The successful management of chronic constipation in infants and children

The physiology of continence: idiopathic fecal constipation and soiling

The anatomic and functional elements contributing to fecal continence and defecation are explored. The high incidence and importance of chronic idiopathic constipation as an entity in itself and a contributing factor to fecal incontinence are emphasized, and its management is discussed. The importance of a proper clinical history and examination is highlighted, and investigative modalities including radiology, transit studies, and anorectal manometry are described and placed in the context of practical clinical management.

Pediatric constipation

The purpose of this article is to present an overview of pediatric constipation. Discussion of the definition from a medical and nursing point of view is included. Intestinal pathophysiology as well as etiological theories of pediatric constipation are reviewed. Current research to date and clinical treatment and experience in the area are presented. A rationale for further nursing research in this area is described.

Long-term follow-up of medically treated childhood constipation

We describe the long-term (mean 6.8 years) follow-up of 43 children treated medically for chronic constipation and encopresis. Overall outcome was quite good. Thirty children (70%) were entirely asymptomatic at follow-up. Intermittent mild constipation persisted in 13 patients; only two required persistent but infrequent laxative therapy. Encopresis persisted in three of 17 children who initially reported this symptom, and was associated with significant behavioral problems.

Constipation in early childhood: patient characteristics, treatment, and longterm follow up

Little is known about chronic constipation in infants, toddlers, and preschool children and longterm outcome after treatment. The symptoms of 174 children < or = 4 years of age, who were evaluated for chronic constipation, are reported in this study together with the long-term outcome in 90 of them. Initial symptoms were infrequent bowel movements in 58%, painful bowel movements in 77% often with screaming, and severe stool withholding manoeuvres in 97%. The treatment of chronic idiopathic constipation consisted of education, faecal disimpaction, prevention of future impaction, and promotion of regular bowel habits with dietary fibre and milk of magnesia, and finally toilet training of the preschool child. Longterm outcome could be evaluated in 90 patients (52%) (mean (SD) 6.9 (2.7)) years after initial evaluation. Fifty seven children (63%) had recovered, defined as no soiling with > or = 3 bowel movements per week, while not receiving treatment. The recovery rate of children < or = 2 years of age was significantly higher than in children > 2 to 4 years of age. Thirty three children (37%) had not recovered. Constipation recurred as soon as laxatives were discontinued in 31 (94%) of them. Laxatives were still used by 33% of the children who had not recovered, 39% had < 3 bowel movements per week, 48% had faecal soiling, 45% had stool withholding, 27% complained of abdominal pain, 73% passed large stools, and 45% still on occasions clogged the toilet with their large stools. Symptoms of chronic constipation persisted in one third of our patients, 3-12 years after initial evaluation and treatment. Children who had not recovered deserve continued follow up, to reinforce and adjust treatment and to prevent faecal soiling.

Use of play with clay to treat children with intractable encopresis

We used play with modeling clay to treat six children, aged 4 to 12 years, with a history of intractable constipation with encopresis for a mean of 5.4 (2 to 8) years, refractory to treatment; biofeedback therapy had not been tried. Clay was chosen because, as a brown, messy material, it was a metaphor for feces and could let the child express either his disgust or aggressivity, or let him build symbolic structures. No interpretation was made during treatment. Four children had no symptoms during 2 months of therapy and no relapse during 1 year of follow-up, one child improved significantly, and one child failed to respond but withdrew from treatment after only three sessions. Modeling clay may be a cheap and effective treatment modality for refractory constipation with encopresis.

No-enema therapy for idiopathic constipation and encopresis

Idiopathic constipation and encopresis of childhood are thought to occur when children volitionally withhold stool. Withholding may be prompted by social pressures or by episodes of painful defecation. Repetitive withholding may result in colonic dilatation and colorectal dysfunction. Therapy involves removal of impacted stool, stool softening, and behavioral therapy. The use of enemas in this therapy is widespread but may be counterproductive. A retrospective review of patients treated without enemas revealed 45 patients whose course could be followed for six months. Ninety-eight percent of these had successful initial cleanouts without enemas; 94% had continued success at six months. These results, comparable with other treatment programs, demonstrate that therapy without enemas is a reasonable alternative in the treatment of childhood constipation and encopresis.

Whole-gut lavage in children using an iso-osmolar solution containing polyethelene glycol (Golytely)

Whole-gut irrigation with an iso-osmolar solution was assessed in 53 children. The lavage was well tolerated without evidence of fluid or electrolyte shift. The rate of infusion to achieve a clear bowel within six to ten hours was 25 to 35 mL/kg/h.

Long-term management of chronic constipation in children

A retrospective clinical study was conducted to determine the success of a strict regimen employing the prolonged use of daily enemas in 203 children with chronic constipation. This study confirmed that the use of long-term daily enemas did eliminate constipation as well as the primary complaint of fecal soiling. The majority of children treated had an excellent to good result (85.8%) over an extended period of time. Patients with a past medical history of imperforate anus or Hirschsprung's disease required longer treatment periods (32.6 and 20.1 months, respectively) than children with other medical problems (rectal prolapse, rectal stricture, malrotation, spina bifida, mental retardation, psychological; 13 months) or patients with functional constipation (5.9 months).

Short-term v long-term quality of life in children following repair of high imperforate anus

In children with high imperforate anus, their quality of life (QOL) is directly related to their success or failure in attaining fecal continence (FC). At the Children's Hospital of Philadelphia, 120 patients were treated for high imperforate anus. Sixty-one patients were available for long-term follow-up ranging from 2.5 to 24 years. The patients were analyzed in three separate time periods. The purpose of the study was to (1) establish a reproducible quantitative and qualitative scoring system for evaluating QOL; (2) identify clinical techniques for maximizing fecal continence; and (3) develop an algorithm for long-term management of children with persistent fecal incontinence. QOL scores and FC scores were similar for males and females. Patient age, however, proved to be a particularly important factor in QOL. As the length of follow-up increased, there was a significant difference in the percentage of those patients with a QOL score higher than FC score; 57% for the youngest patients v 15% and 7% for the older patients (P less than .01). Ninety-two percent of patients who were 10 years old or less had very supportive families. These families used a number of stratagems to minimize incontinent problems: liners in underpants, enemas, meticulous perineal hygiene, and avoidance of certain foods. After 10 years of age, a child's FC score became a major determinant of his QOL. Older children with fecal incontinence could no longer be shielded by parents and were not well tolerated by teachers and peers. From this study, an algorithm is proposed for children with impaired FC.(ABSTRACT TRUNCATED AT 250 WORDS)

A ten-year experience with ninety-two cases of Hirschsprung's disease. Including sixty-seven consecutive endorectal pull-through procedures

From July 1974 through November 1984, 92 patients with Hirschsprung's disease (congenital aganglionosis) have been treated at the University of Michigan-Mott Children's Hospital. This series includes 67 consecutive modified endorectal pull-through (ERPT) procedures in children. Fifty-one of these 67 patients had standard rectosigmoid disease and underwent a successful ERPT with only two major complications. One of these 51 children underwent a successful ERPT but died in the late postoperative period from severe congenital heart disease. Eighteen of the 92 patients suffered from total aganglionosis or long-segment disease. Sixteen of these have undergone an ERPT with no mortality or operative morbidity. The follow-up ranges from 6 months to 10 years. All of the children who have reached 3 years of age are continent. Of the remaining 23 patients, 12 were referred following an unsuccessful pull-through at another hospital. The 12 operations included five Swenson pull-throughs, five Duhamel procedures, one ERPT, and one subtotal colectomy. It was possible to redo or revise the pull-through procedures successfully in all but one patient, who required a permanent colostomy. Finally, 11 children were referred for management of a variety of complications following pull-through procedures performed at other institutions. None of these 11 patients required a reperformance of their pull-through, and all were successfully treated with lesser surgical procedures or with medical management. The excellent functional results and the low morbidity and zero operative mortality are attributed to the technical ease of performing the modified ERPT.