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.

Exploring Community Perspectives on Functional Paediatric Habitual Constipation

(1) Background: Functional habitual constipation (FC) in children is a common gastrointestinal problem. This study aimed to explore the local community's view on this problem, emphasising the challenges that parents face in managing the condition and its impact on the child's quality of life. (2) Methods: A prospective, cross-sectional, community-based study was conducted between March and July 2023. The survey received 933 responses. The target population was adults over 18 years of age living in the Eastern Province of Saudi Arabia. An electronically distributed questionnaire was designed in the Arabic language. (3) Results: The mean knowledge scores were significantly higher in females than males, with t (931) = -2.701 and p = 0.007. The Bonferroni post hoc test results indicated that participants between 20 and 29 years exhibited significantly higher levels of knowledge scores compared to those between 30 and 39 years. Furthermore, the results revealed that those with three or more children had significantly higher knowledge scores compared to those with only one child. (4) Conclusions: This study demonstrated that parents in the local community have a good perceived knowledge of FC, but it needs to be linked with practice. They tended to report high levels of perception and demonstrated better practices. These results emphasise the importance of exploring the local community's view on constipation among children.

Measurement of Polyethylene Glycol 3350 With Standard Household Measuring Devices

OBJECTIVE

Though standard household measuring devices (e.g., teaspoons, tablespoons) are often used in clinical practice to measure pediatric doses of polyethylene glycol 3350 (PEG-3350), no published -literature documents the accuracy of these measurements. Standard dosing for adults is 17 grams, which is 1 capful according to the manufacturer. The objective of this study was to determine the weight of household teaspoons and tablespoons of PEG-3350.

METHODS

PEG-3350 measurements were performed using 5 different household measuring teaspoons and tablespoons and the cap that accompanies the bottle for 3 different brands of PEG-3350. Using an electronic balance to determine weights, 3 investigators completed 5 measurements for each of the 5 measurement devices and PEG-3350 bottle caps as follows: leveled teaspoons and tablespoons, unleveled teaspoons and tablespoons, "heaping" tablespoons, half-capfuls, and capfuls.

RESULTS

A leveled teaspoonful of PEG-3350 weighed ∼3.3 grams and an unleveled teaspoonful weighed ∼3.7 grams. A leveled, unleveled, and heaping tablespoon of PEG-3350 weighed about 10, 11, and 15 grams, respectively. Heaping tablespoons, half-capfuls, and capfuls resulted in the most measurement variability.

CONCLUSIONS

Use of a kitchen scale may be the most precise method of measurement, however not all patients have kitchen scales. Standard household measuring devices (teaspoons and tablespoons) may be used to conveniently measure PEG-3350 doses. Using 1 dedicated measurement device and leveling the dose may improve consistency, which could be beneficial for patients who are sensitive to dose variability.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Evaluation and management of enuresis in the general paediatric setting

Assessing enuresis involves distinguishing monosymptomatic from non-monosymptomatic for this common paediatric problem, and identifying concomitant comorbidities. Addressing co-occurring factors concurrently ensures the best opportunity for a satisfactory outcome. Treatment begins with patient and family education on the natural history of enuresis and practical behavioural guidance. Evidence to support particular interventions is limited, and children and families should be involved when choosing appropriate therapy. Enuresis alarms and desmopressin are treatment options when more active intervention is desired. Clinical refinements and combined treatment modalities are emerging.

The Effect of the Flint Water Crisis Secondary to Increased Lead Levels in Drinking Water on Constipation in Children in the City of Flint, Michigan, USA

Introduction  Constipation is a common condition in children, affecting almost one-third of the population at some point in childhood across the world. Functional constipation is the most common cause, with no clear etiology. From April 25, 2014, through October 16, 2015, the water source for the city of Flint residents was untreated Flint River water, which resulted in lead-contaminated drinking water. Lead poisoning has been associated with constipation and has multisystem sequelae, including neurological, muscular, and hematological impacts. Children may be especially vulnerable to this with their higher water intake-to-body weight ratio. There has been no previous study examining the possible relationship between the Flint water crisis and constipation in children. In our study, we aimed to see if the increased lead level in the water had any effect on constipation in children in Flint. Methods We included all children seen and diagnosed with constipation at Hurley Medical Center's Pediatric Gastrointestinal (GI) Clinic. We included only children seen in 2013 (pre-water crisis) and 2017 (post-water crisis). Children with chronic neurologic disorders, celiac disease, hypothyroidism, diabetes, Hirschsprung's disease, short bowel syndrome, and gastrointestinal surgeries were excluded. We looked at the age of presentation, associated symptoms, medications used, need for hospital admission or emergency department (ED) visits, and improvements at follow-up. Results  A total of 79 patients were included in the study. There were 29 patients from 2013 and 50 patients from 2017 (post-lead exposure period). The rate of constipation referrals to the GI clinic for the Flint population of children was significantly higher in 2017 (p=0.001). The most common associated symptom was abdominal pain in both groups. Straining was more prominent in the 2017 group (60%) compared to the 2013 group (34.5%, p=0.029). There was no clinical or statistically significant difference between the groups noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of urinary tract infection (UTI), abdominal distention, or stool impaction. Conclusions The number of patients referred to Hurley's Pediatric GI Clinic for constipation increased after the lead water crisis in Flint. Moreover, straining has significantly increased in post-lead exposure compared to pre-lead exposure. There was no clinical or statistically significant difference noted in abdominal pain, blood in the stool, fecal incontinence, vomiting, history of UTI, abdominal distention, or stool impaction between both groups. A larger study would need to be done to confirm these findings, rule out other cofactors, and look into minerals in water and their effect on intestine innervations.

Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study

BACKGROUND

When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization.

METHODS

We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori.

KEY RESULTS

One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications.

CONCLUSIONS AND INFERENCES

Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.

Lubiprostone for Pediatric Functional Constipation: Randomized, Controlled, Double-Blind Study With Long-term Extension

BACKGROUND & AIMS

Pediatric functional constipation (PFC) is a common problem in children that causes distress and presents treatment challenges to health care professionals. We conducted a randomized, placebo-controlled trial (study 1) in patients with PFC (6-17 years of age) to evaluate the efficacy and safety of lubiprostone, followed by an open-label extension for those who completed the placebo-controlled phase (study 2).

METHODS

Study 1 (NCT02042183) was a phase 3, multicenter, randomized, double-blind, placebo-controlled, 12-week study evaluating the efficacy and safety of lubiprostone 12 μg twice daily (BID) and 24 μg BID. Study 2 (NCT02138136) was a phase 3, long-term, open-label extension of study 1. In both studies, lubiprostone doses were based on patients' weight. Efficacy was assessed solely based on study 1, with a primary endpoint of overall spontaneous bowel movement (SBM) response (increase of ≥1 SBM/wk vs baseline and ≥3 SBMs/wk for ≥9 weeks, including 3 of the final 4 weeks).

RESULTS

606 patients were randomized to treatment (placebo: n = 202; lubiprostone: n = 404) in study 1. No statistically significant difference in overall SBM response rate was observed between the lubiprostone and placebo groups (18.5% vs 14.4%; P = .2245). Both the 12-μg BID and 24-μg BID doses of lubiprostone were well tolerated in the double-blind and extension phases, with a safety profile consistent with that seen in adult studies.

CONCLUSIONS

Lubiprostone did not demonstrate statistically significant effectiveness over placebo in children and adolescents with PFC but did demonstrate a safety profile similar to that in adults. (ClinicalTrials.gov: Number: NCT02042183; Number: NCT02138136).

Controversies on the relationship between increased body mass index and treatment-resistant chronic constipation in children

BACKGROUND

There are conflicting reports on the association between children with increased body mass index (BMI), and constipation. This retrospective chart review of two groups of children from a primary care clinic was designed to address the controversy.

METHODS

Group-1: Charts of all children seen in a year for general pediatric care were reviewed for incidences of increased BMI (>85th percentile) and constipation as well as overweight recognition in the final diagnosis; Group-2: Children diagnosed with constipation at the same primary care setting for 5 years were identified by ICD-9 code. These charts were reviewed for prevalence of increased BMI and incidences of referral to subspecialty clinic.

RESULTS

Group-1: Three hundred nineteen (33.4%) of the 955 children had increased BMI and 28 (2.93%) had constipation. The prevalence of constipation was not increased among children with increased BMI. Group-2: 24 of the 66 children with constipation were referred to the pediatric gastroenterology clinic. children with increased BMI were three times more likely to be referred (n = 20, p = 0.04). The two groups had a similar prevalence of children with increased BMI (Group 1 = 33.4%; Group 2 = 30.3%).

CONCLUSION

In the general pediatric population, children with an increased BMI were not at an increased risk of developing constipation. However, children with increased BMI and constipation were three times more likely to be referred, presumably for treatment failure, to the pediatric gastroenterology clinic .Hence children with increased BMI were more likely to develop treatment resistant constipation.

Efficacy of polyethylene glycol 3350 as compared to lactulose in treatment of ROME IV criteria-defined pediatric functional constipation: A randomized controlled trial

BACKGROUND AND AIMS

Functional constipation is a common childhood problem, with a prevalence of approximately 3% worldwide. The aim of the study was to compare the efficacy of polyethylene glycol (PEG) 3350 and lactulose in the treatment of pediatric functional constipation.

METHODS

A total of 100 subjects with functional constipation were enrolled and centrally randomized to receive PEG 3350 (0.7-1.5 mg/kg/day) or lactulose (0.7-2.0 g/kg/day).

RESULTS

There was a significant increase in median (min, max) stool frequency within 1 week in the PEG 3350 group as compared to the lactulose group (1 [0, 3] to 8 [3, 39] vs. 1 [0, 3] to 7 [1, 17]) (p-value < 0.01). The trend was maintained at week 2, week 3 (p-value < 0.01), and week 4 (p-value = 0.05) with the PEG 3350 group reporting higher weekly median stool frequency than the lactulose group. The PEG group reported significant reduction in painful bowel movements from 68.8% subjects at baseline to 43.8% at the end of first week, whereas the lactulose group reported an increase from 48.9% to 73.3% (p-value = 0.05). Other parameters of constipation, i.e. straining, large diameter stool, and large fecal mass as reported subjectively by parents, significantly decreased from baseline to the end of the study in the PEG 3350 arm compared to those in the lactulose arm. At the end of week 4, there was a statistically significant reduction in all the ROME IV-defined criteria between the two groups.

CONCLUSION

This study proved that the PEG 3350 treatment group had early symptom relief and significant improvement compared to the lactulose group in pediatric functional constipation.

TRIAL REGISTRATION

Clinical Trials Registry India (CTRI/2018/01/011061).

Parents' Experiences and Information Needs While Caring for a Child With Functional Constipation: A Systematic Review

Pediatric functional constipation (FC) reportedly affects at least 1 in 10 children worldwide. Parent and family education is a key component for successful treatment, yet there is little research exploring what information families need and how to best support them. The aim of this review is to synthesize current evidence on the experiences and information needs of parents caring for a child with FC. We systematically searched published research and completed screening against a priori inclusion criteria. Thirteen studies (n = 10 quantitative, n = 3 qualitative) were included. We found 2 main themes, precarious footing and profound and pervasive effects. Heavy caregiving burdens fueled doubts, misinformation, relationship breakdown, and treatment deviation. In light of clinical recommendations, our findings reveal a potential mismatch between parents' needs and care provision for FC. It is likely that both parents and health care providers would benefit from resources and interventions to improve care related to pediatric FC.

Understanding Parents' Experiences When Caring for a Child With Functional Constipation: Interpretive Description Study

BACKGROUND

Pediatric functional constipation (FC) is a common but serious medical condition. Despite significant effects on children, families, and the health care system, the condition is typically undertreated. Parents carry the primary responsibility for complex treatment programs; therefore, understanding their experiences and needs may offer a critical perspective toward improving clinical care.

OBJECTIVE

The aim of this study is to understand and give voice to parents' experiences and information needs when caring for a child with FC. The ultimate objective is to build an evidence base suitable for creating a digital knowledge translation tool to better support parents caring for a child with FC.

METHODS

This qualitative design used an interpretive description methodology to generate findings aimed at improving clinical care. One-on-one, in-depth interviews were completed either in person or through web-based teleconferencing to explore parents' perspectives. Data collection and analysis occurred concurrently.

RESULTS

Analysis of 16 interviews generated 4 major themes: living in the shadows; not taken seriously, with a subtheme of persevering and advocating; missing information and misinformation; and self-doubt and strained relationships. One minor theme of affirmative influences that foster resilience and hope was identified.

CONCLUSIONS

Parents have unmet needs for support and information related to pediatric FC. To address gaps in current care provision, decision makers may consider interventions for clinicians, resources for parents, and shifting care models to better meet parents' needs.

The impact of incorporating toilet-training status in the pediatric Rome IV criteria for functional constipation in infant and toddlers

BACKGROUND

The diagnosis of functional constipation (FC) is based on the Rome criteria. The last edition of the criteria (Rome IV) for infants and toddlers modified the criteria to differentiate toilet-trained (TT) and non-toilet-trained (NTT) children. These changes have not been validated. We aimed to understand the impact of adding toilet training to the diagnostic criteria and to assess the prevalence of FC.

METHODS

Parents of infants and toddlers from six outpatient clinics (four public, two private) located in three geographically dispersed cities in Colombia completed validated questionnaires to diagnose functional gastrointestinal disorders according to Spanish version of Rome IV criteria (QPGS-IV).

RESULTS

A total of 1334 children (24.4 months ±15.0) participated: 482 (36%) TT and 852 (64%) NTT. The prevalence of FC was 21.1%. The prevalence increased with age, 0-1 years 7.7%; 2 years 18.2%; 3 years 23.7%; and 4 years 37.2%. TT vs NTT for FC 41.9% vs 9.3%, respectively (OR 7.06, 95% CI 5.26-9.47, P < .0001). TT more likely to report ≥ 3 criteria (OR = 2.43, 95% CI 1.41-4.21, P = .0015). 18.3% of TT had episodes of fecal incontinence that met the frequency required by Rome for FC (≤1 episode/week). However, 87.1% had fecal incontinence less often. 7.4% of them characterized as large quantity.

CONCLUSION

We found no changes in the prevalence of FC using the Rome IV criteria vs Rome III. TT children are more likely to have FC. Study suggests that changes in Rome IV criteria were potentially clinically relevant and to have adequate face validity. Future studies should confirm our findings.

Physical Therapy for a Child With Encopresis: A Case Report

PURPOSE

To describe the implementation and effectiveness of a multimodal therapeutic approach used to successfully treat a child with encopresis.

SUMMARY OF KEY POINTS

The child demonstrated chronic constipation, poor pelvic floor muscle awareness, weakness, and incoordination during voiding. He participated in 8 sessions of physical therapy intervention including pelvic floor muscle awareness, strengthening and coordination exercises, behavioral adaptations, diet modification, and use of media, art, and interactive visualization activities.

CONCLUSIONS

The child improved pelvic floor muscle strength and coordination and became fully continent of bowel in home and community settings.

WHAT THIS CASE ADDS TO EVIDENCE-BASED PRACTICE

This case report demonstrates that pediatric age-appropriate educational and motivational tools (media, art, and interactive visualization activities) are readily available, economical, and effective when used in conjunction with current practice to decrease impairments and improve active participation and compliance during treatment of retentive encopresis in the pediatric population.

Treatment failure in children diagnosed with constipation in a paediatric emergency department in relation to Rome III criteria

Objective

To determine if treatment failure varies based on ROME III classification and adherence to guideline congruent therapy among children diagnosed in an emergency department with functional constipation.

Methods

Children aged 1 month to 18 years who were diagnosed with constipation in a paediatric emergency department underwent chart review and 7-day phone follow-up to complete the ROME III questionnaire, confirm treatments administered, and assess treatment failure. Participants were classified according to the ROME III criteria as having functional constipation (FC) or irritable bowel syndrome - constipation (IBS-C) subtype. The primary outcome was treatment failure defined as ≥ 2 of the following: 1) presenting symptom persistence; 2) < 1 bowel movement every other day; 3) pain/difficulty passing stools; and 4) abdominal pain between bowel movements.

Results

Five hundred and thirteen children completed follow-up; 40% (204/513) had FC, 23% (118/513) IBS-C, and 37% (191/513) did not meet either criteria. Treatment failure rates in children who received guideline congruent treatment were 28% (38/135) among those classified as FC and 43% (37/86) among those with IBS-C; P=0.02, a difference of 15% (95% confidence interval [CI]: 0.02, 0.27). On regression analysis, ROME III classification was not an independent predictor of treatment failure (odds ratio [OR]: 1.56 [95% CI: 0.97, 2.51]). At 7-day follow up, pain in between bowel movements was present in 22% (44/204) in FC patients versus 45% (53/118) of IBS-C patients; P=0.001.

Conclusions

Treatment failure rates in children who receive guideline congruent therapy are higher among those with IBS-C, however, after adjustment for known confounders the relationship was not statistically significant.

Update on Associated Risk Factors, Diagnosis, and Management of Recurrent Urinary Tract Infections in Children

Recurrent urinary tract infection (rUTI) continues to challenge pediatric care providers. The diagnosis of an rUTI can be difficult, especially in young febrile children. Antibiotic resistance rates continue to rise, which limits oral treatment options. Prophylactic antibiotics are used commonly to manage rUTI, but their use increases the risk of rUTI with antibiotic-resistant strains without significantly reducing renal scarring. Alternative therapies for rUTI include probiotics and anthocyanidins (eg, cranberry extract) to reduce gut colonization by uropathogens and prevent bacterial adhesion to uroepithelia, but efficacy data for these treatments are sparse. The future of rUTI care rests in addressing the following contemporary issues: best diagnostic practices, risk factors associated with rUTI, and the prevention of recurrent infection. In this review, we summarize the state of the art for each of these issues and highlight future studies that will aim to take an alternative approach to managing rUTI.

Lactulose for the treatment of Chinese children with chronic constipation: A randomized controlled trial

BACKGROUND

This study aimed to investigate the efficacy and safety of lactulose for the treatment of Chinese children with chronic constipation.

METHODS

A total of 100 children with chronic constipation were included in this randomized controlled trial. They were equally and randomly allocated to a treatment group (n = 50) and a placebo group (n = 50). The participants in the treatment group received lactulose, while the subjects in the placebo group received placebo intervention. The children in both groups were treated for a total of 6 weeks. The primary outcome was daily stool frequency. The secondary outcomes consisted of stool consistency, measured by the Bristol Stool Form Scale, abdominal pain, flatulence, as well as the adverse events. All outcomes were measured at baseline and after 6-weeks treatment.

RESULTS

After 6 weeks treatment, lactulose showed better outcomes in daily stool frequency (P < .01), and stool consistency (P < .01), except the abdominal pain (P = .24), and flatulence (P = .44), compared with the placebo. Additionally, no significant differences regarding all adverse events were detected between 2 groups.

CONCLUSION

The results of this study found that lactulose is efficacious for Chinese children with chronic constipation after 6-weeks of treatment.

Some Risk Factors of Chronic Functional Constipation Identified in a Pediatric Population Sample from Romania

We conducted an observational study over a 1-year period, including 234 children aged 4–18 years and their caregivers and a matching control group. 60.73% of the children from the study group were males. Average age for the onset of constipation was 26.39 months. The frequency of defecation was 1/4.59 days (1/1.13 days in the control group). 38.49% of the patients in the sample group had a positive family history of functional constipation. The majority of children with functional constipation come from single-parent families, are raised by relatives, or come from orphanages. Constipated subjects had their last meal of the day at later hours and consumed fast foods more frequently than the children in the control sample. We found a statistically significant difference between groups regarding obesity/overweight and constipation (χ² = 104.94, df = 2, p < 0.001) and regarding physical activity and constipation (χ² = 18.419; df = 3; p < 0.001). There was a positive correlation between the number of hours spent watching television/using the computer and the occurrence of the disease (F = 92.162, p < 0.001, and 95% Cl). Children from broken families, with positive family history, defective dietary habits, obesity and sedentary behavior, are at higher risk to develop chronic functional constipation.

Constipation in Children: A Practical Review

Pediatricians and other child care providers manage a large number of children with constipation, a recurrent medical problem that is frustrating to patients, their care givers, and the health care providers themselves. Most often the constipation in children is functional in nature, and only a very small percentage of patients have an organic cause for it. In this review, we discuss the epidemiology, causes, evaluation, and management of children with functional constipation. [Pediatr Ann. 2016;45(5):e189-e196.].

Fecal Impaction Causing Pelvic Venous Compression and Edema

Chronic constipation is a common condition which may result in fecal impaction. A 13-year-old male with chronic constipation and encopresis presented with fecal impaction for three weeks. The impaction caused abdominal pain, distension, encopresis, and decreased oral intake. He was found in severe distress with non-pitting edema of his feet and ankles along with perineal edema. The pedal edema worsened after receiving a fluid bolus, so concern arose for venous compression or a thrombus. A Duplex Ultrasound demonstrated changes in the venous waveforms of the bilateral external iliac and common femoral veins without thrombosis. Manual disimpaction and polyethylene glycol 3350 with electrolytes resolved the pedal and perineal edema. Four months later, he had soft bowel movements without recurrence of the edema. A repeat Duplex Ultrasound was normal. We present a child in whom severe fecal impaction caused pelvic venous compression resulting in bilateral pedal and perineal edema.

Efficacy and complications of polyethylene glycols for treatment of constipation in children: a meta-analysis

Constipation is a common childhood complaint. In 90% to 95% of children, constipation is functional, which means that there is no objective evidence of an underlying pathological condition. Polyethylene glycol (PEG or macrogol) solution is an osmotic laxative agent that is absorbed in only trace amounts from the gastrointestinal tract and routinely used to treat chronic constipation in adults. Here, we report the results of a meta-analysis of PEG-based laxatives compared with lactulose, milk of magnesia (magnesium hydroxide), oral liquid paraffin (mineral oil), or acacia fiber, psyllium fiber, and fructose in children. This meta-analysis was conducted in accordance with PRISMA guidelines and involved searches of MEDLINE, Cochrane, EMBASE, and Google Scholar databases up to February 10, 2014, using the keywords (Constipation OR Functional Constipation OR Fecal Impaction) AND (Children) AND (Polyethylene Glycol OR Laxative). Primary efficacy outcomes included a number of stool passages/wk and percentage of patients who reported satisfactory stool consistency. Secondary safety outcomes included diarrhea, abdominal pain, nausea or vomiting, pain or straining at defecation, bloating or flatulence, hard stool consistency, poor palatability, and rectal bleeding. We identified 231 articles, 27 of which were suitable for full-text review and 10 of which were used in the meta-analysis. Patients who were treated with PEG experienced more successful disimpaction compared with those treated with non-PEG laxatives. Treatment-related adverse events were acceptable and generally well tolerated. PEG-based laxatives are effective and safe for chronic constipation and for resolving fecal impaction in children. Children's acceptance of PEG-based laxatives appears to be better than non-PEG laxatives. Optimal dosages, routes of administration, and PEG regimens should be determined in future randomized controlled studies and meta-analyses.

Pediatric constipation in the emergency department: evaluation, treatment, and outcomes

OBJECTIVES

Limited knowledge exists surrounding the pharmacologic management of pediatric constipation in the emergency department (ED) setting and the success of interventions. Our primary objective was to determine whether enema administration is associated with 7-day ED revisits for persistent symptoms. Secondary objectives focused on assessing other predictors of ED revisits.

METHODS

We conducted a retrospective cohort study of children <18 years old, diagnosed as having constipation (International Classification of Diseases-10 codes F98.1 nonorganic encopresis, K59.0 constipation) in a pediatric ED in Toronto, Canada, between November 2008 and October 2010.

RESULTS

A total of 3592 visits were included; 6% (n = 225) were associated with a revisit. Children with revisits more frequently had vomiting (28% vs 17%, P = 0.001), more pain (5.7 ± 3.6 vs 4.6-3.6 of 10, P = 0.01), and underwent more blood tests (19% 05, 11%, 95% confidence interval [CI] of the difference 3%-14%] and diagnostic imaging (62% vs 47%, 95% CI of the difference 9%-22%). Children administered an enema were 1.54 times more likely to revisit the ED than those who did not receive an enema (8.6% vs 5.5%, 95% CI of the difference 1.1%-5.2%, P = 0.001). Type of enema administered varied by age (P < 0.001). Regression analysis identified the following independent predictors of revisits: diagnostic imaging (odds ratio [OR] 1.54, 95% CI 1.15-2.06), vomiting (OR 1.45, 95% CI 1.07-1.98), enema administration (OR 1.40, 95% CI 1.05-1.88), and significant medical history (OR 1.26, 95% CI 1.04-1.53).

CONCLUSIONS

Enema administration and diagnostic imaging are associated with revisits in children diagnosed with constipation. Their role in the ED management of pediatric constipation requires further evaluation.

A randomised, double-blind study of polyethylene glycol 4000 and lactulose in the treatment of constipation in children

Background

Chronic constipation is frequent in children. The objective of this study is to compare the efficacy and safety of PEG 4000 and lactulose for the treatment of chronic constipation in young children.

Methods

This randomised, double-blind study enrolled 88 young children aged 12 to 36 months, who were randomly assigned to receive lactulose (3.3 g per day) or PEG 4000 (8 g per day) for four weeks. The primary efficacy variable was stool frequency during the fourth week of treatment. Secondary outcomes were the number and frequency of subjective symptoms associated with defecation at each visit.

Results

Stool frequency was comparable in the two groups at baseline (lactulose: 0.7 ± 0.5; PEG 4000: 0.5 ± 0.55). Mean stool frequency increased from 0.70 ± 0.50 stools/day at baseline to 0.80 ± 0.41 at Week 4 in the lactulose group and from 0.50 ± 0.55 to 1.10 ± 0.55 stools/day in the PEG 4000 group. A significant difference was observed in the adjusted mean change from baseline, which was 0.15 stools/day in the lactulose group and 0.51 stools/day in the PEG 4000 group, with a least-squares mean difference of 0.36 stools/day [95% CI: 0.16 to 0.56]. With respect to secondary outcome variables, stool consistency and ease of stool passage improved more in the PEG 4000 group (p = 0.001). The incidence of adverse events was similar in both groups, the majority of which were mild.

Conclusions

PEG 4000 has superior efficacy to lactulose for the treatment of chronic constipation in young children and is well tolerated.

Trial registration

US National Institute of Health Clinical Trials database; study NCT00255372 first registered 17th November 2005.

Hirschsprung disease

PURPOSE OF REVIEW

Hirschsprung disease is relatively common in children. Surgical techniques are available to remove the aganglionic bowel and reconstruct the intestinal tract. Despite many advances, these children may still be difficult to diagnose, and may have ongoing functional problems after surgical correction.

RECENT FINDINGS

The genetic basis and cause of Hirschsprung disease are becoming increasingly clearer. Definitive diagnosis is based on rectal biopsy, but more sophisticated techniques are permitting earlier and more accurate diagnosis. Surgical correction has evolved from routine use of a colostomy and open laparotomy to one-stage transanal and laparoscopic approaches. The range of postoperative problems is reviewed so that the practicing pediatrician and primary care physician can effectively care for these children. Future advances may include better genotype-phenotype correlation and development of neuronal stem cell techniques.

SUMMARY

Pediatricians and primary care physicians have an important role to play in diagnosing and managing children with Hirschsprung disease.

Efeitos do manejo comportamental de incontinência fecal em adolescente

A incontinência fecal, também conhecida como encoprese, é um transtorno de evacuação que acarreta prejuízos ao desenvolvimento psicossocial e orgânico da criança e do adolescente, e que demanda atenção e cuidado de pais e profissionais de saúde. No amplo contexto de tratamento da encoprese, a psicoterapia constitui importante recurso, sendo a terapia comportamental apontada como uma das modalidades mais promissoras e eficazes para o tratamento dessa dificuldade de eliminação. Este artigo apresenta o estudo dos efeitos do manejo comportamental de quadro de incontinência fecal em um adolescente de 14 anos, atendido em clínica-escola de Psicologia do interior do Estado de São Paulo durante 14 meses. A partir do referencial teórico da análise do comportamento, foi desenvolvido, em contexto psicoterápico, um conjunto de estratégias comportamentais com o cliente, bem como orientações aos pais, visando à gradativa extinção encoprética. No decorrer desse processo, o cliente apresentou significativas aquisições comportamentais de uso regular do banheiro e adequado controle esfincteriano, monitoradas semanalmente, que possibilitaram a plena extinção das ocorrências de sujidade, sendo avaliado o efeito em follow-up realizado três meses após o encerramento dessa intervenção.