A 6-year follow-up study of chronic constipation and soiling in a specialist paediatric service

Prevalence of Defecation Disorders and their Symptoms is Comparable in Children and Young Adults: Cross-Sectional Study

PURPOSE

We aimed to compare the prevalence rates and associated symptoms of constipation and fecal incontinence in children and young adults and evaluate how these patient groups cope with these disorders.

METHODS

A cross-sectional study was performed in which 212 children (8-17 years) and 149 young adults (18-29 years) from the general Dutch population completed a questionnaire about defecation disorders.

RESULTS

Constipation occurred in 15.6% of children and 22.8% of young adults (p=0.55), while the prevalence of fecal incontinence was comparable between groups (7%, p=0.91). The symptoms associated with constipation occurred as often in children as in young adults, while most fecal incontinence symptoms occurred more often in young adults. Approximately 43% of children had constipation for more than 5 years, while 26% of young adults experienced constipation since childhood. Only 27% of constipated children and 21% of constipated young adults received treatment (mostly laxatives). For fecal incontinence, 13% of children and 36% of young adults received treatment (mostly antidiarrheal medications or incontinence pads).

CONCLUSION

In contrast to the general belief, the prevalence of defecation disorders and associated symptoms seem to be comparable in children and young adults. Only a few people with defecation disorders receive adequate treatment.

Shame and guilt in the postnatal period: a systematic review

Objective: The aim of this review was to explore the unique contribution of shame (negative evaluation of the self) and guilt (negative evaluation of behaviour) to postnatal psychological symptoms. Background: Although shame and guilt are related to psychological symptoms, the separate effect of each in postnatal psychological symptoms are not yet known. Methods: Seven electronic databases were systematically reviewed for articles on: (1) quantitative measures of shame, guilt, and psychological symptoms (2) in the postnatal period for infants under two years of age (3) published in English. Results: Of the 1,615 articles retrieved using PRISMA guidelines, five met criteria and were analysed independently by two reviewers using the STROBE criteria. In mothers, shame was significantly related to stress and postnatal depression. Shame significantly predicted postnatal depression. Guilt was significantly related to postnatal depression; however, the relationship was substantially reduced when included with shame. In fathers, shame, but not guilt, was significantly related to stress, anxiety, and depression. Conclusion: Shame and guilt are trans-diagnostic phenomena, negatively impacting on postnatal psychological health, and potentially the parent-child relationship. More research is needed to develop awareness of the unique effects of shame and guilt to optimise perinatal intervention.

Sonographic evaluation of gallbladder motility in children with chronic functional constipation

Background/Aims

Studies in adults suggest that constipation may not be a purely colonic pathology and may be a component of a generalized gastrointestinal (GI) motor disorder in which proximal GI motility can be impaired. Pediatric data are scarce, and the natural history of the disorder remains undefined. We aimed to evaluate gallbladder motility in a subset of Asian children with chronic functional constipation.

Methods

Abdominal ultrasound was performed on 105 children, including 55 patients (aged 3 to 13 years) with chronic functional constipation who met the inclusion criteria and 50 age- and gender-matched controls. The gallbladder contractility index was calculated based on the preprandial and postprandial gallbladder areas. Preprandial and postprandial values for gallbladder volume and wall thickness were evaluated.

Results

The mean value of the contractility index for the patients (15.77±24.68) was significantly lower than the mean value for the controls (43.66±11.58) (p=0.001). The mean postprandial gallbladder volumes and areas were larger in children with gallbladder hypomotility (p<0.05). The mean duration of constipation (4.8 months) was significantly higher (p=0.004) in the children with gall-bladder hypomotility.

Conclusions

Gallbladder motility is significantly impaired in children with chronic functional constipation. This study contributes to the understanding of the underlying pathophysiology, which will enable advancement in and improved management of children with chronic constipation and associated gallbladder hypomotility.

Contrast enema as a guide for senna-based laxatives in managing overflow retentive stool incontinence in pediatrics

OBJECTIVES

Overflow retentive stool incontinence (ORSI) is secondary to constipation and fecal loading. In our study, the dose and duration of senna-based laxatives (SBL) treatment to achieve full defecatory control will be examined for possible correlation with new parameters measured from the initial contrast enema.

METHODS

Initially, an observational study was conducted prospectively on a group of patient with ORSI to define the optimum dose of SBL to achieve full defecatory control with measurement of six parameters in the initial contrast enema (level of colonic dilatation, recto-anal angle, ratio of maximal diameter of dilated colon to last lumbar spine, ratio of maximum diameter of dilated colon to normal descending colon, immediate and after 24-h post-evacuation residual contrast). The result was analyzed statistically to reach a correlation between the radiological data and prescribed dose.

RESULTS

Over 2 and half years, 72 patients were included in the study; their mean age was 6.3 ± 3.33 years. The mean effective starting dose of SBL was 57 ± 18.13 mg/day and the mean effective ending dose was 75 ± 31.68 mg/day. Time lapsed till full defecatory control ranged from 1 to 16 weeks. Statistical correlation revealed that mean effective ending dose of SBL treatment significantly increased with higher levels of colonic dilatation. A weak positive correlation was found for both the mean effective starting and ending doses with the ratio of maximum colonic diameter to last lumbar spine and descending colonic diameters ratio.

CONCLUSION

Senna-based laxatives are effective treatment for overflow retentive stool incontinence and their doses can be adjusted initially depending on the analysis of the radiological data.

A multicenter study on childhood constipation and fecal incontinence: effects on quality of life

OBJECTIVE

To describe the effects of childhood functional constipation compared with functional constipation plus fecal incontinence on quality of life, evaluating effects on physical, psychosocial, and family functioning.

STUDY DESIGN

This prospective, multicenter study collected data from 5 regional children's hospitals. Children meeting Rome III criteria for functional constipation were included. Parents completed the following 5 instruments: Pediatric Quality of Life Inventory (PedsQL), PedsQL-Family Impact Module, Functional Disability Inventory-Parent Version, Pediatric Inventory for Parents (PIP), and Pediatric Symptom Checklist-Parent Report.

RESULTS

Families of 410 children aged 2-18 years (mean [SD], 7.8 [3.5] years; 52% male) were included. Children with functional constipation+fecal incontinence had worse quality of life than children with functional constipation alone (PedsQL Total Score, P ≤ .03). Older children with functional constipation + fecal incontinence had lower quality of life than their younger counterparts (PedsQL Total Score, P ≤ .047). Children with functional constipation+fecal incontinence had worse family functioning (PedsQL-Family Impact Module Total Score, P ≤ .012), greater parental stress (PIP-F Total Score, P ≤ .016; PIP-D Total Score, P ≤ .013), and poorer psychosocial functioning (Pediatric Symptom Checklist Total Score, P ≤ .003). There were no statistically significant between-group differences in physical functioning based on the functional Disability Inventory.

CONCLUSION

Fecal incontinence significantly decreases quality of life compared with functional constipation alone in children. Older children with functional constipation+fecal incontinence may be at particular risk. Strategies for early identification and treatment of constipation along with diagnosis and treatment of related adjustment difficulties may mitigate the negative impact of this highly prevalent condition.

Antegrade continence enema (ACE): predictors of outcome in 111 patients

PURPOSE

The antegrade continence enema (ACE) is used as a means of managing faecal incontinence and constipation with varying outcomes. We aim to evaluate our outcomes of ACEs and identify predictors of outcome.

METHODS

A retrospective case-note review of patients ≤16 years of age undergoing an ACE (March 2000-September 2013) was carried out. Data collected included: patient demographics, functional outcomes and complications. Data are quoted as median (range) and compared using Mann-Whitney and Fisher's exact test. Univariate analysis was performed to identify predictors of successful outcomes. P < 0.05 is significant. Successful outcome = total continence/occasional leakage and failed outcome = regular soiling and/or constipation.

RESULTS

111 patients with complete data sets underwent an ACE [59% male, median age = 9.5 years (3.4-16 years)] and median follow-up = 48 months (4 months-11 years 4 months). Underlying diagnoses were idiopathic constipation (n = 68), anorectal malformation (n = 27), neuropathic bowel (n = 7), Hirschsprung disease (n = 5) and gastrointestinal dysmotility (n = 4). Social continence was achieved in 87/111 (78%). Fifteen percent of patients underwent reversal of ACE due to resolution of symptoms. There was no difference in outcomes related to diagnosis, gender, age or follow-up duration. Complication rate was 20.7% (23/111).

CONCLUSIONS

The ACE is safe and effective in the management of intractable constipation and soiling. No predictors of outcome were identified.

Long-term prognosis for childhood constipation: clinical outcomes in adulthood

OBJECTIVES

This study examines long-term prognoses for children with constipation in adulthood and identifies prognostic factors associated with clinical outcomes.

METHODS

In a Dutch tertiary hospital, children (5-18 years of age) who were diagnosed as having functional constipation were eligible for inclusion. After a 6-week treatment protocol, prospective follow-up evaluations were conducted at 6 and 12 months and annually thereafter. Good clinical outcomes were defined as > or =3 bowel movements per week for > or =4 weeks, with < or =2 fecal incontinence episodes per month, irrespective of laxative use.

RESULTS

A total of 401 children (260 boys; median age: 8 years [interquartile range: 6-9 years]) were included, with a median follow-up period of 11 years (interquartile range: 9-13 years). The dropout rate during follow-up was 15%. Good clinical outcomes were achieved by 80% of patients at 16 years of age. Thereafter, this proportion remained constant at 75%. Poor clinical outcomes at adult age were associated with: older age at onset (odds ratio [OR]: 1.15 [95% confidence interval [CI]: 1.02-1.30]; P = .04), longer delay between onset and first visit to our outpatient clinic (OR: 1.24 [95% CI: 1.10-1.40]; P = .001), and lower defecation frequency at study entry (OR: 0.92 [95% CI: 0.84-1.00]; P = .03).

CONCLUSIONS

One-fourth of children with functional constipation continued to experience symptoms at adult age. Certain risk factors for poor clinical outcomes in adulthood were identified. Referral to a specialized clinic should be considered at an early stage for children who are unresponsive to first-line treatment.

Chronic constipation, atypical eating pattern, weight loss, and anxiety in a 19-year old youth

A 19-year-old female was admitted to a children's hospital weighing 75 pounds. She lost 75 pounds over 2 years and did not menstruate for a year. Despite her dissatisfaction with her thin appearance and desire to weigh more, her inpatient treatment focused on "disordered eating." Adolescent medicine, nutrition, and gastroenterology specialists were consulted. A pediatric psychology consultation was initiated to address anxiety associated with eating as well as abnormal toileting behaviors. The patient reported that she had chronic constipation since the age 3 years with a large, hard, and painful bowel movement once every 1-3 weeks. She had numerous medical and nutritional interventions to improve her bowel functioning, including extensive laxative use and a diet high in fiber (mostly fruits and vegetables). Additionally, an extensive medical evaluation to look for physiological causes for chronic constipation, including Hirschsprung's disease, was not diagnostic. The patient described purposeful stool withholding due to her concern over painful bowel movements. She also avoided peer activities because she did not want to use toilets outside her home. The patient acknowledged that her disordered eating stemmed largely from her toileting difficulties. She described altering her eating habits to avoid bowel movements (e.g., eating small meals, not eating at school) and anxious thoughts while defecating. Defecation anxiety was now affecting other areas of her life. For example, she frequently used copious amounts of toilet paper to ensure thorough cleaning. The patient's parents confirmed her need to thoroughly clean after toilet use, using "almost half a roll of toilet paper." They described other concerning "routines," including refusing to use towels after showering. She dried herself with a fan because of fear that her towel may be dirty. They indicated that during early adolescence, she frequently washed her face to prevent acne breakouts. According to parents, the patient followed doctors' instructions "as though they (were) gospel," deviating from suggestions only with extreme resistance.

Functional constipation in children: a systematic review on prognosis and predictive factors

BACKGROUND AND AIM

Knowledge regarding prognosis and factors influencing the clinical course of functional constipation in children is important to enable general practitioners and paediatricians to give accurate patient information, to compare treatment strategies, and identify children with high risk for unfavourable outcome. The objective of the study was to investigate and summarize the quantity and quality of evidence on prognosis of childhood constipation with and without treatment and its predictive factors.

METHODS

An extensive literature search in MEDLINE and Embase was performed to identify prospective follow-up studies evaluating the prognosis or prognostic determinants of functional constipation. Methodological quality was assessed using a standardised list. Results on prognosis of constipation were statistically pooled, and the influence of prognostic factors was summarised in a best evidence synthesis.

RESULTS

The search strategy resulted in a total of 2882 abstracts. Only 14 publications met our inclusion criteria, of which 21% scored high methodological quality. Included studies showed large heterogeneity in study populations and outcome measures. Without regard to these differences, 49.3% +/- 11.8% of all of the children followed for 6 to 12 months were found to recover and taken off laxatives. The percentage of children who were free from complaints, regardless of laxative use, after 6 to 12 months was 60.6% +/- 19.2%. There is substantial evidence that defecation frequency and a positive family history are not associated with recovery from constipation.

CONCLUSIONS

The few studies published on prognosis of childhood functional constipation and predictive factors showed large heterogeneity and poor methodological quality. Overall, 60.6% of children are found to be free from symptoms after 6 to 12 months. Recovery rate showed no relation with defecation frequency or positive family history. Based on the present literature, we are unable to identify a group of children with high risk for poor prognosis.

A randomized controlled trial of enemas in combination with oral laxative therapy for children with chronic constipation

BACKGROUND & AIMS

After 5 years of intensive oral laxative use, up to 30% of constipated children still have an unsuccessful outcome. Children refractory to oral laxatives might benefit from regular rectal evacuation by enemas. This randomized controlled trial compared the effects of additional treatment with rectal enemas (intervention) with conventional treatment alone (oral laxatives, control) in severely constipated children.

METHODS

In a tertiary hospital in the Netherlands, 100 children, aged 8-18 years, with functional constipation for at least 2 years were randomly assigned to intervention or control groups. The control group received education, behavioral strategies, and oral laxatives. The intervention group was also given 3 rectal enemas/week, reduced by 1 enema/week every 3 months. Outcome measures were defecation and fecal incontinence frequency and overall success at 12, 26, 39, and 52 weeks. Overall success was defined as 3 or more defecations/week and less than 1 fecal incontinence episode/week, irrespective of laxative use.

RESULTS

Defecation frequency normalized in both groups but was significantly higher in the intervention group compared with controls at 26 and 52 weeks (5.6 vs 3.9/week, P = .02, and 5.3 vs 3.9/week, P = .02, respectively). There were no significant differences between groups in reduction of fecal incontinence episodes (P = .49) and overall success rates (P = .67). After 1 year of treatment, the overall success rate was 47.1% in the intervention group versus 36.1% in the control group.

CONCLUSIONS

There is no additional effect of enemas compared with oral laxatives alone as maintenance therapy for severely constipated children.

Gastrointestinal transit in children with chronic idiopathic constipation

Chronic constipation in children is common and produces significant morbidity. Identification of the site of dysmotility in constipation may determine the cause and permit directed management. Scintigraphy differentiates constipated patients with anorectal hold-up from those with colonic slowing. Adults with colonic slowing demonstrate variation in the site of hold-up. However, in children with colonic slowing, variability in the site of hold-up has not been investigated.

PURPOSE

The current study aimed to characterise colonic transit patterns in 64 children with chronic idiopathic constipation.

METHODS

Scintigraphic images were grouped visually by their transit patterns. Intra-observer variation was assessed. Scintigraphic data were analysed quantitatively.

RESULTS

Visual analysis of scintigraphy studies demonstrated normal transit (11/64), anorectal hold-up (7/64) and slow colonic transit (46/64). Transit characteristics in the slow transit group demonstrated three possible subgroups: pancolonic slowing (28/46), discrete hold-up in the transverse colon (10/46) and abnormal small and large bowel transit (8/46). Kappa testing demonstrated consistent characterisation (k = 0.79). Statistical analysis of scintigraphic data demonstrated highly significant differences from normal (P < 0.001) in the subgroups.

CONCLUSION

Scintigraphy demonstrates three possible transit patterns in children with chronic constipation secondary to slow colonic transit.

Health related quality of life in children with constipation-associated fecal incontinence

OBJECTIVES

With a disease-specific questionnaire, this study aimed to evaluate health-related quality of life (HRQoL) in children with constipation in association with clinical characteristics.

STUDY DESIGN

Children with constipation-associated fecal incontinence (n = 114), 8 to 18 years, filled out the Defecation Disorder List at a Dutch tertiary hospital. Correlations and linear regression analysis between clinical characteristics and scores on emotional and social functioning were calculated. Specific concerns of children were described by individual item scores of these domains.

RESULTS

Higher frequency of fecal incontinence episodes was associated with lower emotional and social functioning. Linear regression analysis showed a significant association between social functioning and fecal incontinence, but the variance of the model was low (adjusted R(2)= 0.08). Between 70% to 80% of children were concerned about experiencing fecal incontinence unnoticeably and the attendant social consequences. Children did not report having fewer friends and participated well in social events.

CONCLUSION

Lower HRQoL regarding disease-specific emotional and social functioning was reported in children with frequent episodes of constipation-associated fecal incontinence. However, other nonspecified factors may also influence HRQoL of these children. Most children reported relatively more emotional concerns than social consequences.

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.

Idiopathic slow transit constipation is rare. But delayed passage of meconium is common in the constipation clinic

We hypothesise that constipated children would be more likely to come from a socially deprived background. We also hypothesise that a percentage of children with resistant constipation would have a congenital gut motility problem that might be recognised at birth, and that some of these would have slow transit constipation that could be recognised on nuclear transit study. One hundred and forty children with a constipation related diagnosis were seen in the last 4 years, and were reviewed as a retrospective audit. Twenty-six children who were felt likely to have a congenital cause for their constipation were offered nuclear colon transit study to search for slow transit constipation. One hundred and forty children from the constipation clinic were reviewed. There were 67 females (47.9%) and 73 males (52.1%), a sex ratio near equality. The mean age at presentation was 5.38 years. Forty-one percent were formally discharged, 36% were lost to follow up, and 23% are still being seen. There was a highly significant tendency for these children to have delayed passage of meconium, as compared normal newborns (P << 0.001). Twenty-six children were considered for possible transit study, and 14 were performed. Four of these were normal, seven showed hold up in the recto-sigmoid, and three showed more proximal slow transit. Two of these probably have non ISTC diagnoses. Social class seems similar to the general population on the criterion employed. Delayed passage of meconium in this group was significantly more frequent than in the general population, but only one of the group seems likely to have truly idiopathic slow transit constipation, and he did not have delayed passage of meconium. There is no evidence for an effect of social class in this population. Idiopathic slow transit constipation itself is rare.

Factors associated with childhood constipation

AIM

To evaluate factors associated with constipation, determine its risk factors and identify common methods of managing constipation among schoolchildren from ages 7-12 in Edirne, Turkey.

METHODS

This was a cross-sectional and descriptive study and 1900 children were stratified by the school population, age and gender. The questionnaire collected information from parents about the prevalence of constipation and associated factors as well. It asked about bowel movements, socio-demographic data, personal and family stressors, parental concern about constipation, and treatment methods.

RESULTS

The overall prevalence of constipation was 7.2%. It was 7.3% in boys and 7.2% in girls (P > 0.05). The parameters of siblings with health problems, constipation history in family members, abnormal oral habits, and little regular sporting activity were more common in constipated children than in non-constipated ones (P < 0.05). In the logistic regression analysis, never having used school toilets (OR: 5.9) and having problem to control their bowel after 2 years of age (OR: 3.1) were found to be major risk factors for constipation in schoolchildren ages 7-12 years. Constipated children had a lower consumption rate of fruits and vegetables and a higher consumption rate of milk-group foods, biscuits and macaroni than non-constipated children. Parental concern was at 90% and the rate of medical consultation was 23.2% for constipated children.

CONCLUSIONS

The risk factors for childhood constipation may be genetic, psychological or organic. Bowel functions may be affected by dietary habits. Parents, health and education professionals should give special attention to childhood constipation.

Chronic childhood constipation: a review of the literature and the introduction of a protocolized behavioral intervention program

OBJECTIVE

To release a newly protocolized behavioral intervention program for children with chronic constipation aged 4-18 years with guidance from literature about underlying theories from which the treatment techniques follow.

METHODS

Articles until July 2006 were identified through electronic searches in Medline, PsychInfo and Picarta. There was no limit placed on the time periods searched. Following keywords were used: constipation, encopresis, fecal incontinence, psychotherapy, emotions, randomized controlled trials, parent-child relations, parents, family, psychology, behavioral, behavioral problems, psychopathology, toilet, social, psychosocial, pain, retentive posturing, stool withholding, stool toileting refusal, shame, stress, anxiety. A filter was used to select literature referring to children 0-18 years old. Key constructs and content of sessions for a protocolized behavioral intervention program are derived from literature.

RESULTS

Seventy-one articles on chronic childhood constipation are critically reviewed and categorized into sections on epidemiology, symptomatology, etiology and consequences, treatment and effectivity, and follow-up on chronic childhood constipation. This is followed by an extensive description of our protocolized behavioral intervention program.

CONCLUSION

This is the first article on childhood constipation presenting a full and transparent description of a behavioral intervention program embedded in literature. In addition, a theoretical framework is provided that can serve as a trial paradigm to evaluate intervention effectiveness.

PRACTICE IMPLICATIONS

This article can serve as an extensive guideline in routine practice to treat chronically constipated children. By releasing our protocolized behavioral intervention program and by offering a theoretical framework we expect to provide a good opportunity to evaluate clinical effectivity by both randomized controlled trials and qualitative research methods. Findings will contribute to the implementation of an effective treatment for chronic constipation in childhood.

Influence of positive family history on clinical characteristics of functional constipation

BACKGROUND & AIMS

We observed that there is familial aggregation in patients with functional constipation. Their clinical characteristics have not been studied. The aim of this study was to investigate the clinical characteristics of patients with functional constipation with and without a positive family history.

METHODS

Patients with functional constipation satisfying Rome II criteria were recruited. A Rome II questionnaire on constipation was given to the patients' families to identify whether there were any family members with idiopathic constipation. The clinical characteristics between those with and without positive family history were evaluated.

RESULTS

There were 118 patients with at least one first-degree relative with idiopathic constipation and 114 patients without a positive family history. The patients in the 2 groups were comparable in mean age (P = .3) and sex distribution (P = .09). Patients with positive family history had a younger age of onset (median, 11-20 years vs 21-30 years, P < .0001); longer duration of constipation (20 +/- 14 vs 15 +/- 13, P = .016); more complications, eg, symptomatic hemorrhoids, anal fissure, and rectal prolapse (54.2% vs 40.4%, P = .034); less precipitating factors leading to the onset of constipation (35.6% vs 49.1%, P = .037); more frequent use of digital evacuation (27.1% vs 13.2%, P = .008), but no difference in the association with psychological disorders (P = .3); transit time (P = .5); or manometric dyssynergia (P = .5).

CONCLUSIONS

Patients with idiopathic constipation and with a positive family history exhibited different clinical characteristics. This might be related to the early age of onset of the symptoms, which might, in turn, give clues to the underlying etiology.

Enteric nervous system and developmental abnormalities in childhood

ENS consists of a complex network of neurons, organised in several plexuses, which interact by means of numerous neurotransmitters. It is capable of modulating the intestinal motility, exocrine and endocrine secretions, microcirculation and immune and inflammatory responses within the gastrointestinal tract, independent of the central nervous system. Though the embryological development of various plexuses are completed by mid-way of gestation, the maturation of neurons and nerve plexuses appear to continue well after birth. Therefore, any histological or functional abnormalities related to the gastrointestinal function must be investigated with the ongoing maturational processes in mind.

Constipation services for children: the role of health visitor teams

Constipation among children is a prevalent condition, yet poorly understood. There is little empirical evidence for 'best possible' configurations of services. This article presents a survey of Walsall health visitor team members (HVTMs) which aimed to identify the types of advice and care provided to young children with constipation, pathways to care and ideas for service improvement. Most HVTM consultations were parent-initiated. Few GPs referred children to HVTMs. HVTMs most commonly provided advice about fluids and diet -- only one prescribed medication. HVTMs identified the need for early intervention, consistent information for parents and a clear pathway for all health professionals to follow. Currently, a team from the local primary and hospital NHS trusts is developing an integrated care pathway for paediatric constipation. Success of such pathways depends on their adoption by GPs and hospital-based health professionals, and on evidence of efficacy arising from their evaluation.

The antegrade continence enema successfully treats idiopathic slow-transit constipation

BACKGROUND

Antegrade continence enemas (ACEs) are successful for constipation and/or fecal incontinence caused by anorectal malformations or spina bifida but have been thought to be less successful in the treatment for patients with colonic dysmotility. We studied the long-term efficacy of ACE in a large group of patients with idiopathic slow-transit constipation (STC).

METHODS

We identified 56 children with an appendicostomy for ACE with radiologically proven STC. An independent investigator (SKK) performed confidential telephone interviews.

RESULTS

We assessed 42 of 56 children (31 boys) of mean age 13.1 years (range, 6.9-25). Mean follow-up was at 48 months (range, 3-118). Mean symptom duration before appendicostomy was 7.5 years (range, 1.4-17.4). Indications for appendicostomy were soiling (29/42), inadequate stool evacuation (7/42), and recurrent hospital admissions for nasogastric washouts (6/42). Both quality of life (Templeton quality of life [P < .0001]) and continence (modified Holschneider continence score [P < .0001]) improved with ACE. Soiling frequency decreased in 32 of 42 (11/32 completely continent). Thirty-seven of 42 children had reduced abdominal pain severity (P < .0001) and frequency (P < .0001). Complications included granulation tissue (33/42), stomal infection (18/42), and washout leakage (16/42). Fifteen of 42 children ceased using the appendicostomy (7/15 symptoms resolved). Thirty-five of 42 families felt that their aspirations had been met.

CONCLUSIONS

Antegrade continence enemas were successful in 34 (81%) of 42 children with STC, contradicting views that ACEs are less effective in patients with colonic dysmotility.

[Case-control study of risk factors associated with constipation. The FREI Study]

BACKGROUND

Children represent one of the patient groups most affected by constipation. Our objective was to identify and describe the risk factors associated with childhood constipation.

PATIENTS AND METHODS

The study had a case-control, retrospective, open and multicenter design. Clinical data on possible risk factors were collected through an ad-hoc questionnaire. Two groups were studied: children with and without constipation.

RESULTS

Nine hundred twenty-one children were recruited; of these, 898 (97.6%) were included in the statistical analysis. There were 408 (45.4%) children in the constipated group and 490 (54.5%) in the non-constipated group. Most of the children with constipation (53.6%) had a maternal history of constipation compared with 21.4% of children without constipation (p < 0.05). More than half (53.2%) of the constipated children reported a lack of regularity in their toilet habits while 64.9 % of the children without constipation went to the toilet regularly. Toilet training started slightly earlier (at 3 years) in children without constipation (93.2%) than in those with the disorder (83.8%) (p < 0.05). At school, 57.4% of the children with constipation never used the toilet compared with 26.8% of those without constipation (p < 0.05). A total of 73.4% of children with constipation drank less than four glasses of water per day compared with 47.1% of those without constipation (p < 0.05). Consumption of vegetables and legumes in the diet was significantly lower in children with constipation than in those without (p < 0.05). The risk factors linked to childhood constipation found in this study were a familial history of constipation, irregular toilet habits, low dietary fiber contents and no fruit intake. The main preventive factors against constipation were water and vegetable consumption and training on the use of the toilet at school.

CONCLUSIONS

Daily toilet training and dietary changes are needed to prevent constipation among children and to achieve regular defecation. This preventive intervention should be reinforced at school.

Paediatric constipation for adult surgeons--article 1: targeting the cause

Constipation is very common in all age groups and can be resistant to standard therapies, producing chronic morbidity. Childhood onset constipation frequently produces symptoms that persist into adulthood. Recent advances have been made in the diagnosis and treatment of childhood constipation that could have application in adult practice. In the first part of the present review, the methods of differentiation of patients with a disorder of colonic motility from those with an anorectal hold-up are discussed. Slow transit constipation, with distinct features on colonic manometry and scintigraphy, has only recently been recognized in children. This diagnosis, together with a novel method of placement of a manometric catheter, is described. While the cause of slow transit constipation remains unclear, clinical features that differ between children and adults may provide an insight into the aetiology. The diagnosis of intestinal neuronal dysplasia is explained and the controversy surrounding the diagnosis outlined. We propose that the traditional histological criteria exclude many other clinically significant forms of dysplasia of the enteric nervous system and should be extended.

Chronic constipation in children: organic disorders are a major cause

Diagnostic tools for paediatric chronic constipation have been limited, leading to over 90% of patients with treatment-resistant constipation being diagnosed with chronic idiopathic constipation, with no discernible organic cause. Work in our institution suggests that a number of children with intractable symptoms actually have slow colonic transit leading to slow transit constipation. This paper reviews recent data suggesting that a significant number of the children with chronic treatment-resistant constipation may have organic causes (slow colonic transit and outlet obstruction) and suggests new approaches to the management of children with chronic treatment-resistant constipation.