promising, noninvasive, and safe method for the treatment of constipation. However, there is no published study investigating its use in children with functional constipation. This is a single-center, prospective, longitudinal, and interventional study designed to assess the applicability and clinical outcomes of TPNS in functionally constipated children.

PATIENT CONCERNS

Parents or guardians of patients will be informed of the purpose of the study and will sign an informed consent form. The participants may leave the study at any time without any restrictions.

DIAGNOSIS

Twenty-eight children (7-18 years old) who were diagnosed with intestinal constipation (Rome IV criteria) will be included.

INTERVENTIONS

The patients will be submitted to daily sessions of TPNS for a period of 4 or 8 weeks and will be invited to participate in semistructured interviews at 3 or 4 moments: 1 week before the beginning of TPNS; immediately after the 4 and/or 8 weeks of TPNS; and 4 weeks after the end of the intervention period. In these appointments, the aspects related to bowel habits and quality of life will be assessed.

OUTCOMES

This study will evaluate the increase in the number of bowel movements and stool consistency, the decrease in the number of episodes of retentive fecal incontinence, and the indirect improvement in the overall quality of life.

CONCLUSION

we expect that this study protocol can show the efficacy of this promising method to assist the treatment of children with functional constipation.

Foot reflexology in the management of functional constipation: A systematic review and meta-analysis

BACKGROUND

Foot reflexology has been considered an important complementary therapy for many health-related symptoms, especially for some chronic conditions such as anxiety, stress, pain and fatigue. Some studies also showed that foot reflexology had a significant effect on functional constipation, whereas some studies did not. The effect of foot reflexology on functional constipation remains controversial. Therefore, an evidence-based systematic review and meta-analysis of randomised controlled trials were conducted to investigate the effect of foot reflexology on functional constipation.

METHODS

Randomised controlled trials were identified by searching five electronic databases and hand-searching eligible reference lists. Studies that reported the effect of foot reflexology on functional constipation were included. Two reviewers performed the study screening, quality assessment and data extraction. Any discrepancy was discussed with a third reviewer. Quantitative synthesis was conducted for the same outcome measurements by calculating weighted risk ratios.

RESULTS

A total of 203 records were identified, of which seven were eligible. Overall, foot reflexology significantly increased the curative ratio, with a pooled risk ratio of 1.27 (95% CI: 1.16, 1.40, p < 0.00001). Three trials compared the improvement of constipation-related symptoms after intervention in both the experimental and control groups by evaluating the constipation-related symptom scores. The results all showed that foot reflexology can effectively improve constipation-related symptoms. However, one trial reported that foot reflexology had no significant effect on stool frequency and stool consistency. Two studies indicated that foot reflexology significantly reduced the recurrence rate of functional constipation. One study reported the effect of foot reflexology on compliance with the toilet training, diet and motivation. Nevertheless, no significant improvement was detected.

CONCLUSION

Foot reflexology is an effective complementary therapy for treating functional constipation. However, because of the small number of included studies and their small sample sizes, the current evidence was insufficient to support the effectiveness of foot reflexology in reducing the recurrence rate, improving the constipation-related symptom, and compliance with toilet training, diet and motivation. Randomised controlled trials with long-term follow-up are needed for further investigation.

Constipation

Constipation in otherwise healthy infants and children is a common problem despite confusion about how to precisely define constipation and constipation-related disorders. Constipation may, rarely, be a sign or symptom of a more serious disease or a diagnosis defined only by its symptoms and without any structural or biochemical findings. In the latter case it is classified as a functional gastrointestinal disorder (FGID). FGIDs are defined as disorders that cannot be explained by structural or biochemical findings. The Rome Foundation has standardized diagnostic criteria for all FGIDs. The Rome criteria are based on the available research as well as the clinical experience of the Foundation's assembled experts. The most recent report, Rome IV, described clinical criteria and diagnostic tools and encouraged more rigorous research in the area of FGIDs. The true incidence and prevalence of constipation is difficult to know because it may be treated at home using home remedies or diagnosed at a visit to a primary care provider or to a subspecialist pediatric gastroenterologist. The most recent attempts to define the prevalence of all pediatric FGIDs have been made using the Rome IV criteria. The defined FGID entities that may be associated with the complaint of constipation are infant dyschezia, functional constipation, and nonretentive fecal incontinence. The term encopresis, omitted from Rome IV, is defined by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition The 3 Rome-defined (constipation-related) entities and the APA entity of encopresis are the focus of this review.

Quantification of Intestinal Lactobacillus Species in Children with Functional Constipation by Quantitative Real-Time PCR

Background

Functional constipation is a common and annoying gastrointestinal disorder among children worldwide in which the intestinal microbiota composition plays a fundamental role. This study aimed to compare the quantity of main intestinal Lactobacillus species in constipated children and healthy controls.

Materials and Methods

Fecal samples were collected from 40 children fulfilling Rome IV criteria for functional constipation and 40 healthy volunteers. Quantitative real-time polymerase chain reaction (qPCR) method with species-specific primers was used to investigate seven main Lactobacillus species in fecal samples.

Results

Lactobacillus strains of the patient group were different from the healthy controls, main differences being noticeable decrease in the population quantity of Lactobacillus reuteri (mean 10^2.61 CFU/gram feces) and lower abundance of Lactobacillus fermentum (p<0.0001).

Conclusion

Lactobacillus species might be quantitatively altered in childhood functional constipation. Our findings on the different species of Lactobacillus population showed significantly decreased quantity in the patient group compared with the healthy subjects.