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Comparing quality of life improvement after antegrade continence enema (ACE) therapy for patients with organic and functional constipation / encopresis. J Pediatr Surg 2022; 57:855-860. [PMID: 35115169 DOI: 10.1016/j.jpedsurg.2021.12.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND We compared patient- and family-reported overall and stool-related quality of life (QoL) before and after an antegrade continence enema (ACE) procedure (cecostomy tube insertion) for refractory chronic constipation or fecal incontinence (CCFI). We hypothesized that patients with functional diagnoses experience similar improvements in QoL compared to those with organic diagnoses. METHODS This is a cross-sectional study of patients undergoing cecostomy tube insertion for CCFI at a tertiary pediatric hospital from 2012 to 2019. Patients and/or primary caregivers completed validated stooling and overall QoL surveys based on three time points: before surgery, three months after surgery, and at the time of survey / date of last follow-up. Repeated measures analyses compared scores over time between subjects and within the diagnostic groups. RESULTS The response rate was 65% (22/34 patients, 12 organic and 10 functional diagnoses). Mean age was 8.3 years and 32% of the participants were female. Organic diagnoses were: spina bifida (6), anorectal malformation (5), and Hirschsprung Disease (1). There was substantial improvement in stool-related and overall QoL at three months post-ACE procedure (both p<0.001) for all patients; both scores continued to improve significantly until the date of last follow-up (median 4.1 years, IQR 2.3-5.6, p<0.001). There was no statistically significant difference in scores between patients with organic and functional diagnoses. CONCLUSIONS Caregivers perceive a significant, sustainable improvement in stooling habits and QoL following ACE therapy. The improvement is comparable between patients with a functional diagnosis and those with an underlying organic reason for their CCFI.
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The use of biofeedback for children with fecal incontinence secondary to retentive constipation: Experience of a French Pediatric Center. Clin Res Hepatol Gastroenterol 2021; 45:101550. [PMID: 33481704 DOI: 10.1016/j.clinre.2020.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fecal incontinence (FI) secondary to chronic retentive constipation is a frequent demand in pediatric gastroenterology clinics. The management of constipation in children includes laxatives (polyethylene glycol, PEG), enhanced toilet training, and dietary advice. Biofeedback is a possible treatment for children above the age of 7 years with resistant FI. AIM To analyze any changes in volume to trigger defecation (VTD) and envy score over the course of biofeedback sessions according to clinical response. METHODS In this retrospective study, we reviewed the medical records of 23 children diagnosed with FI according to the Rome IV criteria and treated with biofeedback. For each biofeedback session, a mean VTD by subject was measured. At the end, therapy was considered a success if soiling disappeared and a failure if any persisted. The need to defecate expressed by the child was described as an envy score. A 0-10 visual analog scale was used to express the intensity of this sensation. Follow-up involved calling the parents 12 months after the biofeedback sessions had ended to assess symptoms remotely. RESULTS The study included 19 boys and 4 girls with a median age of 10 years. Patients' ages ranged between 7 and 17 years. None of them had any associated neurological disorders. All children had FI for >1 year. The median number of soiling episodes per week was 7. The average number of biofeedback sessions was 3 (range 1-5). At the end of the rehabilitation sessions, 12 children (52%) were in the "success" group. In the latter, median VTD decreased from 97 ml to 70 ml between the first and last session. In the "failure" group, VTD decreased from 120 ml to 100 ml. The between-group difference in the median VTD at the first session was not statistically significant. The last observation carried forward (LOCF) VTD was significantly lower in the "success" group compared to the "failure" group (70 ml versus 100 ml, p = 0.03). Median envy scores decreased during the biofeedback sessions with no statistical difference between the groups at the last session. Follow-up of children in the "success" group one year after the last biofeedback session revealed that 10 patients had no relapse (83%) and 2 were lost to follow-up. CONCLUSIONS Biofeedback might be an effective tool for the management of FI resistant to medical treatment in children.
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Yıldırım A, Biçer Ş, Hacıhasanoğlu-Aşılar R, Özdamar MY, Şahin H, Gül V. The Effect of Education Given to Children with Functional Constipation and Fecal Incontinence and Their Mothers on Anxiety and Constipation Management. Florence Nightingale Hemsire Derg 2020; 28:321-332. [PMID: 34263211 PMCID: PMC8134022 DOI: 10.5152/fnjn.2020.19134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/17/2020] [Indexed: 11/30/2022] Open
Abstract
AIM This study aimed to determine the effect of multidimensional training program on children with constipation and fecal incontinence and their mothers on anxiety and their constipation management. METHOD The study had an experimental design with a pretest-posttest control group. The intervention group consisted of children diagnosed with functional constipation (n=20) and fecal incontinence (n=21) and their mothers in the Pediatric Surgery Clinic. The control group consisted of healthy (n=20) children who applied to two different Family Health Centers for any reason. Data were collected between February 2016 and June 2017 using a descriptive questionnaire, a nutrient consumption frequency form, the Rome III diagnostic criteria form, and the Trait Anxiety Scale for Children. RESULTS After the training program, the mean score of the Trait Anxiety Scale for Children decreased in both intervention groups (p<0.01) and increased in the control group (p<0.05). In addition, the frequency of the consumption of milk, caffeinated drinks, and white bread was reduced in the children of both intervention groups after the training program. The consumption of dried legumes, vegetables, and whole wheat bread increased. According to the Rome III diagnostic criteria, it was determined that constipation symptoms were not observed in 50% of the children. CONCLUSION The training program had a significant influence on the prevention and management of constipation and anxiety. Given that constipation is associated with both physical and mental health outcomes, the approach for the treatment should be holistic in nature, involving a multidisciplinary team.
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Affiliation(s)
- Arzu Yıldırım
- Department of Psychiatric Nursing, Yalova University Faculty of Health Sciences, Yalova, Turkey
| | - Şenol Biçer
- Department of Pediatric Surgery, Erzincan Binali Yildirim University School of Medicine, General Surgery, Erzincan, Turkey
| | | | - Mustafa Yaşar Özdamar
- Department of Pediatric Surgery, Erzincan Binali Yildirim University School of Medicine, General Surgery, Erzincan, Turkey
| | - Hilal Şahin
- Division of Dietetics, Department of Nutrition and Dietetics, Erzincan Binali Yildirim University Faculty of Health Sciences, Erzincan, Turkey
| | - Vahdet Gül
- Division of Medical Biochemistry / Internal Medicine, Department of Mental Health and Diseases, Erzincan Binali Yildirim University School of Medicine, Basic Medical Sciences, Erzincan, Turkey
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Abstract
Constipation in otherwise healthy infants and children is a common problem despite confusion about how to precisely define constipation and constipation-related disorders. Constipation may, rarely, be a sign or symptom of a more serious disease or a diagnosis defined only by its symptoms and without any structural or biochemical findings. In the latter case it is classified as a functional gastrointestinal disorder (FGID). FGIDs are defined as disorders that cannot be explained by structural or biochemical findings. The Rome Foundation has standardized diagnostic criteria for all FGIDs. The Rome criteria are based on the available research as well as the clinical experience of the Foundation's assembled experts. The most recent report, Rome IV, described clinical criteria and diagnostic tools and encouraged more rigorous research in the area of FGIDs. The true incidence and prevalence of constipation is difficult to know because it may be treated at home using home remedies or diagnosed at a visit to a primary care provider or to a subspecialist pediatric gastroenterologist. The most recent attempts to define the prevalence of all pediatric FGIDs have been made using the Rome IV criteria. The defined FGID entities that may be associated with the complaint of constipation are infant dyschezia, functional constipation, and nonretentive fecal incontinence. The term encopresis, omitted from Rome IV, is defined by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition The 3 Rome-defined (constipation-related) entities and the APA entity of encopresis are the focus of this review.
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Affiliation(s)
| | - Sarah Mayer-Brown
- Department of Psychiatry and Human Behavior, Hasbro Children's Hospital/Rhode Island Hospital, Warren Alpert School of Medicine at Brown University, Providence, RI
| | | | - Wendy Plante
- Department of Psychiatry and Human Behavior, Hasbro Children's Hospital/Rhode Island Hospital, Warren Alpert School of Medicine at Brown University, Providence, RI
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Parrish C, Bartolini E, Song Y, Hernandez E, Green K, Ostrander R. Pediatric medical psychology. Int Rev Psychiatry 2020; 32:284-297. [PMID: 32091271 DOI: 10.1080/09540261.2019.1705258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Paediatric medical psychology is a specialised field within clinical health psychology focussed on the behavioural, developmental, and psychological needs of children, adolescents, and families in healthcare contexts. Paediatric medical psychologists address a myriad of problems by employing evidence-based evaluations and interventions in order to support the well-being of paediatric patients and their families. In this paper, we provide an overview of paediatric medical psychology including the education and training required to be a paediatric psychologist followed by common problems addressed by paediatric psychology, the settings paediatric psychologists work in, and the services they provide. Discussion concludes with future application of integrating paediatric psychology throughout the continuum of care to optimise adjustment and health of paediatric patients.
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Affiliation(s)
- Carisa Parrish
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Ellen Bartolini
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Youlim Song
- Department of Psychological and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Emily Hernandez
- College of Social and Behavioral Sciences, California State University Northridge, Northridge, CA, USA
| | - Katerina Green
- The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rick Ostrander
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
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Abstract
PURPOSE OF REVIEW Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy. RECENT FINDINGS The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.
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7
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Philichi L. Management of Childhood Functional Constipation. J Pediatr Health Care 2018; 32:103-111. [PMID: 29229066 DOI: 10.1016/j.pedhc.2017.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 08/24/2017] [Accepted: 08/30/2017] [Indexed: 12/17/2022]
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Tremback-Ball A, Gherghel E, Hegge A, Kindig K, Marsico H, Scanlon R. The effectiveness of biofeedback therapy in managing Bladder Bowel Dysfunction in children: A systematic review. J Pediatr Rehabil Med 2018; 11:161-173. [PMID: 30223405 DOI: 10.3233/prm-170527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this study was to examine the effects of biofeedback therapy as a non-invasive intervention to treat Bladder Bowel Dysfunction in pediatrics. METHODS Six databases were searched between February 2016 and September 2016. Biofeedback studies for children aged 4-16 with idiopathic urinary or fecal incontinence were included. Articles were excluded on subjects' medical histories, study design, timeline of study, and lacking expert review. Quality was determined using Sackett's Levels of Evidence and the PEDro scale. RESULTS Twelve articles were included in the review. Quality of evidence was moderate, as the average PEDro score of the selected articles was 5.3. The participants' ages ranged from 4-16 years old. Studies demonstrated that a multifactorial approach consisting of biofeedback therapy and behavioral modification can be successful in resolving Bladder Bowel Dysfunction. CONCLUSION Biofeedback is a beneficial treatment for children with dysfunctional voiding and functional fecal incontinence. More conclusive research needs to be completed to explore the effects of biofeedback therapy treatment to make more concrete conclusions. Healthcare professionals should consider biofeedback as an alternative approach in conjunction with traditional treatments. A multidisciplinary approach is best when treating dysfunctional voiding and functional fecal incontinence in the pediatric population.
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Investigating the Effect of Nurse-Centered Strategies on Functional Chronic Constipation of Children aged 3-14 years Referring to Imam Reza Clinic of Shiraz University of Medical Sciences in 2014. SHIRAZ E-MEDICAL JOURNAL 2017. [DOI: 10.5812/semj.14874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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10
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Church JT, Simha S, Wild LC, Teitelbaum DH, Ehrlich PF. Antegrade continence enemas improve quality of life in patients with medically-refractory encopresis. J Pediatr Surg 2017; 52:778-782. [PMID: 28190558 DOI: 10.1016/j.jpedsurg.2017.01.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 01/23/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE Fecal incontinence is a socially debilitating problem for many children. We hypothesized that in selected patients with medically-refractory encopresis, placement of an appendicostomy or cecostomy tube for administration of antegrade continence enemas (ACE) would improve quality of life (QOL). METHODS We reviewed all patients with encopresis who underwent appendicostomy or cecostomy placement from 2003 to 2014 at our institution. We contacted subjects' parents by phone and administered 3 surveys: a survey reflecting current stooling habits, a disease-specific QOL survey, and the PedsQL™ QOL survey. QOL surveys were completed twice by parents, once reflecting pre-operative QOL, then again reflecting current QOL. Pre-procedure and post-procedure scores were compared by paired t-test. RESULTS Ten patients underwent appendicostomy/cecostomy for encopresis. Eight completed phone surveys. All procedures were performed laparoscopically. All patients experienced fecal soiling pre-operatively, whereas 5/8 surveyed patients (63%) noted complete resolution of soiling post-procedure (p<0.01). General and disease-specific QOL improved from pre-procedure to post-procedure in the following domains: social habits, physical activity, ability to spend the night elsewhere, feeling, and overall QOL (p<0.05). PedsQL™ scores improved significantly in physical functioning, social functioning, and overall functioning (p<0.05). CONCLUSIONS Antegrade continence enemas significantly improve quality of life in patients with medically-refractory encopresis, likely related to resolution of soiling. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Joseph T Church
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Sidd Simha
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Laurie C Wild
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Daniel H Teitelbaum
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Peter F Ehrlich
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
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Levy EI, Lemmens R, Vandenplas Y, Devreker T. Functional constipation in children: challenges and solutions. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2017; 8:19-27. [PMID: 29388621 PMCID: PMC5774595 DOI: 10.2147/phmt.s110940] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Elvira Ingrid Levy
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Roel Lemmens
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Yvan Vandenplas
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Thierry Devreker
- Kidz Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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12
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Beaudry-Bellefeuille I, Booth D, Lane SJ. Defecation-Specific Behavior in Children with Functional Defecation Issues: A Systematic Review. Perm J 2017; 21:17-047. [PMID: 29035187 PMCID: PMC5638627 DOI: 10.7812/tpp/17-047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
CONTEXT Atypical defecation habits are common and distressing for children and families and can have a major impact on quality of life. Often, no underlying factor can be identified, and the defecation disorder is considered functional. Current interventions are not successful for up to 50% of children. We suggest this high failure rate may be caused by lack of consistency in descriptors of behavioral indicators for functional defecation problems. Most investigations and descriptors focus on general behavior. There are fewer reports concerning defecation-specific behaviors. OBJECTIVE To develop a thorough inventory of defecation-specific behaviors, providing a more informed foundation for assessment and intervention. DESIGN A systematic review of six common databases was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Reference lists of retained articles were screened for additional studies. MAIN OUTCOME MEASURES Content analysis was used to classify defecation-specific behaviors into 17 categories. RESULTS Our search yielded 2677 articles; 98 peer-reviewed publications were retained for full-text review, and 67 articles were included in the final qualitative synthesis. Although there is inconsistency in reported diagnostic criteria, stool withholding and manifesting pain on defecation are the most commonly reported defecation-specific behaviors. In the studies that included children with autism or attention-deficit/hyperactivity disorder, the defecation-specific behaviors were not unique to the diagnostic group. CONCLUSION Consistent use of established diagnostic criteria, along with use of behaviors identified through this review, lay a foundation for more effective interventions.
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Affiliation(s)
| | - Debbie Booth
- Senior Librarian at the University of Newcastle in Callaghan, New South Wales, Australia.
| | - Shelly J Lane
- Professor of Occupational Therapy at the University of Newcastle School of Health Sciences in Callaghan, New South Wales, Australia.
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13
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Shepard JA, Poler JE, Grabman JH. Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2016; 46:767-797. [PMID: 27911597 DOI: 10.1080/15374416.2016.1247356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pediatric elimination disorders are common in childhood, yet psychosocial correlates are generally unclear. Given the physiological concomitants of both enuresis and encopresis, and the fact that many children with elimination disorders are initially brought to their primary care physician for treatment, medical evaluation and management are crucial and may serve as the first-line treatment approach. Scientific investigation on psychological and behavioral interventions has progressed over the past couple of decades, resulting in the identification of effective treatments for enuresis and encopresis. However, the body of literature has inherent challenges, particularly given the multicomponent nature of many of the treatment packages. This review identified 25 intervention studies-18 for nocturnal enuresis and 7 for encopresis-over the past 15 years and classified them according to the guidelines set forth by the Task Force on the Promotion and Dissemination of Psychological Procedures. For nocturnal enuresis, the urine alarm and dry-bed training were identified as well-established treatments, Full Spectrum Home Therapy was probably efficacious, lifting was possibly efficacious, and hypnotherapy and retention control training were classified as treatments of questionable efficacy. For encopresis, only two probably efficacious treatments were identified: biofeedback and enhanced toilet training (ETT). Best practice recommendations and suggestions for future research are provided to address existing limitations, including heterogeneity and the multicomponent nature of many of the interventions for pediatric elimination disorders.
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Affiliation(s)
- Jaclyn A Shepard
- a Department of Psychiatry & Neurobehavioral Sciences , University of Virginia School of Medicine
| | - Joseph E Poler
- a Department of Psychiatry & Neurobehavioral Sciences , University of Virginia School of Medicine
| | - Jesse H Grabman
- a Department of Psychiatry & Neurobehavioral Sciences , University of Virginia School of Medicine
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14
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Devitt P, Thornley E, Hinks M. An evaluation of an inter-disciplinary constipation clinic for childhood constipation. J Res Nurs 2016. [DOI: 10.1177/1744987107079589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Childhood constipation is a common chronic condition that has considerable implications for both the children who suffer from it and their families. The complex nature of the condition requires an multi-faceted response. Recognising this, a multidisciplinary clinic was set up in a hospital in the north-west of England. This article reports the process and outcomes of an evaluation of the clinic. The evaluation combined data from a number of sources and both qualitative and quantitative data were collected. Questionnaires and one-to-one interviews were employed. The sample included both service users and medical consultants. Families reported on the impact that the condition had on their perceived quality of life. The multidisciplinary `joined-up' approach was valued by both service users and medical consultants.
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Affiliation(s)
- Patric Devitt
- Salford Centre for Nursing Midwifery and Collaborative Research, School of Nursing, University of Salford, Salford,
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15
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Toilet School for Children with Failure to Toilet Train: Comparing a Group Therapy Model with Individual Treatment. J Dev Behav Pediatr 2016; 37:223-30. [PMID: 26950340 DOI: 10.1097/dbp.0000000000000278] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study compared the toileting outcomes of children participating in Toilet School group therapy with children in individual treatment. METHOD All children in this study failed conventional toilet training and were 4 to 6 year, 11 month old. Cases were 63 children who attended a 6-week Toilet School group therapy with their parents. Controls were 62 children who were seen in individual treatment in the same tertiary care program and were matched to cases based on treatment dates. We analyzed the number of toileting benchmarks met for cases and controls. We used a stepwise linear regression model to investigate the contribution of child and family factors in predicting the number of toileting benchmarks met. RESULTS Compared to controls, cases achieved significantly more toileting benchmarks (p < .001) at the end of Toilet School, were more likely to have bowel movements in the toilet (p = .001), and required fewer subsequent visits until completion of toilet training (p = .013). Similarly, at the seventh provider encounter for both controls and cases, the cases continued to achieve significantly more toileting benchmarks (p < .001) and were more likely to have bowel movements in the toilet (p = .002) compared to controls. After adjusting for age, gender, neighborhood poverty level, and number of total clinical visits for fecal incontinence, treatment grouping was the only independent variable that predicted toileting progress. CONCLUSION For children with failure to toilet train, group treatment involving both the child and the family results in greater improvement in toileting outcomes than individual treatment.
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16
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Koppen IJN, von Gontard A, Chase J, Cooper CS, Rittig CS, Bauer SB, Homsy Y, Yang SS, Benninga MA. Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society. J Pediatr Urol 2016; 12:56-64. [PMID: 26654481 DOI: 10.1016/j.jpurol.2015.09.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/30/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI). OBJECTIVE To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI. RECOMMENDATIONS Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.
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Affiliation(s)
- I J N Koppen
- Department of Pediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands.
| | - A von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
| | - J Chase
- Paediatric Gastroenterology Victoria, Royal Children's Hospital, Melbourne, Australia
| | - C S Cooper
- Division of Pediatric Urology, University of Iowa, Iowa City, United States of America
| | - C S Rittig
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - S B Bauer
- Department of Urology, Boston Children's Hospital, Boston, United States of America
| | - Y Homsy
- Children's Urology Group, All Children's Hospital/Johns Hopkins Medicine, University of South Florida, Tampa, FL, United States of America
| | - S S Yang
- Taipei Tzu Chi Hospital, Buddhist Medical Foundation, New Taipei, Taiwan; School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
| | - M A Benninga
- Department of Pediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
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Kuizenga-Wessel S, Di Lorenzo C, Nicholson LM, Butter EM, Ratliff-Schaub KL, Benninga MA, Williams KC. Screening for autism identifies behavioral disorders in children functional defecation disorders. Eur J Pediatr 2016; 175:1371-8. [PMID: 27624626 PMCID: PMC5031734 DOI: 10.1007/s00431-016-2775-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/27/2016] [Accepted: 09/04/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED This study prospectively assessed whether positive screening surveys for autism spectrum disorders (ASDs) in children with functional defecation disorders (FDDs) accurately identify ASD. Parents of children (4-12 years) who met Rome III criteria for functional constipation (FC), FC with fecal incontinence (FI) and functional nonretentive FI (FNRFI) completed two ASD screening surveys. Children with positive screens were referred for psychological evaluation, and a year later, follow-up surveys were conducted. Of the 97 study participants, 30.9 % were diagnosed with FC, 62.9 % with FC with FI, and 6.2 % with FNRFI. ASD surveys were positive for 27 children (27.8 %). New DSM diagnoses were made in 10 out of the 15 children that completed further evaluation. Two (2.1 %) met criteria for ASD, and 12 (12.4 %) met criteria for other behavioral disorders. Average SRS and SCQ-L scores were higher in subjects with FC with FI as compared to FC alone and in those who reported no improvement versus those who reported improvement 1 year later. CONCLUSION While positive ASD screening surveys did not correctly identify ASD in the majority, it did help to identify other unrecognized behavioral disorders in children with FDD. High screening scores were more common in children with FC with FI and in children with poorer responses to current medical treatments. WHAT IS KNOWN •A prior study found that 29 % of children with FDD scored positive on ASD screening questionnaires. •Whether positive screens correctly identify ASD in children with FDD is unknown. What is New: •This study shows that positive ASD screens do not correctly identify ASD in children with FDD. However, the use of ASD screening questionnaires can identify previously unrecognized and untreated behavioral/developmental disorders in children with FDD. •High screening scores are more common in children with FC with FI and in children with poorer responses to current medical treatments.
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Affiliation(s)
- Sophie Kuizenga-Wessel
- Department of Pediatric Gastroenterology, Emma Children's Hospital AMC, H7-250, PO Box 22700, Amsterdam, 1100 DD, The Netherlands. .,Department of Pediatric Gastroenterology, Nationwide Children's Hospital Columbus, Columbus, OH, USA.
| | - Carlo Di Lorenzo
- Department of Pediatric Gastroenterology, Nationwide Children’s Hospital Columbus, Columbus, OH USA
| | - Lisa M. Nicholson
- Department of Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, IL USA
| | - Eric M. Butter
- Department of Behavioral Health, Child Development Center, Nationwide Children’s Hospital, Columbus, OH USA
| | - Karen L. Ratliff-Schaub
- Department of Behavioral Health, Child Development Center, Nationwide Children’s Hospital, Columbus, OH USA
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology, Emma Children’s Hospital AMC, H7-250, PO Box 22700, Amsterdam, 1100 DD The Netherlands
| | - Kent C. Williams
- Department of Pediatric Gastroenterology, Nationwide Children’s Hospital Columbus, Columbus, OH USA
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Abstract
Fecal incontinence is a debilitating problem for many children, especially those with anorectal malformations. Historically, surgical options have included the Malone antegrade continence enema, using an appendicostomy for antegrade colonic enemas. Since the development of this procedure, multiple alternatives have been developed, including the Chait cecostomy tube. Here, we present our technique for laparoscopic cecostomy tube placement. We find that this approach has several advantages, including mobilization of the cecum to allow the tube to be placed below the waistline for optimal cosmesis and comfort, increased safety provided by direct vision of needle access to the cecum, and increased security of the cecum to the abdominal wall allowing for safer tube replacement should it become dislodged in the early postoperative period.
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Rao SS, Benninga MA, Bharucha AE, Chiarioni G, Di Lorenzo C, Whitehead WE. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil 2015; 27:594-609. [PMID: 25828100 PMCID: PMC4409469 DOI: 10.1111/nmo.12520] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 12/30/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anorectal disorders such as dyssynergic defecation, fecal incontinence, levator ani syndrome, and solitary rectal ulcer syndrome are common, and affect both the adult and pediatric populations. Although they are treated with several treatment approaches, over the last two decades, biofeedback therapy using visual and verbal feedback techniques has emerged as an useful option. Because it is safe, it is commonly recommended. However, the clinical efficacy of biofeedback therapy in adults and children is not clearly known, and there is a lack of critical appraisal of the techniques used and the outcomes of biofeedback therapy for these disorders. PURPOSE The American Neurogastroenterology and Motility Society and the European Society of Neurogastroenterology and Motility convened a task force to examine the indications, study performance characteristics, methodologies used, and the efficacy of biofeedback therapy, and to provide evidence-based recommendations. Based on the strength of evidence, biofeedback therapy is recommended for the short-term and long-term treatment of constipation with dyssynergic defecation (Level I, Grade A), and for the treatment of fecal incontinence (Level II, Grade B). Biofeedback therapy may be useful in the short-term treatment of Levator Ani Syndrome with dyssynergic defecation (Level II, Grade B), and solitary rectal ulcer syndrome with dyssynergic defecation (Level III, Grade C), but the evidence is fair. Evidence does not support the use of biofeedback for the treatment of childhood constipation (Level 1, Grade D).
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Affiliation(s)
- Satish S.C. Rao
- Section of Gastroenterology/Hepatology, Georgia Regents University, Augusta, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Emma Children’s Hospital/Academic Medical Centre, Amsterdam, The Netherlands
| | - Adil E Bharucha
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Chiarioni
- Division of Gastroenterology of the University of Verona, A.O.U.I. Verona, Italy and Division of Gastroenterology/Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Carlo Di Lorenzo
- Department of Pediatric Gastroenterology, Nationwide Children’s Hospital, Columbus, OH, USA
| | - William E Whitehead
- Division of Gastroenterology/Hepatology, University of North Carolina, Chapel Hill, NC, USA
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Freeman KA, Riley A, Duke DC, Fu R. Systematic Review and Meta-Analysis of Behavioral Interventions for Fecal Incontinence With Constipation. J Pediatr Psychol 2014; 39:887-902. [DOI: 10.1093/jpepsy/jsu039] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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21
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The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial. BMC Pediatr 2013; 13:112. [PMID: 23914827 PMCID: PMC3750818 DOI: 10.1186/1471-2431-13-112] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 06/17/2013] [Indexed: 12/13/2022] Open
Abstract
Background Functional constipation is a common disorder worldwide and is found in all paediatric age groups. Functional constipation can be caused by delayed colonic transit or dysfunction of the pelvic floor muscles. Standard medical care in paediatric practice is often based on clinical experience and mainly consists of a behavioural approach and toilet training, along with the prescription of laxatives. Evidence to evaluate the effectiveness of pelvic physiotherapy for this complaint is lacking. Methods/design A two-armed multicentre randomised controlled trial has been designed. We hypothesise that the combination of pelvic physiotherapy and standard medical care will be more effective than standard medical care alone for constipated children, aged 5 to 17 years. Children with functional constipation according to the Rome III will be included. Web-based baseline and follow-up measurements, scheduled at 3 and 6 months after inclusion, consist of the numeric rating scale in relation to the perceived severity of the problem, the Strength and Difficulties Questionnaire and subjective improvement post-intervention (global perceived effect). Examination of the pelvic floor muscle functions, including digital testing and biofeedback, will take place during baseline and follow-up measurements at the physiotherapist. The control group will only receive standard medical care, involving at least three contacts during five months, whereas the experimental group will receive standard medical care plus pelvic physiotherapy, with a maximum of six contacts. The physiotherapy intervention will include standard medical care, pelvic floor muscle training, attention to breathing, relaxation and awareness of body and posture. The study duration will be six months from randomisation, with a three-year recruitment period. The primary outcome is the absence of functional constipation according to the Rome III criteria. Discussion This section discusses the relevance of publishing the study design and the development of the presented physiotherapy protocol. It also addresses difficulties when interpreting the literature with regard to the effectiveness of biofeedback, potential confounding, and future research indications. To our knowledge, this article is the first to describe the design of a randomised controlled trial among children with constipation to assess the effect of pelvic physiotherapy as an add-on to standard medical care. Trial registration Current Controlled Trials NL30551.068.09
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22
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Rajindrajith S, Devanarayana NM, Benninga MA. Review article: faecal incontinence in children: epidemiology, pathophysiology, clinical evaluation and management. Aliment Pharmacol Ther 2013; 37:37-48. [PMID: 23106105 DOI: 10.1111/apt.12103] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 05/23/2012] [Accepted: 10/02/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Faecal incontinence (FI) in children is a significant gastrointestinal problem, with great personal and social impacts. It is characterised by recurrent loss of faecal matter into the underwear. Both functional and organic causes contribute to its aetiology with the former predominating. AIM To review the epidemiology, pathophysiology, clinical evaluation and management of functional faecal incontinence in children. METHODS A PubMed search was conducted using search terms f(a)ecal incontinence, and encopresis. Articles on epidemiology, pathophysiology, clinical evaluation, investigation and management of functional FI in children were retrieved and assessed. RESULTS Community prevalence of this distressing problem ranges from 0.8% to 7.8% globally. Male: female ratio varies from 3:1 to 6:1. The diagnosis of FI is often based on established clinical criteria. The majority (82%) have constipation associated functional FI. Biopsychosocial factors play a crucial role in the pathogenesis. Limited physiological testing of anorectal function is recommended in the diagnostic procedures, particularly in children with atypical symptoms and possible organic disorders. Management of FI needs a multidisciplinary approach which includes establishment of an effective doctor-patient partnership, understanding the underlying mechanisms, pharmacotherapy and behavioural treatment. Approximately 15% of children with functional nonretentive faecal incontinence (FNRFI) had the same symptoms at the age of 18 years. CONCLUSION Significant therapeutic advances have been made for retentive faecal incontinence, but treatment options for functional nonretentive faecal incontinence are limited. Limited long-term outcome data show that the majority outgrow faecal incontinence. A substantial proportion of children progress to adulthood with faecal incontinence.
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Affiliation(s)
- S Rajindrajith
- Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.
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Brazzelli M, Griffiths PV, Cody JD, Tappin D. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev 2011; 2011:CD002240. [PMID: 22161370 PMCID: PMC7103956 DOI: 10.1002/14651858.cd002240.pub4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Faecal incontinence is a common and potentially distressing disorder of childhood. OBJECTIVES To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children. SEARCH METHODS We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted authors in the field to identify any additional or unpublished studies. SELECTION CRITERIA Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children. DATA COLLECTION AND ANALYSIS Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate. MAIN RESULTS Twenty one randomised trials with a total of 1371 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65). AUTHORS' CONCLUSIONS There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.
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Affiliation(s)
- Miriam Brazzelli
- University of EdinburghDivision of Clinical NeurosciencesBramwell Dott Building, Western General HospitalCrewe RoadEdinburghUKEH4 2XU
| | - Peter V Griffiths
- Stirling Royal InfirmaryDepartment of Child Psychology1 Randolph RoadStirlingScotlandUKFK8 2AU
| | - June D Cody
- University of AberdeenCochrane Incontinence Review Group2nd Floor, Health Sciences BuildingHealth Sciences BuildingForesterhillAberdeenUKAB25 2ZD
| | - David Tappin
- Glasgow UniversityChild Health DepartmentPEACH UnitQueen Mother's Tower Block, Yorkhill HospitalGlasgowUKG3 8SJ
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Abstract
Constipation in children is an often long-lasting pediatric functional gastrointestinal disorder with a worldwide prevalence varying between 0.7% and 29.6%, and estimated health-care costs of US$3.9 billion per year in the USA alone. The pathophysiology of childhood constipation is multifactorial and remains incompletely understood; however, withholding of stools, starting after an experience of a hard, painful, or frightening bowel movement is the most common cause found in children. A thorough medical history and physical examination, including a rectal examination in combination with a bowel diary, is sufficient in the majority of cases to diagnose constipation. The current standard treatment consists of education, toilet training, disimpaction, maintenance therapy and long-term follow-up. In the past decade, well-designed treatment trials in the pediatric population have emerged and long-term outcome studies have been completed. This Review summarizes the current knowledge of the clinical aspects of childhood constipation, including pathogenesis, diagnosis and treatment, with particular emphasis on the latest available data.
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Nurko S, Scott SM. Coexistence of constipation and incontinence in children and adults. Best Pract Res Clin Gastroenterol 2011; 25:29-41. [PMID: 21382577 PMCID: PMC3050525 DOI: 10.1016/j.bpg.2010.12.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 12/04/2010] [Accepted: 12/15/2010] [Indexed: 01/31/2023]
Abstract
The coexistence of constipation and fecal incontinence has long been recognised in paediatric and geriatric populations, but is grossly underappreciated in the rest of the adult population. In children, functional fecal incontinence is usually associated with constipation, stool retention and incomplete evacuation, and is frequently allied to urinary incontinence. Pathophysiology of the incontinence is incompletely understood, although both in children and adults, it is thought to be secondary to overflow, while in adults it may also be related to pelvic floor dysfunction and denervation. Incontinence has an important impact on quality of life and daily functioning, and in children may be associated with behaviour problems. The treatment of underlying constipation usually results in improvement in incontinence. This review broadly addresses the epidemiology and pathophysiology of coexistent constipation and incontinence in both children and adults, and also reviews clinical presentation and treatment response in pediatrics.
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Affiliation(s)
- S Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, Boston, Massachusetts 02155, USA
| | - SM Scott
- Academic Surgical Unit & Neurogastroenterology Group, Centre for Digestive Diseases Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, Queen Mary University London, UK
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van Everdingen-Faasen EQ, Gerritsen BJ, Mulder PGH, Fliers EA, Groeneweg M. Psychosocial co-morbidity affects treatment outcome in children with fecal incontinence. Eur J Pediatr 2008; 167:985-9. [PMID: 17952465 DOI: 10.1007/s00431-007-0619-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 09/24/2007] [Indexed: 11/28/2022]
Abstract
Fecal incontinence is a common disorder in children. Many children with fecal incontinence have psychosocial co-morbidity. In this study, the effect of psychosocial co-morbidity on the treatment outcome of children with fecal incontinence was evaluated. One hundred and fifty children with fecal incontinence were treated in a multidisciplinary program. All children had been treated unsuccessfully for at least one year before entering the program. The treatment consisted of laxative treatment, psychosocial interventions, and biofeedback training. Psychosocial co-morbidity was classified according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). One hundred and forty-one children were completely analyzed (102 boys, mean age 9.6 (range 6.5-16.5) years). Of these, 31 (22%) children had fecal incontinence without constipation and 110 (78%) children had fecal incontinence associated with constipation. In 95% of children, at least one psychosocial co-morbidity was present. Treatment was successful at 12 months in 69% of patients. Treatment was less successful in children with attention deficit hyperactivity disorder (ADHD), in children with parent-child relational problems, and in mentally retarded children. The results indicate that the early assessment and treatment of psychosocial co-morbidity might improve treatment response in children with fecal incontinence. Children with fecal incontinence are treated less successfully in the first year if they have ADHD, parent-child relational problems, or mental retardation. Psychosocial evaluation and the early assessment and treatment of psychosocial co-morbidity is indicated in order to improve response rate. Family counseling--aimed at improving parent-child relations--should be an integral part of a multidisciplinary treatment program for fecal incontinence.
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Nurko S, Youssef NN, Sabri M, Langseder A, McGowan J, Cleveland M, Di Lorenzo C. PEG3350 in the treatment of childhood constipation: a multicenter, double-blinded, placebo-controlled trial. J Pediatr 2008; 153:254-61, 261.e1. [PMID: 18534221 DOI: 10.1016/j.jpeds.2008.01.039] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2007] [Revised: 12/05/2007] [Accepted: 01/29/2008] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To establish the efficacy and best starting dose of polyethylene glycol (PEG)3350 in the short-term treatment of children with functional constipation. STUDY DESIGN Prospective, randomized, multicenter, double-blinded, placebo-controlled, dose-ranging study of PEG3350 in children with functional constipation. Patients were randomly assigned to either placebo or 0.2 g/kg per day, 0.4 g/kg per day, or 0.8 g/kg per day of PEG3350 after a 1 week run-in period, followed by 2 weeks of treatment. All received behavior modification. The primary outcome was the proportion of patients with a successful treatment response: >or=3 bowel movements (BM) in the second week. RESULTS 103 children (mean, 8.5 +/- 3.1 years) were enrolled. 77%, 74%, and 73% of the 0.2, 0.4, and 0.8 g/kg groups were successfully treated, as compared with 42% receiving placebo (P < .04). There was a significant increase in BM (P < .001) and straining improvement (P < .05) with the different PEG3350 doses. Stool consistency improved significantly for doses 0.4 g/kg or higher (P < .001). There was more abdominal pain and fecal incontinence in patients receiving 0.8 g/kg. PEG3350 was well tolerated. CONCLUSIONS This placebo-controlled study confirms the efficacy and safety of PEG3350 for the short-term treatment of children with functional constipation. We recommend a starting dose of 0.4 g/kg per day.
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Affiliation(s)
- Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Children's Hospital Boston, MA 02115, USA.
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Carvalho RS, Michail S, Ashai-Khan F, Mezoff AG. An update on pediatric gastroenterology and nutrition: a review of some recent advances. Curr Probl Pediatr Adolesc Health Care 2008; 38:204-28. [PMID: 18647667 DOI: 10.1016/j.cppeds.2008.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ryan S Carvalho
- Children's Medical Center of Dayton, Wright State Unicersith Boonsshoft School of Medicine, Department of Pediatrics, Division of Gastroenterology and Nutrition, Dayton, Ohio, USA
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van Dijk M, Bongers MEJ, de Vries GJ, Grootenhuis MA, Last BF, Benninga MA. Behavioral therapy for childhood constipation: a randomized, controlled trial. Pediatrics 2008; 121:e1334-41. [PMID: 18450876 DOI: 10.1542/peds.2007-2402] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE It has been suggested that the addition of behavioral interventions to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. Our aim was to evaluate the clinical effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood. PATIENTS AND METHODS In this randomized, controlled trial conducted in a tertiary hospital in The Netherlands, 134 children aged 4 to 18 years with functional constipation were randomly assigned to 22 weeks (12 visits) of either behavioral therapy or conventional treatment. Primary outcomes were defecation frequency, fecal incontinence frequency, and success rate. Success was defined as defecation frequency of > or = 3 times per week and fecal incontinence frequency of < or = 1 times per 2 weeks irrespective of laxative use. Secondary outcomes were stool-withholding behavior and behavior problems. Outcomes were evaluated at the end of treatment and at 6-months follow-up. All of the analyses were done by intention to treat. RESULTS Defecation frequency was significantly higher for conventional treatment. Fecal incontinence frequency showed no difference between treatments. After 22 weeks, success rates did not differ between conventional treatment and behavioral therapy (respectively, 62.3% and 51.5%), nor did it differ at 6 months of follow-up (respectively, 57.3% and 42.3%). The proportion of children withholding stools was not different between interventions. At follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7% vs 29.2%). CONCLUSION Behavioral therapy with laxatives has no advantage over conventional treatment in treating childhood constipation. However, when behavior problems are present, behavioral therapy or referral to mental health services should be considered.
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Affiliation(s)
- Marieke van Dijk
- Psychosocial Department, Emma Children's Hospital, Academic Medical Center, Room G8-224, PO Box 22700, 1100 DE Amsterdam, The Netherlands.
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Youssef NN. Childhood and adolescent constipation: Review and advances in management. ACTA ACUST UNITED AC 2007; 10:401-11. [PMID: 17897578 DOI: 10.1007/s11938-007-0040-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Constipation is a common symptom throughout all ages in the pediatric population, both sexes, and all educational and socioeconomic levels. It is estimated that 12% to 30% of the general population suffers from functional constipation. A practical overview of pathogenic mechanisms contributing to constipation is presented, with emphasis on evaluation and management options available to the treating practitioner. The evaluation of constipation requires careful history taking and interpretation. Diagnostic tests such as manometry and colonic scintigraphy are reserved for those severely affected. Constipation can be challenging to treat, especially if pain and discomfort are predominant features. Therapy requires early recognition of the problem; support by physicians and family members; identification and explanation of contributing factors; and the providing of medications, including osmotic and/or stimulant laxatives. When constipation becomes refractory to standard medical treatment, more novel considerations may include probiotics, botulinum toxin, mind-body interventions, electrical stimulation of the intestine, and surgery.
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Affiliation(s)
- Nader N Youssef
- Nader N. Youssef, Center for Pediatric Irritable Bowel and Motility Disorders, Goryeb Children’s Hospital at Atlantic Health, University of Medicine and Dentistry of New Jersey, 100 Madison Avenue, Internal Box 82, Morristown, NJ 07962, USA.
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Hansen B, Lehmkuhl U. Verhaltenstherapie bei Enkopresis am Beispiel einer Patientin mit chronischem »Toiletten-Verweigerungssyndrom«. Prax Kinderpsychol Kinderpsychiatr 2007; 56:535-48. [PMID: 17902395 DOI: 10.13109/prkk.2007.56.6.535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Encopresis is one of the areas of the psychiatric diseases in childhood and adolescence that has been less researched. There is not much literature on the treatment of encopresis. The article describes a standard behavioural therapy including a case report on a 7, 9 year old girl with chronic "toilet-refusal-syndrome".
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Affiliation(s)
- Berit Hansen
- Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters.
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Claßen M. Darmentleerung, Sauberkeitsentwicklung bei Kindern und ihre Störungen (Obstipation und Enkopresis). KINDHEIT UND ENTWICKLUNG 2007. [DOI: 10.1026/0942-5403.16.1.50] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Zusammenfassung. Verstopfung und Stuhlinkontinenz bei Kindern stellen für die Betroffenen und deren Familien eine schwere Belastung dar. In den meisten Fällen liegen funktionelle Störungen ohne organische Erkrankungen zugrunde. Trotzdem muss bei jedem Kind eine zielgerichtete somatische Diagnostik erfolgen. Rein psychische Ursachen für Obstipation und Inkontinenz sind eher selten. Nach Eingrenzen der Diagnose kann durch verschiedene Therapieansätze eine Besserung der Symptomatik erfolgen. Neben medikamentösen und diätetischen Maßnahmen stehen verhaltenstherapeutische Ansätze im Vordergrund. Der vorliegende Text gibt einen Überblick über den aktuellen Stand der wissenschaftlichen Erkenntnisse zu Kontinenzentwicklung, Physiologie und Pathophysiologie der Darmentleerung sowie Diagnostik und Behandlung von Obstipation und Enkopresis aus pädiatrisch-gastroenterologischer Sicht.
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Abstract
Fecal incontinence, the loss of feces in the underwear after age 4 years, is a frustrating phenomenon for children and their parents. It is difficult to treat, presenting as a single symptom without any organic cause or signs of constipation. This review addresses the definition of functional nonretentive fecal incontinence and provides an overview of its epidemiology, pathophysiology, clinical features, diagnostic work-up and prognosis.
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Affiliation(s)
- Marloes E J Bongers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, The Netherlands.
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Liem O, Di Lorenzo C, Taminiau JA, Mousa HM, Benninga MA. Current Treatment of Childhood Constipation. ACTA ACUST UNITED AC 2007. [DOI: 10.1159/000101716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev 2006:CD002240. [PMID: 16625557 DOI: 10.1002/14651858.cd002240.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Faecal incontinence is a common and potentially distressing disorder of childhood. OBJECTIVES To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children. SEARCH STRATEGY We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 February 2006). SELECTION CRITERIA Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children. DATA COLLECTION AND ANALYSIS Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate. MAIN RESULTS Eighteen randomised trials with a total of 1168 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons. Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months). In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65). AUTHORS' CONCLUSIONS There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.
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Affiliation(s)
- M Brazzelli
- University of Edinburgh, Bramwell Dott Building, Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh, UK, EH4 2XU.
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Burket RC, Cox DJ, Tam AP, Ritterband L, Borowitz S, Sutphen J, Stein CA, Kovatchev B. Does "stubbornness" have a role in pediatric constipation? J Dev Behav Pediatr 2006; 27:106-11. [PMID: 16682873 DOI: 10.1097/00004703-200604000-00004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to determine if children with constipation are more stubborn, both in general and specifically regarding toileting behaviors, than children without constipation. A secondary objective was to determine if constipated children who are more stubborn are less likely to respond to routine therapeutic interventions than less stubborn constipated children. One hundred one children aged 2 to 6 years, who were first-time presenters (never received treatment) to their primary care physician (PCP) with constipation, were compared with 84 nonconstipated control children of similar age range. Comparison measures included general stubbornness and toilet-specific stubbornness (active resistance to participating in appropriate toileting behaviors). Measures of stubbornness were generated from retrospective questionnaires, prospective toileting diaries completed by the parents, and direct experimenter observations. The constipated children were treated by their PCP for 2 months and then reassessed. Constipated children were perceived by their parents to be significantly more stubborn than control children generally and specifically in terms of toileting. Some study evidence suggested that constipated children who continued to have difficulties after 2 months of treatment by their PCPs were perceived by their parents to have significantly more general stubbornness than constipated children who responded to treatment. Parent-perceived toilet-specific stubbornness significantly improved after successful treatment of the constipation by their PCP. The finding that constipated children had more parent-perceived stubbornness than children without constipation is notable because it may play a role in the development and/or maintenance of this bowel dysfunction as well as being an obstacle in treatment compliance.
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Affiliation(s)
- Roger C Burket
- University of Virginia Health Sciences Center, Charlottesville, VA, USA.
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Abstract
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.
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Affiliation(s)
- B R Southwell
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
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Affiliation(s)
- M A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Academic Medical Centre, Amsterdam, the Netherlands.
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Ritterband LM, Cox DJ, Walker LS, Kovatchev B, McKnight L, Patel K, Borowitz S, Sutphen J. An Internet intervention as adjunctive therapy for pediatric encopresis. J Consult Clin Psychol 2003; 71:910-7. [PMID: 14516239 DOI: 10.1037/0022-006x.71.5.910] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study evaluated the benefits of enhanced toilet training delivered through the Internet for children with encopresis. Twenty-four children with encopresis were randomly assigned to the Internet intervention group (Web) or no Internet intervention group (No-Web). All participants continued to receive routine care from their primary care physician. The Web participants demonstrated greater improvements in terms of reduced fecal soiling, increased defecation in the toilet, and increased unprompted trips to the toilet (ps<.02). Both groups demonstrated similar improvements in knowledge and toileting behaviors. Internet interventions may be an effective way of delivering sophisticated behavioral interventions to a large and dispersed population in a convenient format.
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Affiliation(s)
- Lee M Ritterband
- Department of Psychiatric Medicine, Center for Behavioral Medicine Research, University of Virginia Health System, Charlottesville, VA 22908 USA.
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Pashankar DS, Bishop WP, Loening-Baucke V. Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis. Clin Pediatr (Phila) 2003; 42:815-9. [PMID: 14686553 DOI: 10.1177/000992280304200907] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Seventy-four children (43 with chronic constipation, 31 with constipation and encopresis) treated with polyethylene glycol 3350 (PEG) for longer than 3 months were studied to assess long-term efficacy. The mean duration of PEG therapy was 8.4 months (range, 3-30). Weekly stool frequency, stool consistency, and symptoms associated with constipation improved significantly with PEG therapy in all 74 patients. In 31 children with encopresis, soiling ceased completely in 16 patients and frequency of soiling decreased significantly in all others. The average effective long-term dose of PEG was 0.7 g/kg/day. Long-term PEG therapy is effective for the treatment of chronic constipation with and without encopresis in children.
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Affiliation(s)
- Dinesh S Pashankar
- Division of Gastroenterology, Children's Hospital of Iowa, University of Iowa, Iowa City, Iowa 52242-1083, USA
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Fishman L, Rappaport L, Schonwald A, Nurko S. Trends in referral to a single encopresis clinic over 20 years. Pediatrics 2003; 111:e604-7. [PMID: 12728118 DOI: 10.1542/peds.111.5.e604] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To compare the characteristics of children with encopresis referred to a single encopresis clinic over the course of 20 years, including symptoms, previous diagnostic and therapeutic interventions, and parental attitudes. METHODS A retrospective study was conducted of an encopresis clinic at a tertiary care pediatric hospital. Questionnaires at initial evaluation elicited information about bowel habits, soiling, previous evaluations, previous treatments, and parental attitudes. RESULTS In 503 children with encopresis, the average age of referral dropped from 115 months during the earliest 5 years to 77 months during the most recent 5 years. Children who had soiling for >3 years before referral decreased from 63% to 12%. The use of barium enema before referral decreased from 14% to 5%, as did psychological evaluation, from 25% to 14%. Previous therapy with enemas decreased from 45% to 27%. Mineral oil use remained at approximately 50%, and 20% of children had no previous treatment. Symptoms at referral and parental attitudes did not change across the years. CONCLUSIONS Children are now referred at an earlier age to our tertiary encopresis clinic. The number of invasive and psychological evaluations has decreased before referral. However, treatment by many primary care providers before the referral has not changed. These data may suggest that pediatricians have increased awareness of encopresis and greater appreciation of its primarily physical rather than psychological nature. Additional studies will be needed to determine how these factors affect outcome.
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Affiliation(s)
- Laurie Fishman
- Combined Program in Gastroenterology and Nutrition, Children's Hospital, Boston, Massachusetts 02115, USA.
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