Constipation in childhood

Effect of adding telerehabilitation home program to pharmaceutical treatment on the symptoms and the quality of life in children with functional constipation: a randomized controlled trial

Painful defecation, the passage of hard stools, unpleasant or irregular bowel deviation/movements from regular rate, and/or the feeling of not enough elimination of stool are common symptoms of functional constipation. The goals in treating constipation are to produce soft, painless stools and to prevent the re-accumulation of feces. This study looked at how the telerehabilitation home program (TRP) affected the symptoms of FC and the children who were constipated in terms of their quality of life. A randomized controlled trial included 400 children aging 4-18 years with functional constipation distributed in two groups: control group consisted of 200 children receiving pharmaceutical treatment and the intervention group consisted of 200 children receiving the telerehabilitation home program in addition to pharmaceutical treatment. Both groups received the interventions for 6 months. The outcomes in terms of functional constipation symptoms and quality of life are measured and compared pre- and post-interventions. Adding the telerehabilitation home program to pharmaceutical treatment of functional constipation in children results in prominent improvement in the condition; there is a significant difference between the intervention and control group in all Rome criteria which assess symptoms of functional constipation except rush to the bath-room to poop which showed non-significant difference; there is also a significant difference between the intervention and control group in all domains of the SF-36 questionnaire which assess quality of life except the mental health domain which showed non-significant difference.

CONCLUSION

Adding the telerehabilitation home program to pharmaceutical treatment of functional constipation in children results in prominent improvement in symptoms of functional constipation and quality of life.

TRIAL REGISTRATION

Our study was registered retrospectively with Clinicaltrials.gov under the identifier NCT06207721 on 5 January 2024.

WHAT IS KNOWN

• Painful defecation, passage of hard stools, unpleasant or irregular bowel movements, feeling of incomplete stool elimination are common symptoms of functional constipation. • Goals in treating constipation include producing soft, painless stools and preventing re-accumulation of feces.

WHAT IS NEW

• Adding telerehabilitation home program to pharmaceutical treatment resulted in significant improvement in functional constipation symptoms and quality of life. • Significant differences between intervention group (200 children receiving telerehabilitation home program in addition to pharmaceutical treatment) and control group (200 children receiving pharmaceutical treatment) were observed in all Rome criteria except for rush to the bathroom to poop, and in all domains of SF36 questionnaire except for the mental health domain.

Frequency of Functional Constipation in Lebanese Children: A Cross-Sectional Study Based on Parental Reporting

Aim: To determine the frequency and possible associated dietary and environmental factors of functional constipation (FC) among children in Lebanon followed at a single pediatric health system. Method: A prospective cross-sectional study was conducted in all pediatrics clinics at the American University of Beirut Medical Center (AUBMC). Children aged 2-7 years presenting for a well-child visit were recruited. Data relating to the child's bowel habits and other history items were obtained from parental questionnaires. Results: The mean age of the 172 recruited participants was 4.94 years with 56.4% being males. FC was present in 32.6% of the participants. Although there was no difference in the frequency of FC based on age and gender, the peak frequency of FC was at 5 years. The daily frequency of withholding stools was 64.3%, and 46.6% of the children with FC always experienced straining while stooling for the past 2 months. Decreased physical activity and diet were not significantly associated with FC. Conclusion: The present study shows that 32.6% of children aged 2-7 years in Lebanon suffer from constipation while only 51.7% of the recruited children's physicians inquire about the child's bowel movement during the well check visit. These numbers highlight the need to raise more awareness among pediatricians on the need to screen for constipation during clinic visits as a standard of care practice.

Approach to Constipation in Children: Recommendations for Evaluation and Management

Constipation is common in childhood, and most patients can be successfully managed by their primary care provider. However, some patients will require more specialized management either due to an underlying congenital colorectal disorder such as Hirschsprung disease or anorectal malformation or due to severe functional constipation that is refractory to medical management.

Stool-toileting refusal in preschool age children: A follow-up study

BACKGROUND

Stool-toileting refusal in preschool-aged children is a significant issue that strongly impacts both the child and the family, signaling a challenging period. We investigated the relationships between temperament, traumatic life events, parental sociodemographic characteristics, and psychological burdens and these behaviors. Our goal was to identify factors that may contribute to the chronicity of this stool-toileting refusal behavior.

METHODS

Conducted as a single-center, prospective, controlled design, the research involved children exhibiting stool-toileting refusal for at least one month, alongside healthy individuals of similar age and sex. Evaluation covered sociodemographic characteristics, parental psychopathologies, children's temperament features, and life events. Follow-up questionnaires, administered one year later, assessed stool-toileting refusal behavior.

FINDINGS

An evaluation at the end of one year revealed that stool-toileting refusal behavior persisted in 11 of the 31 children. A family history of constipation, comorbid enuresis in the child, maternal psychiatric disorders, and rhythmic temperament features were significantly higher than in the healthy group. Children with persistent stool-toileting refusal behavior exhibited notably lower activity levels.

DISCUSSION

The study's results indicated associations between the TSC rhythmicity score, comorbid constipation and enuresis, and maternal psychiatric illness in preschool-aged children with stool-toileting refusal behavior. A notable association was identified between the continuation of stool-toileting refusal behavior and a low TSC activity score. Advanced statistical methods did not reveal significant differences, highlighting the need for larger sample studies.

IMPLICATIONS TO PRACTICE

Applying the study's findings to clinical practice involves considering factors such as a family history of constipation, comorbid enuresis in the child, maternal psychiatric disorders, and rhythmic temperament features as potential indicators of persistent stool-toileting refusal in preschool-aged children, guiding healthcare professionals in tailored assessments and interventions.

The psychosocial implication of childhood constipation on the children and family: A scoping review protocol

Background

Constipation is a common problem in childhood that can have psychological, emotional, social, and health-related quality-of-life (HRQOL) consequences on children and their families. Primary or functional constipation (FC) has no known underlying pathology but is associated with lifestyle, psychological, and behavioural factors. Misdiagnosis and inadequate management of constipation can result in chronicity that can continue to adulthood, reducing quality of life for the child and their parents/family. It also causes emotional, psychological and emotional distress and concern for children and their families. This scoping review aims to answer the research question, "What has been reported about the psychosocial implication of childhood constipation among children and their families?"

Methods

The methodology for this scoping review will draw on the six stages of Arksey and O'Malley Framework and the updated and refined version by Peters et al. (2022). The process and reporting will follow the PRISMA-ScR guidelines. The Population, Concept and Context (PCC) framework will guide the development of inclusion criteria and the search strategy for this scoping review. Systematic literature searches of PUBMED, CINAHL, ASSIA, PsycInfo and Cochrane Library will be conducted from inception to present. The critical appraisal will be performed on selected articles to promote trustworthiness and methodological rigour. Plans for consultation exercise and dissemination of findings will also be presented.

Conclusion

This scoping review aims to present a comprehensive synthesis of the characteristics and extent of available literature to develop an understanding of and identify gaps in current knowledge regarding the psychosocial implication of childhood constipation on children and their families.

Building public trust and confidence in secondary use of health data for healthcare improvement and research: a qualitative study pre-protocol

Background  Secondary use of health data provides opportunities to drive improvements in healthcare provision, personalised medicine, comparative effectiveness research, health services innovation, and policy and practice. However, secondary data use requires compliance with relevant legislation, implementation of technical safeguards, ethical data management, and respect for data sharers. Existing evidence suggests widespread support for secondary use of health data among the public, which co-exists with concerns about privacy, confidentiality and misuse of data. Balancing the protection of individuals' rights against the use of their health data for societal benefits is of vital importance, and trust underpins this process. The study protocol explores how to build public trust and confidence in the secondary use of health data through all key stakeholder groups in Ireland, towards developing a culture that promotes a safe and trustworthy use of data. Methods  This study will adopt a qualitative cross-sectional approach conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research COREQ guidelines. Participants in the study will include academics and researchers; healthcare professionals, data protection, ethics and privacy experts and data controllers; pharmaceutical industry and patients and public. Purposive and convenience sampling techniques will be utilised to recruit the participants, and data will be collected utilizing focus groups that may be supplemented with semi-structured interviews. Data will be coded by themes using reflexive thematic analysis (TA) and collective intelligence (CI) will be convened post-analysis to explore the preliminary findings with the participants. Ethics and Dissemination  Ethical approval was obtained from the Royal College of Surgeons in Ireland Research Ethics Committee (REC202208013). Final data analysis and dissemination is expected by Q1 2024. Findings will be disseminated through peer-reviewed journal publications, presentations at relevant conferences, and other academic, public and policy channels. Lay summaries will be designed for Public and Patient Involvement (PPI) contributors and general public.

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.

Effect of probiotics intake on constipation in children: an umbrella review

Based on existing systematic reviews and meta-analyse we conducted this comprehensive review to evaluate the quality, effectiveness, and bias of evidence regarding the relationship between probiotic intake and improved constipation outcomes in children. A total of nine meta-analyses and systematic reviews were extracted from 628 articles, summarizing seven effectiveness indicators and the incidence of adverse reactions in the treatment of constipation. According to the results, our study revealed that the intake of probiotics in children with FC significantly improved treatment success rate and defecation frequency, while decreased the recurrence rate of constipation. However, no significant association was detected between probiotics intake and frequency of abdominal pain, stool consistency, frequency of defecation pain, frequency of fecal incontinence of children with FC. The intake of probiotics did not increase the incidence of adverse reactions and demonstrated good safety.

Radiologically supervised bowel management program outcome in patients with chronic idiopathic constipation

PURPOSE

This study aimed to analyze our radiologically supervised bowel management program (RS-BMP) outcomes in patients with chronic idiopathic constipation (CIC).

METHODS

A retrospective study was conducted. We included all patients with CIC who participated in our RS-BMP at Children´s Hospital Colorado from July 2016 to October 2022.

RESULTS

Eighty patients were included. The average time with constipation was 5.6 years. Before our RS-BMP, 95% had received non-radiologically supervised treatments, and 71% had attempted two or more treatments. Overall, 90% had tried Polyethylene Glycol and 43% Senna. Nine patients had a history of Botox injections. Five underwent anterograde continence procedure, and one a sigmoidectomy. Behavioral disorders (BD) were found in 23%. At the end of the RS-BMP, 96% of patients had successful outcomes, 73% were on Senna, and 27% were on enemas. Megarectum was detected in 93% of patients with successful outcomes and 100% with unsuccessful outcomes (p = 0.210). Of the patients with BD, 89% had successful outcomes, and 11% had unsuccessful.

CONCLUSION

Our RS-BMP has been proven to be effective in treating CIC. The radiologically supervised use of Senna and enemas was the appropriate treatment in 96% of the patients. BD and megarectum were associated with unsuccessful outcomes.

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.

Evaluation of Chronic Constipation in Children With Autism Spectrum Disorder

OBJECTIVES

Chronic constipation occurs frequently in children with autism spectrum disorder (ASD). The primary objective was to determine whether chronic constipation is associated with a higher rate of abnormal colonic motor activity in ASD children than in non-ASD children. A secondary goal was to determine if clinical variables could identify children with ASD at risk for possessing abnormal colonic motility.

METHODS

A retrospective, propensity-matched, case-control study compared colonic manometry (CM) of an ASD cohort and non-ASD controls with chronic constipation. Clinical variables were evaluated as potential predictors for abnormal colonic motility.

RESULTS

Fifty-six patients with ASD and 123 controls without the diagnosis of ASD who underwent CM were included. Propensity score resulted in 35 matched cohorts of ASD and controls. The rate of abnormal CM findings between ASD and matched controls (24% vs 20%, P = 0.78) did not differ significantly. A prediction model of abnormal CM that included ASD diagnosis, duration of constipation, and soiling achieved a sensitivity of 0.94 and specificity of 0.65. The risk for abnormal colonic motility increased 11% for every 1-year increase in duration of constipation. Odds for abnormal motility were 30 times higher in ASD children with soiling than controls with soiling (P < 0.0001).

CONCLUSIONS

Chronic constipation does not appear to be associated with a higher rate of abnormal colonic motility in children with ASD. Clinical information of disease duration and presence of soiling due to constipation show promise in identifying patients with ASD at a greater risk for abnormal colonic motility.

Relationship between family-related factors and functional constipation among Chinese preschoolers: a case–control study

Background

Constipation is one of the common symptoms in childhood. The prevalence of FC is about 0.5% to 32% and still on the rise according to global statistics. The aim of this study is to explore the associations between family-related factors (e.g., parental conflict, parenting style, and parent–child relationship) and functional constipation of preschool children based on family system theory.

Methods

The study is a case–control survey of preschoolers in China. In total, 108 preschoolers with functional constipation diagnosed with pediatric Rome IV criteria and 324 healthy examination preschoolers without functional constipation were enrolled in the study. Parents completed the following 5 instruments: General information questionnaire, the Parental Conflict Scale, the Parenting Style Questionnaire, the Child-parent Relationship Scale and the Children’s Emotional Adjustment Scale-Preschool Version.

Results

Nine categories of factors which significantly predicted functional constipation in preschoolers were retained in the final logistic regression model: Second child in birth order (OR = 0.456; 95% CI, 0.229 to 0.910), children picky eating (OR = 2.936; 95% CI, 1.133 to 7.611), bad bowel habits (OR = 2.896; 95% CI, 1.391 to 6.028), parental history of constipation (OR = 3.259; 95% CI, 1.600 to 6.639), parents blaming the child for having a bad bowel movement (OR = 3.788; 95% CI, 1.391 to 10.318), more than 3 h of fathers-child interaction time per day (OR = 0.137; 95% CI, 0.024 to 0.778), parental conflict (OR = 1.981; 95% CI, 0.950 to 3.831), doting or authoritarian parenting style (OR = 1.644; 95% CI, 1.067 to 2.534, OR = 2.481; 95% CI, 1.362 to 4.519), and anxiety control or temper control in children (OR = 0.492; 95% CI, 0.303 to 0.799, OR = 0.189; 95% CI, 0.103 to 0.348).

Conclusions

This study identified the significant associations between family-related factors and functional constipation in preschool children, which provide implications for healthcare professionals to address functional constipation in early childhood using a preventive lens.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03521-w.

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.

Understanding the physiology of human defaecation and disorders of continence and evacuation

The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.

Long-Term Follow-Up Results of Fecal Microbiota Transplantation for Irritable Bowel Syndrome: A Single-Center, Retrospective Study

Objective: This study aimed to investigate the long-term efficacy of fecal microbiota transplantation (FMT) in patients with irritable bowel syndrome (IBS).

Study Methods: In this single-center long-term follow-up study, FMT treatment was administered to patients with moderate to severe IBS (IBS severity scoring system (IBS-SSS) > 175). After 1 year of treatment, it was decided whether to repeat FMT based on IBS-SSS score (IBS-SSS > 175). Baseline characteristics before and after FMT and questionnaires were completed at 1, 3, 6, 12, 24, 36, 48, and 60 months after FMT. The study outcomes included treatment efficacy rates, change of IBS-SSS, IBS-specific quality of life and fatigue, effect on stool frequency, Bristol Stool Scale for IBS-C and IBS-D, and side effects.

Results: A total of 227 patients (47.58% IBS-C, 39.21% IBS-D, and 13.22% IBS-M) were recruited (142 females and 85 males with a mean age of 41.89 ± 13.57 years). The efficacy rates were 108 (51.92%), 147 (74.62%), 125 (74.41 %), 88 (71.54%), 78 (75.00%), 65 (73.03%), 45 (61.64%), and 37 (62.71%) at different follow-up time points. The total IBS-SSS score was 321.37 ± 73.89 before FMT, which significantly decreased after 1 month. The IBS-specific quality of life (IBS-QoL) score was 40.24 ± 11.34 before FMT, increased gradually, and was significantly higher at 3 months compared to before FMT. The total Fatigue Assessment Scale (FAS) score was 47 ± 8.64 before FMT and was significantly lower at 3 months. During follow-up, 89 (39.21%) side effects occurred that were alleviated by symptomatic treatment, and no serious adverse events were detected.

Conclusion: Based on 60 months of long-term follow-up, the safety and efficacy of FMT for IBS was established. However, as the treatment effect declines over time, periodic and repetitive FMT is required for a sustained effect.

Neurogenic Bowel Dysfunction in Children and Adolescents

Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.

Diagnosing Constipation Spectrum Disorders in a Primary Care Setting

Understanding pathophysiological causes of constipation is worthwhile in directing therapy and improving symptoms. This review aims to identify and fill gaps in the understanding of the pathophysiology of constipation, understand its prevalence, review diagnostic tools available to primary care physicians (PCPs), and highlight patients’ expectations for the management of this common spectrum of disorders. Literature searches conducted via PubMed included terms related to constipation, diagnosis, and patient perceptions. Case studies were developed to highlight the differences between patients who may be appropriately managed in the primary care setting and those requiring specialty consultation. Myriad pathophysiological factors may contribute to constipation, including stool consistency, altered intestinal motility, gut microbiome, anorectal abnormalities, as well as behavioral and psychological factors. Common diagnoses of “primary constipation” include slow-transit constipation, defecation disorders, irritable bowel syndrome with constipation, and chronic idiopathic constipation. A detailed medical history should be conducted to exclude alarm features and PCPs should be familiar with pathophysiological factors that cause constipation, available diagnostic tools, alarm signs, and the various classification criteria for constipation subtypes in order to diagnose and treat patients accordingly. PCPs should understand when a referral to a gastroenterologist, anorectal specialist, pelvic floor physical therapist, and/or mental health specialist is appropriate.

Bladder and Bowel Dysfunction Network: Improving the Management of Pediatric Bladder and Bowel Dysfunction

Lower urinary tract symptoms with constipation characterize bladder and bowel dysfunction (BBD). Due to high referral volumes to hospital pediatric urology clinics and time-consuming appointments, wait times are prolonged. Initial management consists of behavioral modification strategies that could be accomplished by community pediatricians. We aimed to create a network of community pediatricians trained in BBD (BBDN) management and assess its impact on care.

METHODS

We distributed a survey to pediatricians, and those interested attended training consisting of lectures and clinical shadowing. Patients referred to a hospital pediatric urology clinic were triaged to the BBDN and completed the dysfunctional voiding symptom score and satisfaction surveys at baseline and follow-up. The Bristol stool chart was used to assess constipation. Results were compared between BBDN and hospital clinic patients.

RESULTS

Surveyed pediatricians (n = 100) most commonly managed BBD with PEG3350 and dietary changes and were less likely to recommend bladder retraining strategies. Baseline characteristics were similar in BBDN (n = 100) and hospital clinic patients (n = 23). Both groups had similar improvements in dysfunctional voiding symptom score from baseline to follow-up (10.1 ± 4.2 to 5.6 ± 3.3, P = 0.01, versus 10.1 ± 4.2 to 7.8 ± 4.5, P = 0.02). BBDN patients waited less time for their follow-up visit with 56 (28-70) days versus 94.5 (85-109) days for hospital clinic patients (P < 0.001). Both groups demonstrated high familial satisfaction.

CONCLUSIONS

Community pediatricians may require more knowledge of management strategies for BBD. Our pilot study demonstrates that implementing a BBDN is feasible, results in shorter wait times, and similar improvement in symptoms and patient satisfaction than a hospital pediatric urology clinic.

Development and Assessment of a Pictographic Pediatric Constipation Action Plan

OBJECTIVE

To assess the Uniformed Services Constipation Action Plan (USCAP) as an evidence-based, personalized, clinical action tool with pictograms to aid clinicians and families in the management of functional constipation.

STUDY DESIGN

The USCAP facilitates the management functional constipation by using a health literacy-informed approach to provide instructions for pharmacotherapies and lifestyle modifications. This study included part 1 (pictogram validation) and part 2 (assessment). For part 1, pictogram transparency, translucency, and recall were assessed by parent survey (transparency ≥85%, mean translucency score ≥5, recall ≥85% required for validation). For part 2, the USCAP was assessed by parents, clinical librarians, and clinicians. Parental perceptions (n = 65) were assessed using the Consumer Information Rating Form (17 questions) to gauge comprehensibility, design quality and usefulness. Readability was assessed by 5 formulas and a Readability Composite Score was calculated. Clinical librarians (n = 3) used the Patient Education Materials Assessment Tool to measure understandability (19 questions) and actionability (7 questions) (>80% rating was acceptable). Suitability was assessed by clinicians (n = 34) using Doak's Suitability Assessment of Materials (superior ≥70% rating).

RESULTS

All 12 pictograms demonstrated appropriate transparency, translucency, and recall. Parental perceptions reflected appropriate comprehensibility, design quality, and usefulness. The Readability Composite Score was consistent with a fifth-grade level. Clinical librarians reported acceptable understandability and actionability. Clinicians reported superior suitability.

CONCLUSIONS

The USCAP met all criteria for clinical implementation and future study of USCAP implementation for treating children with chronic functional constipation.

Experiences of parents who give pharmacological treatment to children with functional constipation at home

Aim

The aim was to explore the lived experiences of parents who give oral and rectal pharmacological treatment to their children with functional constipation at home.

Design

A phenomenological design with a reflective lifeworld research approach that describes phenomena as they are experienced by individuals.

Methods

From January–May 2019, 15 interviews were conducted with parents of children with functional constipation with home‐based oral and rectal treatment. Parents were recruited from three different healthcare levels. Open‐ended questions were used starting from the description of a normal day with constipation treatment. Analyses were made with an open and reflective ‘bridling’ attitude.

Findings

Constipation treatment causes parents to question their parental identity and what it means to be a good parent. Forced treatment makes them feel abusive and acting against their will as parents. There is a conflict between doubt and second thoughts about the treatment, the urge to treat based on the child's needs and encouragement from healthcare professionals to give treatment.

Conclusion

As pharmacological constipation treatment can be experienced as challenging, it is important to help parents make an informed decision about how such treatment should be carried out at home. The findings reveal a medical treatment situation where parents hesitate and children resist, resulting in insecure parents who question their parental identity.

Impact

The findings point to the importance of supporting parents in treatment situations. Healthcare providers need to treat children with constipation with greater focus and more prompt management to prevent these families from lingering longer than necessary in the healthcare system.

Surgical Interventions for Functional Constipation: An Update

Chronic idiopathic constipation, also known as functional constipation, is defined as difficult and infrequent defecation without an identifiable organic cause. Medical management with laxatives is effective for the majority of constipated children. However there is a subset of patients who may need evaluation by a surgeon. As constipation progresses, it can lead to fecal retention and rectal and sigmoid distension, which impairs normal colorectal motility. Surgical interventions are influenced by the results of: a rectal biopsy, transit studies, the presence of megacolon/megarectum on contrast enema, the degree of soiling/incontinence, anorectal manometry findings, and colonic motility evaluation. In this review, we describe the different surgical options available (intestinal diversion, antegrade enemas, sacral nerve stimulation, colonic resections, and Botulinum toxin injection) and provide guidance on how to choose the best procedure for a given patient.

Laxative Metabolites from the Leaves of Moringa oleifera

Three new flavonoids, quercetin-3-O-6-[methyl-(S)-3-hydroxy-3-methylglutaroyl(1→6]-β-d-glucopyranoside (1), kaempferol-3-O-[methyl-(S)-3-hydroxy-3-methylglutaroyl(1→6)]-β-d-glucopyranoside (2), and quercetin-3-O-6-[(E)-4-methoxy-5-methylhexa-2,4-dienoatyl(1→6)]-β-d-glucopyranoside (3), and two new alkaloids, 5-dehydroxymethyl-pyrrolemarumine 4″-O-α-l-rhamnopyranoside (4) and N¹-methyl-N²-((4-O-α-l-rhamnopyranoside)benzyl) oxalamide (5), together with 45 known compounds (6-50) were isolated from the leaves of Moringa oleifera Lam. Among those compounds, 1-octacosanol (50), a straight-chain 28-carbon alcohol, exhibited good activity against diphenoxylate-induced constipation in mice, which is obtained as a laxative constituent from the plant for the first time. In order to have an accurate understanding of the content of compound 50, a quantification with gas chromatography-tandem mass spectrometry (GC-MS/MS) was carried out. The anti-inflammatory and α-glucosidase inhibitory activity of some compounds also was assessed.

Laxative Effects of Yangyin Tongmi Capsule on a Model of Diphenoxylate-Induced Constipation in Mice

Constipation is characterized by reduced number of bowel movements, dry stools, and difficult defecation. Yangyin Tongmi capsule (YTC), a traditional Chinese formula, is used in the treatment of constipation, while the underlying mechanisms remain unknown. Herein, this work attempted to prove the effects of YTC on constipation treatment and its possible mechanisms. KM mice were randomly divided into four groups (n = 10/group) and treated with double distilled water (Control), diphenoxylate (Model: 10 mg/kg), or diphenoxylate plus low-dose YTC (L-YTC: 0.6 g/kg) or high-dose YTC (H-YTC: 1.2 g/kg). The data indicated that YTC can significantly shorten the discharge time of the first black stool, improve intestinal propulsion rate, and increase the water content and quantity of feces in mice. ELISA suggested that YTC regulate the content of intestinal hormones and neurotransmitters, such as motilin (MTL), gastrin (GT), somatostatin (SST), substance P (SP), acetylcholine (Ach), and nitric oxide (NO). The expression levels of aquaporin 3 (AQP3) and aquaporin 8 (AQP8) in the colon were examined by immunohistochemistry. In the meantime, the expression levels of P2X2, C-kit, and stem cell factor (SCF) in the colon were examined by western blot analysis. The results of this study suggest that YTC has mitigative effects on diphenoxylate-induced constipation by regulating the content of intestinal hormones and neurotransmitters and regulating the expression of related proteins in the colon.

Constipation in CKD

Constipation is one of the most common gastrointestinal disorders among patients with chronic kidney disease (CKD) partly because of their sedentary lifestyle, low fiber and fluid intake, concomitant medications (e.g., phosphate binders), and multiple comorbidities (e.g., diabetes). Although constipation is usually perceived as a benign, often self-limited condition, recent evidence has challenged this most common perception of constipation. The chronic symptoms of constipation negatively affect patients' quality of life and impose a considerable social and economic burden. Furthermore, recent epidemiological studies have revealed that constipation is independently associated with adverse clinical outcomes, such as end-stage renal disease (ESRD), cardiovascular (CV) disease, and mortality, potentially mediated by the alteration of gut microbiota and the increased production of fecal metabolites. Given the importance of the gut in the disposal of uremic toxins and in acid-base and mineral homeostasis with declining kidney function, the presence of constipation in CKD may limit or even preclude these ancillary gastrointestinal roles, potentially contributing to excess morbidity and mortality. With the advent of new drug classes for constipation, some of which showing unique renoprotective properties, the adequate management of constipation in CKD may provide additional therapeutic benefits beyond its conventional defecation control. Nevertheless, the problem of constipation in CKD has long been underrecognized and its management strategies have scarcely been documented. This review outlines the current understanding of the diagnosis, prevalence, etiology, outcome, and treatment of constipation in CKD, and aims to discuss its novel clinical and therapeutic implications.

Value of Fluoroscopic Defecography in Constipated Children With Abnormal Colon Transit Time Test Results

Background/Aims

Colon transit time (CTT) test is regarded as the gold standard for evaluating colon transit function. Fluoroscopic defecography (FD) is a dynamic radiologic test to assess anorectal function. The aim is to evaluate the value of FD in constipated children with abnormal CTT test results.

Methods

Fifty-one children (27 girls) with a mean age of 9.8 ± 3.2 years who met Rome III criteria for constipation and older than 5 years with abnormal CTT test results underwent FD.

Results

Of 51 children, 27 (52.9%) showed positive findings on FD, including pelvic floor dyssynergia (PFD) (10/27, 37.0%), structural abnormality (15/27, 55.6%) (rectocele 53.3%, intussusception 33.3%, and both 13.4%), and both PFD and rectocele (2/27, 7.4%). In terms of CTT test subtype, of 35 children who had outlet obstruction type in CTT test, 19 (54.2%) had positive findings, including PFD (8/19, 42.1%), structural abnormality (9/19, 47.4%) (rectocele 55.6%, intussusception 22.2%, and both 22.2%), and both PFD and rectocele (2/19, 10.5%). Of the 16 children who had slow transit type of CTT test, 8 (50.0%) had positive findings, including PFD (2/8, 25.0%) and structural abnormality (6/8, 75.0%). Of the 6 children who had structural abnormality, 3 (50.0%) had rectocele and 3 (50.0%) had intussusception. For the 2 children (2/16, 12.5%) who had PFD, puborectalis muscle relax failure was found on FD. Puborectalis muscle relax failure was treated with biofeedback and medication. In the minor abnormalities, medication continued without additional therapeutic modalities.

Conclusions

FD was valuable for both diagnoses of underlying causes and interpretation of CTT test results in children with abnormal CTT test results. Therefore, this study suggests that FD and CTT tests should be incorporated into logical thinking for constipation in children.

A Comparison of the Efficacy of Enema Solutions in Pediatric Emergency Department Patients

BACKGROUND

Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection.

OBJECTIVE

Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the "pink lady," a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate.

METHODS

We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus.

RESULTS

There were 768 records included. Median age was 6.2 years (interquartile range 3.3-10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain.

CONCLUSIONS

There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.

Complementary and Integrative Management of Pediatric Lower Urinary Tract Dysfunction Implemented within an Interprofessional Clinic

Lower urinary tract dysfunction in children is a common multifactorial functional problem that often correlates with bowel dysfunction and behavioral disorders. Ideal management combines integrative therapies that optimize bladder and bowel habits, address behavioral issues, foster mind–body connection, and improve pelvic floor muscle dysfunction. Movement therapies that teach diaphragmatic breathing and relaxation, mind–body awareness, and healthy pelvic floor muscle function are vital for long-term symptom improvement in children. This paper outlines recommendations for integrative management of these patients and discusses a recently developed interprofessional clinic that aims to better meet these patients’ complex needs and to provide patients with an integrated holistic plan of care. Additional work is needed to scientifically assess these treatment models and educate providers across the various disciplines that evaluate and treat these patients.

When poorly conducted systematic reviews and meta-analyses can mislead: a critical appraisal and update of systematic reviews and meta-analyses examining the effects of probiotics in the treatment of functional constipation in children

BACKGROUND

Recent systematic reviews and meta-analyses on the efficacy of probiotics in the treatment of functional constipation in children have yielded conflicting results.

OBJECTIVES

The aim of this study was to critically review and update the evidence in this field by mapping all the steps involved against those reported in previous reviews, in an attempt to understand the nature of their conflicting results.

METHODS

Four literature databases, trial registries, and citations were searched through December 1, 2018. We included randomized controlled trials (RCTs) that assessed the effects of probiotics compared with placebo or treatment as usual on defecation frequency [bowel movements (BMs)/wk] or treatment success rates in children with functional constipation. Independent reviewers extracted the data and assessed risk of bias in each RCT. Data were pooled with (inverse variance) random-effects models.

RESULTS

We identified 17 RCTs, of which 14 and 11 provided sufficient data to enable meta-analysis of the effects of probiotics compared with control on defecation frequency (n = 965) or treatment success (n = 835), respectively. When compared to (any) control intervention, probiotics did not significantly increase defecation frequency [weighted mean difference (WMD): 0.28 BMs/wk; 95% CI: -0.12, 0.69; P = 0.165] but were more efficacious in achieving treatment success (RR: 1.24; 95% CI: 1.03, 1.50; P = 0.024). These effects did not differ by type of control (i.e., active or inactive) intervention. However, in analyses confined to the RCTs that were free of high risk of bias (only 5), probiotics did not confer any beneficial effects on defecation frequency (WMD: -0.55 BMs/wk; 95% CI: -1.37, 0.26; P = 0.185) and achievement of treatment success (RR: 1.01; 95% CI: 0.90, 1.13; P = 0.873), compared with control interventions.

CONCLUSIONS

The current evidence thus does not support the use of probiotics as a single or coadjuvant therapy for treatment of functional constipation in children and refutes recently published reviews reporting favorable effects of probiotics. Conflicting findings of previous reviews resulted from methodologic errors, highlighting the susceptibility of evidence synthesis to oversights in study selection, quality assessments, and data extraction and collation. This review was registered at PROSPERO as CRD42019119109.

Physiology of Electrolyte Transport in the Gut: Implications for Disease

We now have an increased understanding of the genetics, cell biology, and physiology of electrolyte transport processes in the mammalian intestine, due to the availability of sophisticated methodologies ranging from genome wide association studies to CRISPR-CAS technology, stem cell-derived organoids, 3D microscopy, electron cryomicroscopy, single cell RNA sequencing, transgenic methodologies, and tools to manipulate cellular processes at a molecular level. This knowledge has simultaneously underscored the complexity of biological systems and the interdependence of multiple regulatory systems. In addition to the plethora of mammalian neurohumoral factors and their cross talk, advances in pyrosequencing and metagenomic analyses have highlighted the relevance of the microbiome to intestinal regulation. This article provides an overview of our current understanding of electrolyte transport processes in the small and large intestine, their regulation in health and how dysregulation at multiple levels can result in disease. Intestinal electrolyte transport is a balance of ion secretory and ion absorptive processes, all exquisitely dependent on the basolateral Na⁺ /K⁺ ATPase; when this balance goes awry, it can result in diarrhea or in constipation. The key transporters involved in secretion are the apical membrane Cl^- channels and the basolateral Na⁺ -K⁺ -2Cl^- cotransporter, NKCC1 and K⁺ channels. Absorption chiefly involves apical membrane Na⁺ /H⁺ exchangers and Cl^- /HCO₃ ^- exchangers in the small intestine and proximal colon and Na⁺ channels in the distal colon. Key examples of our current understanding of infectious, inflammatory, and genetic diarrheal diseases and of constipation are provided. © 2019 American Physiological Society. Compr Physiol 9:947-1023, 2019.

Controversies in the Management of Functional Constipation in Children

PURPOSE OF REVIEW

Functional constipation (FC) in children is a common health problem with reported worldwide prevalence rates up to 32.2%. The majority of children with constipation respond to oral laxative treatment. After 5 years of intensive treatment, however, approximately 50% of children remain symptomatic. To discuss the evidence for new treatments in these children, including pre- and probiotics, pelvic physiotherapy, prucalopride, sacral nerve stimulation, and surgery, and to highlight the controversies surrounding them.

RECENT FINDINGS

Pre- and probiotics and prucalopride are not effective in the treatment of childhood constipation. Pelvic physiotherapy and sacral nerve stimulation are promising treatment options but larger trials are needed. Surgery for pediatric constipation is the treatment of last resort. Large, well-designed placebo-controlled trials with proper outcome measures, as suggested by the Rome foundation pediatric subcommittee on clinical trials, are necessary to provide more insight regarding the efficacy of new treatments in childhood constipation.

Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children's Continence Society

BACKGROUND

We present a consensus view from the International Children's Continence Society (ICCS) on the evaluation and management of bladder bowel dysfunction (BBD) in children with urinary tract infection (UTI). The statement aims to highlight the importance of BBD in the development and recurrence of childhood UTI and its management to reduce its associated morbidity and sequelae.

METHODS

A systematic literature search was done on PubMed, Embase, and Scopus databases until August 15, 2016. Relevant publications concerning BBD and its relationship with UTI among children were reviewed and aggregated for statements of recommendation. Discussion by the ICCS Board and a multi-disciplinary core group of authors resulted in a document available on its website for all ICCS members to review. Insights and feedback were considered with consensus and agreement reached to finalize this position statement.

RESULTS

BBD in children with UTI is summarized. Details regarding epidemiology, pathophysiology, and recommendations for general and family practitioners and pediatricians relating to the evaluation and management of this condition are presented.

CONCLUSIONS

This document serves as the position statement from ICCS, based on literature review and expert opinion providing our current understanding of BBD in children with UTI.

Picky eating in children: causes and consequences

Picky eating is a common behaviour in early childhood. There is neither a universally accepted definition of picky eating, nor is there agreement on the best tool to identify it. Causes of picky eating include early feeding difficulties, late introduction of lumpy foods at weaning, pressure to eat and early choosiness, especially if the mother is worried by this; protective factors include the provision of fresh foods and eating the same meal as the child. The consequences for the child's diet include poor dietary variety and a possible distortion of nutrient intakes, with low intakes of iron and zinc (associated with low intakes of meat, and fruit and vegetables) being of particular concern. Low intakes of dietary fibre, as a result of low intakes of fruit and vegetables, are associated with constipation in picky eaters. There may be developmental difficulties in some children with persistent picky eating. There is little evidence, however, for a consistent effect of being a picky eater on growth trajectories. There may be a small subgroup of children in whom picky eating does not resolve who might be at risk of thinness during adolescence, or of developing an eating disorder or adult picky eating: these children need to be identified at an early age to enable support, monitoring and advice to be offered to parents. Strategies for avoiding or ameliorating picky eating include repeated exposures to unfamiliar foods, parental modelling of eating fruit and vegetables and unfamiliar foods, and the creation of positive social experiences around mealtimes.

Is celiac disease misdiagnosed in children with functional constipation?

BACKGROUND/AIMS

Functional constipation is one of the common problems in childhood, and it comprises approximately 5% of the pediatric outpatient clinical applications. On the other hand, celiac disease (CD) is an immune enteropathy with the prevalence between 1/150 and 1/200. In addition to the classical symptoms of the disease such as diarrhea and weight loss, the incidence of atypical symptoms is increasing. This study aims to determine the prevalence of CD in patients with chronic constipation.

MATERIALS AND METHODS

The study was conducted between 2010 and 2012 and included 1046 children (range, 2-18 y; median, 11.4 y) diagnosed with chronic constipation according to the Rome III criteria. Serum immunoglobulin A, tissue transglutaminase, and/or anti-endomysial antibodies were examined. The patients with serological positive results were subjected to upper gastrointestinal system endoscopy and duodenal biopsy to confirm the diagnosis of CD.

RESULTS

Blood tests were positive in 36 patients (3.25%). One of the patients had Hashimoto's thyroiditis, and 4 patients had short stature. Endoscopic findings included nodularity in bulbus and duodenal mucosa (n=16), scalloping fold (n=13), and normal mucosa (n=5). Histopathologic findings revealed that 10 patients had total villous atrophy, 24 patients had subtotal and partial villous atrophy, and 34 patients had intraepithelial lymphocyte infiltration. All patients followed a gluten-free diet, resulting in a resolution of symptoms.

CONCLUSION

In the present study, a CD ratio of 1:28 was diagnosed in chronically constipated children. The use of screening tests for CD should be considered in children with conventional treatment-resistant constipation.

Effectiveness of Probiotics in Children With Functional Abdominal Pain Disorders and Functional Constipation: A Systematic Review

OBJECTIVE

The objective of this study was to investigate the effect of probiotics on functional abdominal pain disorders (FAPD) and functional constipation (FC).

METHODS

A systematic review was conducted, searching PubMed and Cochrane databases from inception to January 2018 for randomized controlled trials (RCTs) investigating the efficacy of probiotics in children aged 4 to 18 years with FAPD or children aged 0 to 18 years with FC.

RESULTS

A total of 657 citations were identified. Finally, 11 RCTs for FAPD and 6 RCTs for FC were included. Some evidence exists for Lactobacillus rhamnosus GG (n=3) in reducing frequency and intensity of abdominal pain in children with irritable bowel syndrome. There is no evidence to recommend L. reuteri DSM 17938 (n=5), a mix of Bifidobacterium infantis, Bifidobacterium breve and Bifidobacterium longum (n=1), Bifidobacterium lactis (n=1) or VSL#3 (n=1) for children with FAPD. No evidence exists to support the use of Lactobacillus casei rhamnosus LCR35 (n=1), B. lactis DN173 010 (n=1), B. longum (n=1), L. reuteri DSM 17938 (n=1), a mix of B. infantis, B. breve and B. longum (n=1), or Protexin mix (n=1) for children with FC. In general, studies had an unclear or high risk of bias.

CONCLUSIONS

Insufficient evidence exists for the use of probiotics in FAPD and FC, only L. rhamnosus GG seems to reduce frequency and intensity of abdominal pain but only in children with irritable bowel syndrome. A better understanding of differences in gut microbiota in health and disease might lead to better probiotic strategies to treat disease.

Physiology of the Gut: Experimental Models for Investigating Intestinal Fluid and Electrolyte Transport

Once thought to be exclusively an absorptive tissue, the intestine is now recognized as an important secretory tissue, playing a key role in body ion and fluid homeostasis. Given the intestine's role in fluid homeostasis, it is not surprising that important clinical pathologies arise from imbalances in fluid absorption and secretion. Perhaps the most important examples of this can be seen in enterotoxigenic secretory diarrheas with extreme fluid secretion, and Cystic Fibrosis with little or no fluid secretion. A mechanistic understanding of the cellular pathways regulating ion and fluid transport has been obtained from a variety of approaches and model systems. These have ranged from the intact intestine to a single intestinal epithelial cell type. Although for many years a reductionist approach has held sway for investigating intestinal transport, the growing realization that physiologic processes should really be examined within a physiological context has seen a marked increase in studies using models that are essentially mini-intestines in a dish. The aim of this chapter is to provide a historical context for our understanding of intestinal ion and fluid transport, and to highlight the model systems that have been used to acquire this knowledge.

Physiotherapy plus conventional treatment versus conventional treatment only in the treatment of functional constipation in children: design of a randomized controlled trial and cost-effectiveness study in primary care

BACKGROUND

Our aim was to design a study to evaluate the effectiveness and cost-effectiveness of adding physiotherapy to conventional treatment for children with functional constipation in primary care. Physiotherapy is focusing on improving the coordination between the pelvic floor and abdominal musculature during bowel movement, while conventional treatment is mainly focusing on symptomatic relief of symptoms, therefore, we expect the effects of physiotherapy will be more sustainable than the effects of conventional treatment. In this paper we describe the final study design and how the design was adapted, to overcome recruitment problems.

METHODS

We designed a randomized controlled trial of children aged 4-17 years with functional constipation diagnosed by a general practitioner or pediatrician. Children in the intervention group received physiotherapy plus conventional treatment, and those in the control group received conventional treatment only. Follow-up measurements took place at 4 and 8 months. The primary outcome was treatment success defined according to the Rome-III criteria as the absence of functional constipation, with no laxative use. Secondary outcomes were absence of functional constipation irrespective of laxative use, quality of life, global perceived effect, and costs. Children were recruited from September 2014 to February 2017. Initially, we aimed to include children with recent symptom onset. However, in the first phase of enrollment we were confronted with an unforeseen recruitment problem: many children and their parents refused randomization because physiotherapy was considered too burdensome for the stage of disease. Therefore, we decided to also include children with a longer duration of symptoms. In total 134 children were included.

DISCUSSION

The target number of participants is achieved. Therefore, the results may change thinking about the management of functional constipation in children.

TRAIL REGISTRATION

Netherlands Trial Register ( NTR4797 ), registered 8 September 2014.

Botulinum toxin injection for childhood constipation is safe and can be effective regardless of anal sphincter dynamics

BACKGROUND

Childhood constipation is common. Previously, internal anal sphincterotomy has been used for hypertensive/non-relaxing sphincters; however, recent benefit has been shown with Botulinum Toxin (BT) injections. The aim is to investigate BT, including response duration, symptom association and effectiveness in relation to sphincter dynamics.

METHODS

Retrospective study of 164 children receiving sphincter BT for severe constipation unresponsive to medication management. Charts reviewed for symptoms, anorectal manometry (ARM) findings and response defined by decreased pain or increased defecation. Patients were grouped: normal sphincter pressure (≤50 mmHg), elevated (>50 mmHg), normal and abnormal rectoanal inhibitory reflex (RAIR).

RESULTS

There were 142 analyzed and 124 completed ARMs; 98 (70%) had positive response with 57% lasting greater than 6 months. 36 had normal sphincter pressure with 24 (69%) responding. 88 had elevated pressure with 60 (68%) responding (p=0.87). 90 normal RAIRs with 64 (71%) responding. 34 abnormal RAIRs with 22 (64%) responding (p=0.41). With logistic regression, fecal incontinence prior to BT was a predictor of poor response (p= 0.02). The most common side effect was fecal incontinence typically resolving within week with equal frequency regardless of sphincter dynamics.

CONCLUSIONS

BT is effective for children with chronic constipation. Patients with fecal incontinence are less likely to respond. More than half had prolonged beneficial response. Those with normal and abnormal sphincter dynamics had similar responses and without differences in side effects. Therefore, injection may be considered in patients with intractable constipation unresponsive to medication, regardless of anal sphincter dynamics.

LEVEL OF EVIDENCE

Level III (Treatment Study: Retrospective comparative study).

Recommendations for pharmacological clinical trials in children with functional constipation: The Rome foundation pediatric subcommittee on clinical trials

BACKGROUND

Evidence for the efficacy of commonly used drugs in the treatment of childhood functional constipation (FC) is scarce, studies are often of low quality and study designs are heterogeneous. Thus, recommendations for the design of clinical trials in childhood FC are needed.

PURPOSE

Members of the Rome Foundation and a member of the Pediatric Committee of the European Medicines Agency formed a committee to create recommendations for the design of clinical trials in children with FC.

KEY RECOMMENDATIONS

This committee recommends conducting randomized, double-blind, placebo-controlled, parallel-group clinical trials to assess the efficacy of new drugs for the treatment of childhood FC. Pediatric study participants should be included based on fulfilling the Rome IV criteria for FC. A treatment free run-in period for baseline assessment is recommended. The trial duration should be at least 8 weeks. Treatment success is defined as no longer meeting the Rome IV criteria for FC. Stool consistency should be reported based on the Bristol Stool Scale. Endpoints of drug efficacy need to be tailored to the developmental age of the patient population.

Hirschsprung disease - integrating basic science and clinical medicine to improve outcomes

Hirschsprung disease is defined by the absence of enteric neurons at the end of the bowel. The enteric nervous system (ENS) is the intrinsic nervous system of the bowel and regulates most aspects of bowel function. When the ENS is missing, there are no neurally mediated propulsive motility patterns, and the bowel remains contracted, causing functional obstruction. Symptoms of Hirschsprung disease include constipation, vomiting, abdominal distension and growth failure. Untreated disease usually causes death in childhood because bloodstream bacterial infections occur in the context of bowel inflammation (enterocolitis) or bowel perforation. Current treatment is surgical resection of the bowel to remove or bypass regions where the ENS is missing, but many children have problems after surgery. Although the anatomy of Hirschsprung disease is simple, many clinical features remain enigmatic, and diagnosis and management remain challenging. For example, the age of presentation and the type of symptoms that occur vary dramatically among patients, even though every affected child has missing neurons in the distal bowel at birth. In this Review, basic science discoveries are linked to clinical manifestations of Hirschsprung disease, including partial penetrance, enterocolitis and genetics. Insights into disease mechanisms that might lead to new prevention, diagnostic and treatment strategies are described.

Effects of Interferential Electrical Stimulation Plus Pelvic Floor Muscles Exercises on Functional Constipation in Children: A Randomized Clinical Trial

OBJECTIVES

Functional constipation is a common condition in children. We assessed the effectiveness of combined interferential (IF) electrical stimulation and pelvic floor muscle (PFM) exercises on functional constipation in children.

METHODS

We conducted a single-center, double-blind randomized clinical trial study during 2014-2017 in Tehran, Iran. Ninety children, aged 5-13 years, who fulfilled Rome III criteria were enrolled and randomly assigned into two treatment groups. Case group (n=45) underwent IF electrical stimulation and PFM exercises, whereas the control group (n=45) received PFM exercises plus sham stimulation. A complete bowel habit diary (with concerning data on the frequency of defecation per week, stool form, and the number of fecal soiling episodes), a constipation score questionnaire, and a visual pain score were recorded before, after the treatment and 6 months later for all participants. In addition, children in both groups were assessed with a constipation-related quality-of-life questionnaire before, after the end of treatment sessions, and 6 months after the treatment.

RESULTS

Treatment success was achieved for 88.4% of children in the case group compared with 43.2% of children in the control group after the treatment (P<0.003). The median constipation score was reduced in both groups, with the cases having significantly lower scores after the treatment (4 vs. 8, P<0.000). Stool form normalized in 75.6% of the cases and 45.5% of the controls after the treatment (P<0.01).

CONCLUSIONS

Our results showed that using IF electrical stimulation as an adjuvant therapy to the medical and rehabilitation programs significantly boosts the effects of treatment among these patients.

Physical activity may decrease the likelihood of children developing constipation

AIM

Childhood constipation is common. We evaluated children diagnosed with constipation, who were referred to an Icelandic paediatric emergency department, and determined the effect of lifestyle factors on its aetiology.

METHODS

The parents of children who were diagnosed with constipation and participated in a phase IIB clinical trial on laxative suppositories answered an online questionnaire about their children's lifestyle and constipation in March-April 2013. The parents of nonconstipated children that visited the paediatric department of Landspitali University Hospital or an Icelandic outpatient clinic answered the same questionnaire.

RESULTS

We analysed responses regarding 190 children aged one year to 18 years: 60 with constipation and 130 without. We found that 40% of the constipated children had recurrent symptoms, 27% had to seek medical attention more than once and 33% received medication per rectum. The 47 of 130 control group subjects aged 10-18 were much more likely to exercise more than three times a week (72%) and for more than a hour (62%) than the 26 of 60 constipated children of the same age (42% and 35%, respectively).

CONCLUSION

Constipation risk factors varied with age and many children diagnosed with constipation had recurrent symptoms. Physical activity may affect the likelihood of developing constipation in older children.

Sacral neuromodulation versus personalized conservative treatment in patients with idiopathic slow-transit constipation: study protocol of the No.2-trial, a multicenter open-label randomized controlled trial and cost-effectiveness analysis

PURPOSE

The evidence regarding the (cost-)effectiveness of sacral neuromodulation (SNM) in patients with therapy-resistant idiopathic slow-transit constipation is of suboptimal quality. The Dutch Ministry of Health, Welfare and Sports has granted conditional reimbursement for SNM treatment. The objective is to assess the effectiveness, cost-effectiveness, and budget impact of SNM compared to personalized conservative treatment (PCT) in patients with idiopathic slow-transit constipation refractory to conservative treatment.

METHODS

This study is an open-label, multicenter randomized controlled trial. Patients aged 14 to 80 with slow-transit constipation, a defecation frequency (DF) < 3 per week and meeting at least one other Rome-IV criterion, are eligible. Patients with obstructed outlet, irritable bowel syndrome, bowel pathology, or rectal prolapse are excluded. Patients are randomized to SNM or PCT. The primary outcome is success at 6 months (DF ≥ 3 a week), requiring a sample size of 64 (α = 0.05, β = 0.80, 30% difference in success). Secondary outcomes are straining, sense of incomplete evacuation, constipation severity, fatigue, constipation specific and generic quality of life, and costs at 6 months. Long-term costs and effectiveness will be estimated by a decision analytic model. The time frame is 57 months, starting October 2016. SNM treatment costs are funded by the Dutch conditional reimbursement program, research costs by Medtronic.

CONCLUSIONS

The results of this trial will be used to make a final decision regarding reimbursement of SNM from the Dutch Health Care Package in this patient group.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov , identifier NCT02961582, on 12 October 2016.

Luminally Acting Agents for Constipation Treatment: A Review Based on Literatures and Patents

Constipation is one of the most frequently reported gastrointestinal (GI) disorders that negatively impacts quality of life and is associated with a significant economic burden to the patients and society. Traditional treatments including lifestyle modification and laxatives are often ineffective in the more severe forms of constipation and over the long term. New medications targeting at intestinal chloride channels and colonic serotonin receptors have been demonstrated effective in recent years. Emerging agents focusing on improving intestinal secretion and/or colonic motility have been shown effective in animal models and even in clinical trials. Recognization of the role of cystic fibrosis transmembrane regulator (CFTR) and calcium-activated chloride channels (CaCCs) in intestine fluid secretion and motility modulation makes CFTR and CaCCs promising molecule targets for anti-constipation therapy. Although there are multiple choices for constipation treatment, there is still a recognized need for new medications in anti-constipation therapy. The present review covers the discovery of luminally acting agents for constipation treatment described in both patents (2011–present) and scientific literatures.

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.