Medical presentation of constipation from childhood to early adulthood: a population-based cohort study

Providing a Constipation Action Plan to Families of Children With Constipation Decreases Health Care Utilization

OBJECTIVES

To evaluate whether providing a constipation action plan (CAP) to families of children with constipation at outpatient gastroenterology (GI) visits affects health care utilization of the GI department.

METHODS

We created a CAP to be included in the after visit summary of children seen in our GI Clinic. We compared the number of patient telephone calls, electronic messages, and urgent care (UC) visits, emergency department (ED) visits, and hospitalizations within 3 months after the visit of patients who received the CAP compared to those who did not using inverse probability treatment weighting (IPTW) analysis. For families who received the CAP at a follow-up visit, we compared these variables in the 3 months before and after the CAP was provided using paired t test and McNemar's test as appropriate.

RESULTS

We included 336 patients who received the CAP and 2812 who did not. After IPTW adjustment, there were fewer patient telephone calls for patients who received the CAP (P = 0.0006). The difference in patient electronic messages was not statistically significant (P = 0.09). For the 45 patients who received the CAP at a follow-up visit, there were on average 1.8 more patient telephone calls made prior to receiving the CAP than after (95% confidence interval (CI) = 0.8-2.8; P = 0.0007) and 2.3 more patient electronic messages received (95% CI = 0.1-4.5; P = 0.04). There were no differences in UC/emergency department visits or hospitalizations.

CONCLUSIONS

We found that providing a CAP to families of children with constipation decreases health care utilization. Further studies are needed to determine whether this impacts patient outcomes.

Comparisons between Manual Lymph Drainage, Abdominal Massage, and Electrical Stimulation on Functional Constipation Outcomes: A Randomized, Controlled Trial

BACKGROUND

Evidence supports abdominal massage (AM) or electrical stimulation (ES) as effective in treating functional constipation (FC). Manual lymph drainage (MLD) may also be beneficial, however, it was not previously investigated or compared to ES and AM.

METHODS

Sixteen college-aged males and 36 females were recruited. Participants were randomly assigned to MLD, AM or ES. Heart rate variability (HRV) measures for total power (TP), high frequency (HF), low frequency and LF/HF ratio assessed ANS outcomes. state-trait anxiety inventory (STAI) and stress response inventory (SRI) assessed psychological factors and bowel movement frequency (BMF) and duration (BMD) were recorded daily.

RESULTS

MLD significantly improved all ANS measures (p≤0.01); AM significantly improved LF, HF and LF/HF ratios (p = 0.04); and ES significantly improved LF (p = 0.1). STAI measures improved, but not significantly in all groups. SRI improved significantly from MLD (p < 0.01), AM (p = 0.04) and ES (p < 0.01), but changes were not significant between groups. BMD improved significantly in all groups (p≤ 0.02). BMF improved significantly only following MLD and AM (p < 0.1), but differences between groups were not significant (p = 0.39).

CONCLUSIONS

MLD significantly reduced FC symptoms and MLD had greater improvements than AM or ES.

Constipation-Related Health Care Utilization in Children Before and After Hospitalization for Constipation

We studied constipation-related health care among children before and after constipation admission. Index admissions for constipation in 2010-2011 were identified in the Truven Marketscan Database, which includes children receiving Medicaid in 10 states. We measured number of and spending for outpatient constipation visits 12 months before and after index hospitalizations. We also measured spending for constipation hospitalizations and rehospitalization rate. There were 780 index constipation admissions. The median number of outpatient constipation visits was 1 (interquartile range [IQR] = 0, 3) in the 12 months before and 2 (IQR [0, 4]) after admission ( P = .001). Median outpatient spending for constipation was $110 (IQR [0, 429]) before and $132 (IQR [0, 431]) after admission ( P = .2). Median spending for index constipation admissions was $5295 (IQR [2756, 8267]); 78 children (10%) were rehospitalized for constipation within 12 months. Constipation-related health care utilization increased after constipation admission. Median spending for one constipation admission was 50 times the median spending for 12 months of outpatient constipation visits.

Healthcare Utilization and Spending for Constipation in Children With Versus Without Complex Chronic Conditions

OBJECTIVES

The aim of the study was to examine the prevalence of diagnosis and treatment for constipation among children receiving Medicaid and to compare healthcare utilization and spending for constipation among children based on number of complex chronic conditions (CCCs).

METHODS

Retrospective cohort study of 4.9 million children ages 1 to 17 years enrolled in Medicaid from 2009 to 2011 in 10 states in the Truven Marketscan Database. Constipation was identified using International Classification of Disease, 9th revision codes for constipation (564.0x), intestinal impaction (560.3x), or encopresis (307.7). Outpatient and inpatient utilization and spending for constipation were assessed. CCC status was identified using validated methodology.

RESULTS

A total of 267,188 children (5.4%) were diagnosed with constipation. Total constipation spending was $79.5 million. Outpatient constipation spending was $66.8 million (84.1%) during 406,814 visits, mean spending $120/visit. Among children with constipation, 1363 (0.5%) received inpatient treatment, accounting for $12.2 million (15.4%) of constipation spending, mean spending $7815/hospitalization. Of children hospitalized for constipation, 552 (40.5%) did not have an outpatient visit for constipation before admission. Approximately 6.8% of children in the study had ≥1 CCC; these children accounted for 33.5% of total constipation spending, 70.3% of inpatient constipation spending, and 19.8% of emergency department constipation spending. Constipation prevalence was 11.0% for children with 1 CCC, 16.6% with 2 CCCs, and 27.1% with ≥3 CCCs.

CONCLUSIONS

Although the majority of pediatric constipation treatment occurs in the outpatient setting, inpatient care accounts for a sizable percentage of spending. Children with CCCs have a higher prevalence of constipation and account for a disproportionate amount of constipation healthcare utilization and spending.

Value of 24-hour Delayed Film of Barium Enema for Evaluation of Colon Transit Function in Young Children with Constipation

Background/Aims

A colon transit time test using radio-opaque markers (CTTRM) is considered the gold standard for evaluating colon transit function. A 24-hour delayed film of barium enema (BE) has been used as a supplementary method in structural evaluations. The aim of this study was to evaluate the utility of a 24-hour delayed BE film for assessing colon transit function in young children with constipation.

Methods

In total, 93 children with constipation who performed both single-contrast BE and CTTRM were enrolled in this study. Of these, the data from 70 children were analyzed (males 33, females 37; mean age [range], 5.63 ± 2.94 [2–14] years). The basic principle of the study is “velocity = distance/time”. Time values were identified in both studies, and the colon length and distance of barium movement were measured on the 24-hour delayed BE film. Thus, colon transit velocity values could be calculated using both methods. The correlation between colon transit velocity using a 24-hour delayed BE film versus CTTRM was analyzed statistically.

Results

Median value (interquartile range) of colon transit velocity using CTTRM was 1.57 (1.07–2.89) cm/hr, and that using BE of that was 1.58 (0.94–2.07) cm/hr. The Spearman correlation coefficient was 0.438 (P < 0.001) for the overall group. The correlation was strongest in children younger than 4 years (r = 0.537, P = 0.032).

Conclusions

Although the correlation between BE and CTTRM was not very strong, the 24-hour delayed BE film could provide broad information about colon transit function in young children, especially those under 4 years who usually cannot undergo CTTRM.

Use of Rome II versus Rome III criteria for diagnosis of functional constipation in young children

BACKGROUND

There has been no study to evaluate the use of the Rome III criteria for diagnosis of constipation in the unselected young pediatric population. The aim of this study was to evaluate and compare the use of the Rome II and Rome III criteria for diagnosis of constipation in a group of unselected young Thai children.

METHODS

This cross-sectional study was conducted in 3010 healthy children aged 4 months-5 years who attended a well-baby clinic. Data concerning bowel habits and behavioral components of defecation of the children were obtained by interviewing the parents. Presence of a large fecal mass in the rectum of children with possible constipation was evaluated by abdominal palpation.

RESULTS

Seventy-one children (2.4%) were found to have constipation, based on at least one of the two sets of criteria, at the time of interview. The prevalence of constipation as defined according to the Rome II and Rome III criteria for functional constipation (FC) was 1.9% and 1.6%, respectively. The majority of constipated children (47.9%) met the diagnostic criteria of both the Rome II and Rome III for FC, followed by the Rome II criteria for FC alone (32.4%) and the Rome III criteria for FC alone (18.3%). Twenty-one children (0.7%) whose parents reported defecation difficulties did not fulfill any diagnostic criteria for constipation.

CONCLUSIONS

The prevalence of FC in young Thai children is low. For unselected young children, the Rome II criteria for FC are still appropriate for diagnosis of FC.

Yield and cost of performing screening tests for constipation in children

BACKGROUND

Chronic constipation is one of the most common reasons for pediatric outpatient visits. Clinical guidelines recommend that the work-up for chronic refractory constipation include thyroid function tests, celiac serology, and measurement of calcium and lead levels. Data to justify routine screening of constipated children using these laboratory tests are lacking.

OBJECTIVES

To study the prevalence of celiac disease, hypothyroidism, hypercalcemia and lead poisoning in children with chronic constipation; and to estimate the health care costs of applying the guideline recommendations.

METHOD

Charts of constipated children from 2007 to 2011 were reviewed for the present retrospective cohort study. Results and costs of thyroid function tests, celiac panel, total immunoglobulin (Ig) A, and determination of lead and calcium levels were analyzed.

RESULTS

A total of 7472 children (mean age 7.9 years; 3908 female) were evaluated: 1731 patients were screened for celiac antibodies; 55 had elevated tissue transglutaminase IgA levels and 29 had biopsy-positive celiac disease. Only three celiac patients had constipation as the sole presenting symptom; 1703 patients were screened for total IgA levels; 55 had IgA deficiency and two had biopsy-positive celiac disease; 2332 had free T4 and⁄or thyroid-stimulating hormone levels; and 14 had hypothyroidism. Only two patients had constipation as the sole presenting symptom; 4651 patients had calcium levels measured, 10 of whom had high levels but normal repeat values. Three patients had normal lead levels. The mean cost per patient was USD$1,014. Total screening cost for all patients was USD$4.7 million.

CONCLUSION

Constipation alone did not increase the likelihood of celiac disease or hypothyroidism above the population prevalence. No benefit of screening for hypercalcemia was found. High health care costs were associated with the use of screening tests for organic constipation.

Balloon expulsion test as a screen for outlet obstruction in children with chronic constipation

OBJECTIVE

Chronic constipation (CC) is a common problem in pediatrics and is often the result of obstructed defecation. The aim of the present study was to study the feasibility and efficacy of the balloon expulsion test (BET) in the diagnosis and management of children with CC.

METHODS

Retrospective study comparing BET and high-resolution anorectal manometry (ARM). The BET was done together with ARM in 29 children, ages 8 to 19 years, with CC. For BET, a 60-mL balloon was used. Passage of balloon in 1 minute or less was considered normal.

RESULTS

Fifteen of the 29 children had a normal BET. Of these, 14 also had an ARM, all of which were normal (except for 2 cases with a hypertonic baseline anal sphincter). Thus 12 of 14 with BET and ARM were normal on both (correlation between the tests 86%). Of the 14 children that failed BET, 10 had distal abnormalities by ARM, contrast studies, EMG, or assessment by a pelvic physical therapist. All of the patients with a nonrelaxing sphincter or outlet obstruction were treated with laxatives, anal sphincter Botox, and/or pelvic physical therapy and biofeedback. In follow-up of at least 3 months, all of the patients with a failed BET were improved.

CONCLUSIONS

We found a high correlation between a normal ARM and BET. If the BET is abnormal and the ARM does not identify a cause for the distal obstruction, additional studies may be needed, including contrast enema, defecography, or electromyography. BET appears to be a safe, reliable, and useful test in the evaluation and management of CC in children.

Direct medical costs of constipation from childhood to early adulthood: a population-based birth cohort study

BACKGROUND

Although direct medical costs for constipation-related medical visits are thought to be high, to date there have been no studies examining whether longitudinal resource use is persistently elevated in children with constipation. Our aim was to estimate the incremental direct medical costs and types of health care use associated with constipation from childhood to early adulthood.

METHODS

A nested case-control study was conducted to evaluate the incremental costs associated with constipation. The original sample consisted of 5718 children in a population-based birth cohort who were born during 1976 to 1982 in Rochester, MN. The cases included individuals who presented to medical facilities with constipation. The controls were matched and randomly selected among all noncases in the sample. Direct medical costs for cases and controls were collected from the time subjects were between 5 and 18 years of age or until the subject emigrated from the community.

RESULTS

We identified 250 cases with a diagnosis of constipation in the birth cohort. Although the mean inpatient costs for cases were $9994 (95% Confidence interval [CI] 2538-37,201) compared with $2391 (95% CI 923-7452) for controls (P = 0.22) during the time period, the mean outpatient costs for cases were $13,927 (95% CI 11,325-16,525) compared with $3448 (95% CI 3771-4621) for controls (P < 0.001) during the same time period. The mean annual number of emergency department visits for cases was 0.66 (95% CI 0.62-0.70) compared with 0.34 (95% CI 0.32-0.35) for controls (P < 0.0001).

CONCLUSIONS

Individuals with constipation have higher medical care use. Outpatient costs and emergency department use were significantly greater for individuals with constipation from childhood to early adulthood.

Longitudinal direct medical costs associated with constipation in women

BACKGROUND

Although direct medical costs for constipation-related medical visits are thought to be high, to date, there have been no studies examining longitudinal resource utilisation in adults with constipation.

AIM

To estimate the incremental direct medical costs associated with constipation in women.

METHODS

This is a nested case-control study. The study population consisted of all mothers of 5718 children in the population-based birth cohort born during 1976-1982 in a community. The cases presented to the medical facilities with constipation. The controls were randomly selected and matched to cases in a 2:1 ratio. Direct medical costs for constipated women and controls were collected for the years 1987-2002.

RESULTS

We identified 168 women with a diagnosis of constipation. The total direct medical costs over the 15-year period for constipated subjects were more than double those of controls [$63 591 (95% CI: 49 786-81 396) vs. $24 529 (95% CI: 20 667-29 260)]. The overall out-patient costs for constipated women were $38 897 (95% CI: 31 381-48 253) compared to $15 110 (95% CI: 12 904-17 781) for controls. The median of annual out-patient visits for constipated women was 0.16 compared to 0.11 for controls.

CONCLUSION

Women with constipation have significantly higher medical care utilisation and expenditures compared with women without constipation.

Colonic transit studies: normal values for adults and children with comparison of radiological and scintigraphic methods

The sitz or plastic marker study for colonic transit has been around for many years. It is applicable where an X-ray machine exists, is widely used and is accepted as the gold standard for diagnosing constipation. Recently, radiopharmaceutical methods have been developed. The theme of this review is their possible roles in the assessment of paediatric bowel motility disorders in patients presenting to paediatric surgeons. This review presents data on total and segmental transit in normal adults and children and comparing the two techniques in adults. Reliability and reproducibility are presented. Normative data for colonic transit in adults and children are discussed and parameters for assessing abnormal transit are reviewed. Normal colonic transit takes 20-56 h. Plastic marker studies are more readily accessible, but the assessment may be misleading with current methods. Plastic markers show faster transit than scintigraphy. It is difficult to compare the two techniques because methods of reporting are different. Using scintigraphy, repeatability is good. Separation of normal from slow transit in the ascending colon is apparent at 24 and 48 h, but the determination of transit through the distal colon/rectum in adults may require studies of more than 7 days. In conclusion, plastic marker studies and scintigraphy show similar transit rates in young adults and children. However, scintigraphy has advantages of allowing transit through the stomach and small intestine to be measured and has proved useful in the diagnostic workup of children with intractable constipation.

Outcome of functional constipation in childhood: a 10-year follow-up study

OBJECTIVES

To assess the outcome of patients presenting with functional constipation in childhood during a 10-year period and to determine any risk factors for developing persistent constipation throughout adolescence and adulthood.

PATIENTS AND METHODS

72 children (mean age 4 years; 40 boys) referred for constipation were included in a longitudinal set of observations. Initial workup included segmental colonic transit time and anorectal manometry; 45 of the 72 patients could be reevaluated 10 to 12 years later.

RESULTS

21 of 45 patients (46%; 95% confidence interval 29% to 67%) remained constipated at follow-up. Encopresis and recurrent abdominal pain were present in 25% and 56% of patients, respectively. Patients with anorectal dyssynergia remained more frequently constipated at follow-up than the others: 61% versus 29% (P < .05).

CONCLUSION

Almost 50% of patients presenting with constipation during childhood remained constipated on long-term follow-up. Anorectal dyssynergia is associated with a worse prognosis.

A systematic review of treatments for constipation in children and young adults undergoing cancer treatment

Constipation is a common problem in children and young people with cancer. Treatment of this complication is subject to wide variation in practice. We undertook a systematic review of randomized controlled trials to build a rational approach to prophylaxis and treatment of this complication. Randomized controlled trials of any intervention (pharmacologic, physical, complementary, or alternative) to prevent or treat constipation were to be included if they included children and young people 16 years old and younger who were undergoing treatment for malignancy. Of the 1336 abstracts retrieved from the searches, only 3 papers were identified for further assessment, and no studies were suitable for inclusion. There are no good data on which to base the management of constipation in children and young people with cancer. This is not to say that we do not know if laxatives work-they are clearly effective. Our ignorance is of the comparative value of different agents. The practical problems with undertaking specific trials of supportive care measures are large, and integration of such questions into treatment trials is essential.