Treatment of childhood encopresis: a randomized trial comparing three treatment protocols

Comparing quality of life improvement after antegrade continence enema (ACE) therapy for patients with organic and functional constipation / encopresis

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.

The use of biofeedback for children with fecal incontinence secondary to retentive constipation: Experience of a French Pediatric Center

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.

The Effect of Education Given to Children with Functional Constipation and Fecal Incontinence and Their Mothers on Anxiety and Constipation Management

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.

Constipation

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.

Pediatric medical psychology

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.

A Practical Guide to Biofeedback Therapy for Pelvic Floor Disorders

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.

The effectiveness of biofeedback therapy in managing Bladder Bowel Dysfunction in children: A systematic review

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.

Antegrade continence enemas improve quality of life in patients with medically-refractory encopresis

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.

Functional constipation in children: challenges and solutions

This review intends to update what is known about and what is still a challenge in functional constipation (FC) in children regarding epidemiology, pathophysiology, diagnosis, and management. Although FC is a common childhood problem, its global burden remains unknown as data from parts of the world are missing. Another problem is that there is a large variation in prevalence due to differences in study methods and defining age groups. The pathophysiology of FC remains unclear to date but is probably multifactorial. Withholding behavior is likely to be the most important factor in toddlers and young children. Genetics may also play a role since many patients have positive family history, but mutations in genes associated with FC have not been found. Over the past years, different diagnostic criteria for FC in infants and children have been proposed. This year, Rome IV criteria have been released. Compared to Rome III, it eliminates two diagnostic criteria in children under the age of 4 who still wear diapers. Physical examination and taking a thorough medical history are recommended, but other investigations such as abdominal radiography, transabdominal recto-ultrasonography, colonic transit time, rectal biopsies, and colon manometry are not routinely recommended. Regarding treatment, guidelines recommend disimpaction and maintenance therapy with polyethylene glycol (PEG) with or without electrolytes. But experience shows that acceptability, adherence, and tolerance to PEG are still a challenge. Counseling of parents and children about causes of FC is often neglected. Recent studies suggest that behavior therapy added to laxative therapy improves the relief of symptoms. Further homogeneous studies, better-defined outcomes, and studies conducted in primary care are needed.

Defecation-Specific Behavior in Children with Functional Defecation Issues: A Systematic Review

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.

Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders

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.

An evaluation of an inter-disciplinary constipation clinic for childhood constipation

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.

Toilet School for Children with Failure to Toilet Train: Comparing a Group Therapy Model with Individual Treatment

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.

Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society

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.

Screening for autism identifies behavioral disorders in children functional defecation disorders

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.

Laparoscopic Cecostomy Tube Placement

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.

ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders

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).

The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial

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

Review article: faecal incontinence in children: epidemiology, pathophysiology, clinical evaluation and management

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.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

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.

Constipation in childhood

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.

Coexistence of constipation and incontinence in children and adults

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.

Psychosocial co-morbidity affects treatment outcome in children with fecal incontinence

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.

PEG3350 in the treatment of childhood constipation: a multicenter, double-blinded, placebo-controlled trial

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.

Behavioral therapy for childhood constipation: a randomized, controlled trial

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.

Childhood and adolescent constipation: Review and advances in management

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.

Verhaltenstherapie bei Enkopresis am Beispiel einer Patientin mit chronischem »Toiletten-Verweigerungssyndrom«

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".

Darmentleerung, Sauberkeitsentwicklung bei Kindern und ihre Störungen (Obstipation und Enkopresis)

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.

Functional nonretentive fecal incontinence in children

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.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

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.

Does "stubbornness" have a role in pediatric constipation?

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.

Chronic constipation in children: organic disorders are a major cause

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

An Internet intervention as adjunctive therapy for pediatric encopresis

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.

Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis

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.

Trends in referral to a single encopresis clinic over 20 years

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.