Childhood constipation; an overview of genetic studies and associated syndromes

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.

Psychiatric Features of Children with Chronic Functional Constipation: Focusing on Individuals with Autism Spectrum Disorder

PURPOSE

The present study aimed to assess the psychiatric characteristics of children with chronic functional constipation using the Aberrant Behavior Checklist-Japanese version and the Pervasive Developmental Disorders/Autism Society Japan Rating Scale, and to examine the frequency of autism spectrum disorder in children with chronic functional constipation. We also investigated differences in treatment duration between children with and without autism spectrum disorder.

METHODS

Treatment outcomes were examined retrospectively for 55 participants (chronic functional constipation group: n = 30, mean age 3.4 years; control group: n = 25, mean age, 4.5 years). The association between chronic functional constipation and autism spectrum disorder was evaluated using multivariable logistic regression analysis.

RESULTS

The mean Aberrant Behavior Checklist score and frequency of individuals with autism spectrum disorder were significantly higher in the chronic functional constipation group. After adjusting for age and sex, chronic functional constipation was significantly associated with autism spectrum disorder. In the chronic functional constipation group, the frequency of onset was significantly higher in children with autism spectrum disorder under 1 year of age. When treated, the mean duration of constipation was significantly longer in children with autism spectrum disorder.

CONCLUSION

Pediatricians, pediatric surgeons, and child psychiatrists should work closely to ensure appropriate treatment of chronic functional constipation in children with autism spectrum disorder.

Multicentre Study Into the Use of Polyethylene Glycol With Electrolytes Over at Least 6 Months to Treat Constipation in Paediatric Populations

Background

Constipation is a common clinical problem in children, for which the first-line therapeutic options are osmotic laxatives, mainly polyethylene glycol (PEG). These treatments are often prescribed for short or limited periods, with progressive treatment withdrawal often resulting in relapses. However, there are a few studies into the long-term use (≥6 months) of PEG 3350 with electrolytes (PEG+E) in terms of the patients' clinical evolution.

Objectives

To assess bowel movement and other relevant symptoms in children with constipation receiving PEG+E (≥6 months), as well as parent/caregiver satisfaction with this treatment.

Methods

A retrospective, observational, descriptive, longitudinal, and multicentre study was carried out on 74 children diagnosed with functional constipation (ROME IV criteria) who had received PEG+E (≥6 months). Bowel control was assessed using the Bristol stool scale, and the parent's/caregiver's perception of the treatment was also evaluated employing a nonvalidated questionnaire.

Results

Children with an average duration of constipation >1 year experienced a significant improvement in bowel movements and stool consistency when using PEG+E. The mean duration of use was 18.6 (±13.4) months, without the need to adjust the dose for weight. All clinical symptoms improved significantly except bloating, and all the parents/caregivers confirmed these clinical improvements.

Conclusions

Children treated with PEG+E (≥6 months) normalised their bowel movements, improving the clinical symptoms related to constipation in the absence of serious advert events or the need for dosage adjustments due to weight gain. Parents/caregivers reported good satisfaction with PEG+E treatment.

Diagnosing Hirschsprung Disease in Children Younger than 6 Months of Age: Insights in Incidence of Complications of Rectal Suction Biopsy and Other Final Diagnoses

BACKGROUND

 The gold standard for diagnosing Hirschsprung disease (HD) in patients younger than 6 months is pathological examination of rectal suction biopsy (RSB). The aim of this study was to gain insight into the following: (1) complications following RSB, (2) final diagnosis of patients referred for RSB, and (3) factors associated with HD.

METHODS

 Patients suspected of HD referred for RSB at our center were analyzed retrospectively. Severity of complications of RSB was assessed using Clavien-Dindo (CD) grading. Factors associated with HD were tested using multivariate logistic regression analysis.

RESULTS

 From 2000 to 2021, 371 patients underwent RSB because of infrequent defecation, at a median age of 44 days. Three patients developed ongoing rectal bleeding (0.8%) graded CD1. Most frequent final diagnoses were: HD (n = 151, 40.7%), functional constipation (n = 113, 31%), idiopathic meconium ileus (n = 11, 3%), and food intolerance (n = 11, 3%). Associated factors for HD were male sex (odds ratio [OR], 3.19; confidence interval [CI], 1.56-6.53), presence of syndrome (OR, 7.18; CI, 1.63-31.69), younger age at time of RSB (OR, 0.98; CI, 0.85-0.98), meconium passage for more than 48 hours (OR, 3.15; CI, 1.51-6.56), distended abdomen (OR, 2.09; CI, 1.07-4.07), bilious vomiting (OR, 6.39; CI, 3.28-12.47), and failure to thrive (OR, 8.46; CI, 2.11-34.02) (model R 2 = 0.566).

CONCLUSION

 RSB is a safe procedure with few and only minor complications. In the majority of patients referred for RSB under the age of 6 months, HD was found followed by a functional cause for the defecation problems. RSB should be obtained on a low threshold in all patients under the age of 6 months with the suspicion of HD.

Cows' Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review

Constipation is a very common disorder, mostly functional in nature, that may persist for years in up to 35-52% of children. Food allergy prevalence, severity and persistence are increasing over time, and cows' milk protein is the commonest food allergen recognised to affect gastrointestinal motility in children. There is mounting evidence of the role of cows' milk (CM) allergy (CMA) in children with constipation. With this narrative review, we aim to provide clinicians with an updated and critical overview of food allergy-associated constipation. We searched Embase, Medline and the Cochrane Library, using keywords related to the topic. Only reviews and studies including children aged 0-17 years that were published in English were considered. Constipation has been reported in 4.6% of infants with CMA; the prevalence of food allergy underlying chronic constipation in children resistant to conventional treatment and presenting to tertiary clinics ranges between 28% and 78%. The identification of predisposing risk factors and of a specific phenotype of food allergy-induced constipation remains elusive. No allergic tests, radiological or motility investigations achieve sufficient sensitivity and specificity to screen children for CMA-related constipation. A 4-week cows' milk protein (CMP) elimination diet may be considered for children with chronic constipation resistant to conventional treatment and who lack alarm sign/symptoms of organic diseases. In subjects with ameliorated symptoms on CMP elimination, the diagnosis of CMA should be confirmed by a food challenge to avoid an unnecessary protracted diet.

The magnitude and management of functional constipation at pediatric gastroenterology clinics: A survey study of various countries

BACKGROUND AND AIM

There have been no large-scale epidemiological study of functional constipation of pediatric gastroenterology services. This survey was undertaken to investigate the prevalence of functional constipation and magnitude of related problems in hospital settings of various countries as well as the practice of pediatric gastroenterologists in management of these conditions.

METHODS

The survey was conducted by sending questionnaires to members of Societies for Pediatric Gastroenterology Hepatology and Nutrition of various continents.

RESULTS

A total of 274 pediatric gastroenterologists from 41 countries participated in this study. Functional constipation accounted for overall 30% of patients attending pediatric gastroenterology outpatient clinics. In comparison with non-western countries, respondents from western countries reported significantly higher median annual numbers of new patients with intractable functional constipation (10 [4,25] vs 5 [2,10], P < 0.001), dyssynergic defecation (3 [0,15] vs 1 [0,4], P < 0.001), and colonic inertia (2 [0,5] vs 0 [0,1], P < 0.001). The use of high dose polyethylene glycol for fecal disimpaction was significantly more commonly among respondents from western countries, whereas rectal enema was significantly more favored in non-western countries. Respondents from different continents reported significant discrepancies in choices of investigations and management of patients with dyssynergic defecation and colonic inertia.

CONCLUSIONS

Functional constipation is a major problem for pediatric gastroenterology outpatient services worldwide. There were significant variations in the investigations of choice and therapeutic management of functional constipation, intractable functional constipation, and related problems among pediatric gastroenterologists of different geographic regions.

Observation on the Efficacy of Shouhui Tongbian Capsule in the Treatment of Functional Constipation and Study on Its Regulatory Effect on Intestinal Flora

Functional constipation is relatively common in both adults and children, exhibiting similar symptoms. However, there are significant differences in the epidemiology, symptomatology, pathophysiology, diagnostic tests, and treatment management of functional constipation by age. The treatment of functional constipation is generally based on lifestyle interventions, pelvic floor interventions, and pharmacotherapy. Pharmacological treatment is popular as the most direct and effective modality, especially the herbal preparations (e.g., Shouhui Tongbian capsule), which are popular for their lower toxic side effects and less physiological reactions. In our clinical study, patients with functional constipation who took Shouhui Tongbian capsules for a longer period of time showed significantly better improvement than those who took them for a shorter period of time (P < 0.001). Relative to the duration of the disease, the improvement effect was higher in patients with short duration of the disease than in patients with long duration of the disease (P < 0.001). What's more, Shouhui Tongbian capsule had a regulating effect on intestinal flora, and the regulating effect was stronger in patients with a shorter disease duration.

Emotional and behavioural problems in children and adolescents: The role of constipation

AIM

The functional constipation (FC) is a source of an expressive suffering in children, negatively affecting their emotional, social, and physical well-being. The objective of this study is to describe the clinical and behavioural characteristics of children/adolescents with FC.

METHODS

A cross-sectional, observational, analytical study was conducted in public places by interviewing parents of children/adolescents about their child's bowel habits and psychological profile. Bowel symptoms were investigated using the Rome IV criteria. The Strengths and Difficulties Questionnaire (SDQ) was used to evaluate the emotional and behavioural problems.

RESULTS

Of 799 children/adolescents included, 424 (53.1%) were female. Mean age was 9.1 ± 2.7 years. FC prevalence was 20.4%. The most common symptoms in Rome IV criteria were 'painful or hard bowel movements' (n = 110; 67.5%; 95% confidence interval: 60.0-74.3) and 'retentive posturing or excessive volitional stool retention' (n = 89; 54.6%; 95% confidence interval: 46.9-62.1). Median scores for internalising symptoms (7; interquartile range (IQR): 4-9 vs. 5; IQR: 2-7; P < 0.001) and externalising symptoms (7; IQR 4-11 vs. 6; IQR 3-9; P < 0.001) were higher in constipated children compared to non-constipated participants, respectively. The SDQ domains that were associated with FC were emotional symptoms (median 4, P < 0.001) and conduct problems (median 3, P < 0.001). No association was found between faecal incontinence and median scores for the internalising/externalising symptoms. All Rome IV criteria were associated with abnormal overall SDQ scores.

CONCLUSION

Children and adolescents with FC had more emotional and behavioural problems irrespective of whether faecal incontinence was present or not, with higher scores for internalising and externalising symptoms compared to non-constipated children.

Urofacial (ochoa) syndrome: A literature review

The Urofacial or Ochoa Syndrome (UFS or UFOS) is characterized by an inverted facial expression (those affected seem crying while smiling) associated with lower urinary tract dysfunction without evident obstructive or neurological cause. It is associated with autosomal recessive inheritance mutations in the HPSE2 gene, located at 10q23-q24, and the LRGI2 gene, located in 1p13.2; however, in up to 16% of patients, no associated mutations have been found. Recent evidence suggests that these genes are critical to an adequate neurological development to the lower urinary tract and that the origin of the disease seems to be due to peripheral neuropathy. There is clinical variability among patients with UFS and not all present the classic two components, and it has even been genetically confirmed in patients with a prior diagnosis of Hinman Syndrome or other bladder dysfunctions. Also, the presence of nocturnal lagophthalmos in these patients was recently described. Early recognition and timely diagnosis are critical to preventing complications such as urinary tract infections or chronic kidney disease. Next, the history of Urofacial Syndrome, the advances in its pathophysiology, and its clinical characteristics is reviewed.

BLADDER AND BOWEL DYSFUNCTION IN MOTHERS AND CHILDREN: A POPULATION-BASED CROSS-SECTIONAL STUDY

BACKGROUND

Recently it was shown an association between lower urinary tract symptoms in mothers and their children. However, the role of functional constipation in this binomial is unclear.

OBJECTIVE

To evaluate bladder and bowel dysfunction between mothers and children.

METHODS

A population-based cross-sectional study. Mothers and their children responded a self-administrated questionnaire composed by Rome IV criteria, International Consultation on Incontinence Questionnaire - Overactive Bladder, Dysfunctional Voiding Scoring System and demographic questions.

RESULTS

A total of 441 mother-child pairs was obtained. Children's mean age was 9.1±2.7 years, with 249 (56.5%) female. Mothers' mean age was 35.7±6.1 years. Isolated constipation was present at 35 (7.9%) children and 74 (16.8%) mothers. Isolated lower urinary tract symptoms were present in 139 (31.5%) children and 92 (20.9%) mothers and bladder bowel dysfunction occurred in 51 (11.6%) children and 78 (17.7%) mothers. There wasn't any association between isolated lower urinary tract symptoms in children and isolated lower urinary tract symptoms in mothers (P=0.31). In univariate analysis there were an association between bladder bowel dysfunction in children and bladder bowel dysfunction in mothers (OR=4.8 IC 95% 2.6-9.6, P<0.001) and isolated constipation in children and isolated constipation in mothers (OR=3.0 IC 95% 1.4-6.4, P=0.003). In multivariate analysis mothers with bladder bowel dysfunction was the only independent factor associated with bladder bowel dysfunction in children (OR=5.4 IC 95% 2.5-11.6, P<0.001).

CONCLUSION

Mothers with bladder bowel dysfunction are more likely to have a child with bladder bowel dysfunction. Association between these two dysfunctions plays an important role in this familiar presentation.

The Relationship between Functional Constipation and Dietary Habits in School-Age Japanese Children

Functional constipation negatively affects school-related quality of life for children and adolescents. We investigated the association between functional constipation, defined according to the Rome criteria version III, and dietary habits. The subjects of this cross-sectional study were 1,140 5th graders and 1,054 8th graders attending schools in Shunan City, Japan in 2012. Functional constipation was defined as having two or more symptoms of constipation. Dietary habits were assessed using a brief questionnaire. Self-reported biological, demographic and lifestyle information was obtained. Using multiple logistic models, dose-dependent associations among subgroups stratified with quintiles of nutrient and food intake were examined. The prevalence of functional constipation ranged from 3.7% to 8.3% across the grades. The most prevalent symptom was pain or hard stools. There was a link between higher rates of functional constipation and lower levels of dietary fiber intake, vegetables, and fruits (p_trend=0.010-0.030). Associations with vegetables and fruits attenuated when controlling for dietary fiber intake (p_trend=0.074-0.150). When 5th and 8th graders were separately analyzed, intake of dietary fiber, water from foods, and vegetables had beneficial effects on functional constipation in 8th graders (p_trend=0.005-0.038), and fruit intake had a beneficial effect in 5th graders (p_trend=0.012). Modification of dietary habits may have a positive effect in reducing functional constipation in school-age children. Diets rich in fiber, vegetables, and fruits, have the potential to improve functional constipation in Japanese children and adolescents.

Psychosocial risks for constipation and soiling in primary school children

To examine prospective associations between psychosocial problems and childhood constipation and soiling. We used latent classes of constipation and soiling ('constipation alone', 'soiling alone', 'constipation with soiling') extracted from longitudinal maternally reported data on constipation (4-10 years) and soiling (4-9 years) from 8435 children (4353 males, 4082 females) from the ALSPAC cohort. We examined the association between maternally reported psychosocial problems at 2-3 years (difficult temperament, behaviour/emotional problems, temper tantrums, behavioural sleep problems and stressful events) and the latent classes using multinomial logistic regression adjusted for a range of confounders relating to the child and family (reference category = normative latent class with very low probability of constipation/soiling). Difficult temperament and emotional/behaviour problems were associated with increased odds of constipation and soiling. Associations were generally strongest for 'constipation with soiling', e.g. difficult mood: 1.42 (1.23-1.64); behaviour problems: 1.48 (1.28-1.71); temper tantrums: 1.89 (1.34-2.65); lack of a regular sleep routine 2.09 (1.35-3.25). Stressful life events were associated with constipation alone [1.23 (1.12-1.36)] and constipation with soiling [1.32 (1.14-1.52)], but not soiling alone. Additional comparisons of the non-normative latent classes provided evidence for differential associations with the risk factors, e.g. frequent temper tantrums were associated with a greater than twofold increase in the odds of constipation with soiling versus constipation alone. Psychosocial problems in early childhood are risk factors for constipation and soiling at school age. An increased understanding of early risk factors for constipation and soiling could aid the identification of children who require treatment.

Gastrointestinal Symptoms in Children and Adolescents With Neurofibromatosis Type 1

OBJECTIVES

Neurofibromatosis type 1 (NF1) is a complex genetic disorder characterized by symptoms of the skin and nervous system. A previous study indicated that constipation is common in children with NF1. The aim of the present study was to investigate the phenotype and prevalence of gastrointestinal (GI) symptoms in a population of 4 to 17-year-olds with NF1 compared with their unaffected siblings.

METHODS

GI symptoms were assessed with a web-based, parent or self-administered, validated, Rome III diagnostic questionnaire. Participants were recruited from 1 of 2 Danish National Centers of Expertise for NF1. Logistic regression was used to estimate the prevalence of functional dyspepsia, irritable bowel syndrome (IBS), and constipation in each group and the groups were compared using odds ratio (OR).

RESULTS

We compared 102 NF1 patients (median age 10.3 years) and 46 of their unaffected siblings (median age 10 years). The overall likelihood of having GI symptoms usually attributed to either functional dyspepsia, IBS, or constipation was 30.4% in patients versus 10.9% in siblings, OR 3.58 (95% confidence interval 1.30 to 9.79). The prevalence of constipation was 22.5% in patients and 4.3% in siblings, OR 6.41 (95% confidence interval 1.45 to 28.24). The use of laxatives was 16% (n = 16) in patients and 2% (n = 1) in siblings.

CONCLUSIONS

Overall, GI symptoms attributed to functional dyspepsia, IBS or constipation are more common in 4 to 17-year-olds with NF1 when compared with their unaffected siblings. The high prevalence indicates that GI dysfunction in NF1 is not functional but may be part of the underlying NF1 disorder.

Functional constipation in children: challenges and solutions

This review intends to update what is known about and what is still a challenge in functional constipation (FC) in children regarding epidemiology, pathophysiology, diagnosis, and management. Although FC is a common childhood problem, its global burden remains unknown as data from parts of the world are missing. Another problem is that there is a large variation in prevalence due to differences in study methods and defining age groups. The pathophysiology of FC remains unclear to date but is probably multifactorial. Withholding behavior is likely to be the most important factor in toddlers and young children. Genetics may also play a role since many patients have positive family history, but mutations in genes associated with FC have not been found. Over the past years, different diagnostic criteria for FC in infants and children have been proposed. This year, Rome IV criteria have been released. Compared to Rome III, it eliminates two diagnostic criteria in children under the age of 4 who still wear diapers. Physical examination and taking a thorough medical history are recommended, but other investigations such as abdominal radiography, transabdominal recto-ultrasonography, colonic transit time, rectal biopsies, and colon manometry are not routinely recommended. Regarding treatment, guidelines recommend disimpaction and maintenance therapy with polyethylene glycol (PEG) with or without electrolytes. But experience shows that acceptability, adherence, and tolerance to PEG are still a challenge. Counseling of parents and children about causes of FC is often neglected. Recent studies suggest that behavior therapy added to laxative therapy improves the relief of symptoms. Further homogeneous studies, better-defined outcomes, and studies conducted in primary care are needed.

Parental characteristics and functional constipation in children: a cross-sectional cohort study

OBJECTIVE

To evaluate personality, psychological health, physical health and childrearing practices in mothers and fathers of children with functional constipation (FC) compared with mothers and fathers of healthy controls.

DESIGN

Cross-sectional cohort study.

SETTING

Outpatient paediatric gastroenterology clinic at a tertiary hospital in the Netherlands.

PATIENTS

Parents of children (4-16 years) presenting with FC were included between January 2010 and August 2012. Participating parents were asked to recruit parents of another child of the same age without FC as their own controls. Data of 116 mothers and 115 fathers of 127 children with FC, and 84 mothers and 73 fathers of 91 children without FC were collected.

MAIN OUTCOME MEASURES

Parental characteristics were evaluated by using the NEO Five-Factor Inventory to assess personality, the Brief Symptom Inventory and Physical Symptom Checklist to assess psychological and physical health and the Ghent Parental Behavior Scale to assess childrearing practices.

RESULTS

Mothers of constipated children had significant higher scores on the neuroticism personality factor and reported higher rates of overall psychological distress and depression. Both mothers and fathers of children with FC reported significant more physical symptoms than parents of children without FC. Mothers of children with FC showed more positive childrearing practices compared with controls.

CONCLUSIONS

Personality, psychological and physical health, and childrearing practices differ significantly between parents of children with FC and parents of control subjects. Parental factors should be taken into account when evaluating children with FC.

Chronic constipation and chronic disease management

Urbanization, population aging and lifestyle changes have resulted in great changes in global disease pattern and medical model. Chronic non-communicable diseases have become the main cause of premature death around the world in the 21^st century, and their prevention and control have also changed from "treatment" to "management". As a result, chronic disease management (CDM) model arises. Chronic constipation (CC) has a hidden onset, complex etiology, prolonged course, and high prevalence, and it can induce a variety of diseases and affect the quality of life seriously. Mainstream therapy for CC is empirical treatment for facilitating feces excretion, but it may lead to more serious symptoms. Application of the CDM model to CC management may solve this problem. In the current review, we will discuss the progress in research of CC and the current status of CDM.

Childhood constipation as an emerging public health problem

Functional constipation (FC) is a significant health problem in children and contrary to common belief, has serious ramifications on the lives of children and their families. It is defined by the Rome criteria which encourage the use of multiple clinical features for diagnosis. FC in children has a high prevalence (0.7%-29%) worldwide, both in developed and developing countries. Biopsychosocial risk factors such as psychological stress, poor dietary habits, obesity and child maltreatment are commonly identified predisposing factors for FC. FC poses a significant healthcare burden on the already overstretched health budgets of many countries in terms of out-patient care, in-patient care, expenditure for investigations and prescriptions. Complications are common and range from minor psychological disturbances, to lower health-related quality of life. FC in children also has a significant impact on families. Many paediatric clinical trials have poor methodological quality, and drugs proved to be useful in adults, are not effective in relieving symptoms in children. A significant proportion of inadequately treated children have similar symptoms as adults. These factors show that constipation is an increasing public health problem across the world with a significant medical, social and economic impact. This article highlights the potential public health impact of FC and the possibility of overcoming this problem by concentrating on modifiable risk factors rather than expending resources on high cost investigations and therapeutic modalities.

Genetics of enteric neuropathies

Abnormal development or disturbed functioning of the enteric nervous system (ENS), the intrinsic innervation of the gastrointestinal tract, is associated with the development of neuropathic gastrointestinal motility disorders. Here, we review the underlying molecular basis of these disorders and hypothesize that many of them have a common defective biological mechanism. Genetic burden and environmental components affecting this common mechanism are ultimately responsible for disease severity and symptom heterogeneity. We believe that they act together as the fulcrum in a seesaw balanced with harmful and protective factors, and are responsible for a continuum of symptoms ranging from neuronal hyperplasia to absence of neurons.

Constipation and Outcomes of Cecostomy

Constipation, defined as delay or difficulty in defecation, present for 2 or more weeks, is a common problem encountered by both primary and specialty medical providers. There are no randomized controlled trials on the use of antegrade enemas in the pediatric population. Most published papers are based on the experience at a particular center. The aim of this article is to describe the pathophysiology of constipation, review the contribution of colonic manometry to the diagnosis of constipation, summarize the advancements in the management of constipation through the use of antegrade enemas, and study the outcomes of cecostomy at different centers. This study is a comprehensive literature review generated by computerized search of literature, supplemented by review of monographs and textbooks in pathology, gastroenterology, and surgery. Literature search was performed using the publications from 1997 to 2012. The search included publications of all types presenting or reviewing data on cecostomy. The antegrade continence enema is a therapeutic option for defecation disorders when maximal conventional therapy is not successful. Symptoms of defecation disorders in children with different underlying etiologies improve significantly after a cecostomy is created. In addition, there is a benefit on the patients' physical activity, healthcare utilization, and general well-being. Based on the review of published literature it seems that antegrade enemas are a successful therapeutic option in children with severe constipation and/or fecal incontinence. With the advent of cecostomy buttons, patient compliance and the overall cosmetic appearance have improved.

Stressful Life Events in Children With Functional Defecation Disorders

OBJECTIVES

The aim of the study was to determine the prevalence of stressful life events including (sexual) abuse in children with functional defecation disorders by performing a systematic review.

METHODS

We searched MEDLINE, EMBASE, and PsycINFO for cohort, case-control and cross-sectional studies investigating the prevalence of stressful life events, including (sexual) abuse in children with functional defecation disorders.

RESULTS

The search yielded 946 articles, of which 8 were included with data from 654 children with functional constipation and 1931 children with (constipation-associated) fecal incontinence (FI). Overall, children with functional defecation disorders had been significantly more exposed to stressful life events than healthy children, with prevalence rates ranging from 1.6% to 90.9%. Being bullied, being a relational victim, interruption of toilet training, punishment by parents during toilet training, and hospitalization were significantly related to FI, whereas separation from the best friend, failure in an examination, severe illness in a close family member, loss of job by a parent, frequent punishment, and living in a war-affected area were significantly related to constipation. Only 1 study measured the prevalence of child abuse, which reported a significantly higher prevalence of child (sexual) abuse in children with FI compared with controls.

CONCLUSIONS

The prevalence of stressful life events, including (sexual) abuse is significantly higher in children with functional defecation disorders compared with healthy children. To gain more insight into the true prevalence of child (sexual) abuse in children with functional defecation disorders, more studies are clearly needed.

Pediatric intestinal motility disorders

Pediatric intestinal motility disorders affect many children and thus not only impose a significant impact on pediatric health care in general but also on the quality of life of the affected patient. Furthermore, some of these conditions might also have implications for adulthood. Pediatric intestinal motility disorders frequently present as chronic constipation in toddler age children. Most of these conditions are functional, meaning that constipation does not have an organic etiology, but in 5% of the cases, an underlying, clearly organic disorder can be identified. Patients with organic causes for intestinal motility disorders usually present in early infancy or even right after birth. The most striking clinical feature of children with severe intestinal motility disorders is the delayed passage of meconium in the newborn period. This sign is highly indicative of the presence of Hirschsprung disease (HD), which is the most frequent congenital disorder of intestinal motility. HD is a rare but important congenital disease and the most significant entity of pediatric intestinal motility disorders. The etiology and pathogenesis of HD have been extensively studied over the last several decades. A defect in neural crest derived cell migration has been proven as an underlying cause of HD, leading to an aganglionic distal end of the gut. Numerous basic science and clinical research related studies have been conducted to better diagnose and treat HD. Resection of the aganglionic bowel remains the gold standard for treatment of HD. Most recent studies show, at least experimentally, the possibility of a stem cell based therapy for HD. This editorial also includes rare causes of pediatric intestinal motility disorders such as hypoganglionosis, dysganglionosis, chronic intestinal pseudo-obstruction and ganglioneuromatosis in multiple endocrine metaplasia. Underlying organic pathologies are rare in pediatric intestinal motility disorders but must be recognized as early as possible.

Functional constipation in children: the pediatric surgeon's perspective

The prevalence of functional constipation in children is almost 10%. The etiology is multifactorial and not fully understood. In the majority of cases, there is no organic explanation for the symptoms. However, it is very important to exclude organic causes, particularly in neonates and infants. There are warning symptoms, such as delayed passage of meconium, bilious vomiting and abdominal distention that should prompt further investigations. Fecal incontinence is a very common symptom secondary to fecal impaction. The first-line treatment for both disimpaction and maintenance is use of laxatives. Parental education is extremely important. There are very limited data on surgical approaches for functional constipation.

Autism spectrum disorders in children with functional defecation disorders

OBJECTIVE

To prospectively assess the prevalence of autism spectrum disorder (ASD) symptoms in children presenting with functional defecation disorders.

STUDY DESIGN

Children (age 4-12 years) with functional constipation or functional non-retentive fecal incontinence according to the Rome III criteria referred to a specialized outpatient clinic were included. Parents completed 2 validated ASD screening questionnaires about their child; the Social Responsiveness Scale (SRS) and the Social Communication Questionnaire-Lifetime (SCQ-L). A total SRS score of ≥ 51 is a strong indicator for the presence of ASD. On the SCQ-L, a score of ≥ 15 is suggestive for ASD.

RESULTS

In total, 242 patients (130 males, median age 7.9 years) were included. Of these, 91% were diagnosed with functional constipation and 9% with functional non-retentive fecal incontinence. Thirteen children (5.4%) had previously been diagnosed with ASD. Twenty-six children (11%) had both SRS and SCQ-L scores at or above cutoff points, strongly suggestive for the presence of ASD. Solely high SRS were present in 42 children (17%), whereas two children (1%) only had high SCQ-L scores. Altogether, 29% had ASD symptoms, indicated by SRS and/or SCQ-L scores at or above the cutoff values. These children were older than children without ASD symptoms and presented with a longer duration of symptoms.

CONCLUSIONS

A substantial number of children (29%) presenting with a functional defecation disorder at a tertiary hospital has concomitant ASD symptoms. Clinicians should be aware of ASD symptoms in children with functional defecation disorders.

Constipation in children with neurofibromatosis type 1

BACKGROUND AND OBJECTIVES

Neurofibromatosis type 1 (NF1) is a hereditary, heterogenic, and multiorganic disease. The NF1 phenotype shows great variability in expressivity and often includes symptoms from the central and peripheral nervous systems. Bowel symptoms have been reported, but gastrointestinal function in NF1 remains to be described in detail. In this first systematic study of bowel function in children with NF1, we aimed to investigate symptoms of constipation and test the hypotheses that children with NF1 have abnormally large rectum and prolonged colonic transit time (CTT).

METHODS

A total of 20 children with NF1 (age 8.2 ± 2.4 years) were evaluated with medical history; clinical examination; digital rectal examination; bowel and dietary diaries; Rome III criteria; measurement of rectal diameter by transabdominal ultrasound; and radiographic estimation of CTT. The control group for assessment of rectal diameter comprised 23 healthy children (mean age 9.1 ± 2.7 years).

RESULTS

A total of 6 children with NF1 (30%) were constipated according to Rome III criteria. Average rectal diameter was significantly larger than for healthy children (32.9 ± 7.2 mm vs 21.4 ± 5.9 mm, P < 0.0001). Median CTT in NF1 children was 53 hours (range 26-101). Compared with existing normative data, CTT was prolonged (>84 hours) in 3 (19%).

CONCLUSIONS

Symptoms of constipation were surprisingly common in children with NF1. Correspondingly, rectal diameters were abnormally large and a higher proportion than expected had prolonged CTT. The underlying pathophysiology remains obscure, but we hypothesise that abnormalities of the enteric nervous system or disturbed cellular growth could be present.

Management of functional constipation in children with lower urinary tract symptoms: report from the Standardization Committee of the International Children's Continence Society

PURPOSE

We present a consensus view of members of the International Children's Continence Society (ICCS) together with pediatric gastroenterologists, experts in the field of functional gastrointestinal disorders, on the management of functional constipation in children with lower urinary tract symptoms.

MATERIALS AND METHODS

Discussions were held by the board of the ICCS and a multidisciplinary core group of authors was appointed. The draft document review process was open to all ICCS members via the website. Feedback was considered by the core authors and, by agreement, amendments were made as necessary.

RESULTS

Guidelines on the assessment, and pharmacological and nonpharmacological management of functional constipation in children with lower urinary tract symptoms are outlined.

CONCLUSIONS

The final document is not a systematic literature review. It includes relevant research when available, as well as expert opinion on the current understanding of functional constipation in children with lower urinary tract symptoms. The document is intended to be clinically useful in primary, secondary and tertiary care settings.

Review article: faecal incontinence in children: epidemiology, pathophysiology, clinical evaluation and management

BACKGROUND

Faecal incontinence (FI) in children is a significant gastrointestinal problem, with great personal and social impacts. It is characterised by recurrent loss of faecal matter into the underwear. Both functional and organic causes contribute to its aetiology with the former predominating.

AIM

To review the epidemiology, pathophysiology, clinical evaluation and management of functional faecal incontinence in children.

METHODS

A PubMed search was conducted using search terms f(a)ecal incontinence, and encopresis. Articles on epidemiology, pathophysiology, clinical evaluation, investigation and management of functional FI in children were retrieved and assessed.

RESULTS

Community prevalence of this distressing problem ranges from 0.8% to 7.8% globally. Male: female ratio varies from 3:1 to 6:1. The diagnosis of FI is often based on established clinical criteria. The majority (82%) have constipation associated functional FI. Biopsychosocial factors play a crucial role in the pathogenesis. Limited physiological testing of anorectal function is recommended in the diagnostic procedures, particularly in children with atypical symptoms and possible organic disorders. Management of FI needs a multidisciplinary approach which includes establishment of an effective doctor-patient partnership, understanding the underlying mechanisms, pharmacotherapy and behavioural treatment. Approximately 15% of children with functional nonretentive faecal incontinence (FNRFI) had the same symptoms at the age of 18 years.

CONCLUSION

Significant therapeutic advances have been made for retentive faecal incontinence, but treatment options for functional nonretentive faecal incontinence are limited. Limited long-term outcome data show that the majority outgrow faecal incontinence. A substantial proportion of children progress to adulthood with faecal incontinence.

Constipation in childhood

Constipation in children is an often long-lasting pediatric functional gastrointestinal disorder with a worldwide prevalence varying between 0.7% and 29.6%, and estimated health-care costs of US$3.9 billion per year in the USA alone. The pathophysiology of childhood constipation is multifactorial and remains incompletely understood; however, withholding of stools, starting after an experience of a hard, painful, or frightening bowel movement is the most common cause found in children. A thorough medical history and physical examination, including a rectal examination in combination with a bowel diary, is sufficient in the majority of cases to diagnose constipation. The current standard treatment consists of education, toilet training, disimpaction, maintenance therapy and long-term follow-up. In the past decade, well-designed treatment trials in the pediatric population have emerged and long-term outcome studies have been completed. This Review summarizes the current knowledge of the clinical aspects of childhood constipation, including pathogenesis, diagnosis and treatment, with particular emphasis on the latest available data.