Encopresis

Efficacy of atypical antipsychotics in the treatment of fecal incontinence in children and adolescents: a randomized clinical trial

OBJECTIVES

Functional retentive overflow incontinence (retentive FI) is the most common cause of fecal soiling in children. Based on the clinical experiences, the treatment of retentive FI in patients with comorbid psychiatric disorders was accelerated when Risperidone was used as treatment for their psychiatric comorbidities; therefore, this study was conducted to evaluate the effect of risperidone in the treatment of retentive FI in children and adolescents.

METHODS

In this double-blind, randomized, placebo-controlled trial, 140 patients aged 4-16 years eligible for the study were randomized into two groups, receiving either 0.25-0.5 mg of Risperidone syrup (n = 70) or maltodextrin syrup (placebo group, n = 70) every 12 h daily for 12 weeks. Sociodemographic data, including age, sex, weight, height, BMI, BMI z-score, and socioeconomic status, was recorded, and the number of nocturnal FI, diurnal FI, and painful defecations was measured.

RESULTS

136 participants (69 on Risperidone and 67 on placebo) were included in the study. Mean age of participants in the intervention and placebo groups were 7.2 ± 2.4 years and 8.0 ± 3.1 years, respectively. The mean number of nocturnal FI (Ptrend=0.39) and diurnal FI (Ptrend=0.48) in patients without psychiatric comorbidities, and the number of painful defecations for participants with and without psychiatric comorbidities (P = 0.49, P = 0.47, respectively) were not significantly different between the groups, but a significant effect was observed in diurnal FI after Risperidone treatment in patients with psychiatric comorbidities (P < 0.001).

CONCLUSION

Risperidone, when used along with other non-pharmacological interventions, may be helpful in treating FI in pediatric patients with psychiatric comorbidities.

Paediatric constipation for general paediatricians: Review using a case-based and evidence-based approach

Constipation is a common problem in childhood. The most common type of constipation is functional, accounting for 90-95% of all cases. The aim of this review is to provide clinical scenarios with treatment using evidence-based information, and management strategies and a clinical algorithm to guide the management of constipation in children. Recent guidelines and online information sites are detailed. Clinical red flags and organic causes of constipation are included. Four clinical scenarios are presented: case (1) 4-month-old child with constipation since birth and likely Hirschsprung disease; case (2) 6-month-old infant with infant dyschezia; case (3) 4-year old with functional constipation; and; case (4) 9-year old with treatment resistant constipation. Children with functional constipation need a thorough history and physical exam to rule out the presence of any 'red flags' but do not require laboratory investigations. Management includes education and demystification, disimpaction followed by maintenance therapy with oral laxatives, dietary counselling and toilet training. Treatment options differ between infants and children. Disimpaction and maintenance regimens for common laxatives are presented. On treatment failure or on suspicion of organic disease the patient should be referred for further evaluation. The radionuclide intestinal transit study (scintigraphy) is a useful modality for evaluation and planning of management in treatment-resistant children. Treatment options for treatment-resistant patients are presented. High-level evidence (meta-analyses) for pharmalogical and non-pharmalogical treatment modalities are reviewed and an algorithm for assessment and treatment are presented.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Effect of OROS methylphenidate on encopresis in children with attention-deficit/hyperactivity disorder

OBJECTIVES

Although encopresis shows a high rate of comorbidity in patients with attention-deficit/hyperactivity disorder (ADHD), the etiologic origin of this relationship and the effect of ADHD drugs on encopresis are unclear. In this chart review, we explored the effect of OROS long-acting methylphenidate (MPH) treatment on encopresis in children with ADHD. We also evaluated the relationship between the clinical variables of ADHD and encopresis.

METHODS

The sample consisted of 21 children and adolescents (20 boys and 1 girl) with encopresis and coexisting ADHD 7-15 years of age. Their clinical characteristics and baseline (visit 1) and end of the second months' (visit 2) Conners' Parent Rating Scale (CPRS) subscores were recorded. Retrospective clinician determinations were made using the Clinical Global Impressions-Severity subscale (CGI-S) for encopresis severity and the Clinical Global Impressions-Improvement subscale (CGI-I) for encopresis response.

RESULTS

According to the CGI-I, 14 subjects (71.4 %) showed much or very much improvement in their encopresis at the second visit. All of the CPRS scores showed a significant reduction during the second visit. No association was found between the CGI-I score and the changes in any of the CPRS scores. Baseline oppositional defiant disorder (ODD) and conduct disorder (CD) scores were correlated with the CGI-S score; however, no association was found between core ADHD symptom severity and the CGI-S score. With regard to the encopresis outcome, the baseline CD score was negatively correlated with the CGI-I score, and the baseline ODD score was prone to show a negative correlation with the CGI-I score.

CONCLUSIONS

These results suggest that coexisting behavioral problems may be a vulnerability factor based on the severity of encopresis, and that MPH treatment may have a positive effect on encopresis in children and adolescents with ADHD.

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.

Primary care: constipation and encopresis treatment strategies and reasons to refer

The purpose of the study was to assess constipation and encopresis treatment strategies of primary care providers and determine reasons to refer to a pediatric gastroenterology specialist. A closed-ended questionnaire was mailed to a convenience sampling of 237 pediatric primary care providers. Ninety-one questionnaires were returned with a 38% response rate: 74 (81%) pediatricians and 17 (19%) nurse practitioners. The majority of responders recommended pharmacologic treatment and diet changes. Many providers (73%) estimated a 75%-100% success rate when managing constipation, whereas 19% providers estimated a greater than 80% success rate with encopresis patients. The number one reason to refer was unresponsiveness to treatment (71%), followed by parents want a second opinion (15%), rule out organic cause (9%), and management is too time-consuming (5%). Both primary care providers and pediatric gastroenterologists use medication strategies, but diet recommendations are not the same. Unresponsiveness to treatment is the main reason for referral. If better management can occur in the primary care setting, costly specialty services may be avoided and possibly reduce healthcare costs.

Childhood constipation: evaluation and management

Constipation is a common problem in children. It is also a long-term problem persisting for many months to years in children. Approximately 95% of childhood constipation is functional in nature without any obvious cause. Evaluation of a child with constipation requires a thorough history and physical examination. Hirschsprung's disease is an important cause of constipation arising in infancy and requires a thorough diagnostic evaluation and surgical treatment. Treatment of functional constipation in children requires a well-designed plan and a team approach involving the child, parents, and a health care provider. Treatment involves education of the family about constipation and encopresis, fecal disimpaction, and long-term maintenance therapy of laxatives and behavioral modification. Laxatives such as magnesium hydroxide, lactulose, and mineral oil have been used in children for a long time. A new laxative, polyethylene glycol 3350, has been used successfully in children with constipation and encopresis. Several novel therapeutic interventions have been tried for children presenting with intractable constipation, refractory to conventional treatment.

Bacterial overgrowth and methane production in children with encopresis

OBJECTIVES

To assess the prevalence of small intestinal bacterial overgrowth (SIBO) and methane production in children with encopresis.

STUDY DESIGN

Radiographic fecal impaction (FI) scores were assessed in children with secondary, retentive encopresis and compared with the breath test results. Breath tests with hypoosmotic lactulose solution were performed in both the study patients (n = 50) and gastrointestinal control subjects (n = 39) groups.

RESULTS

The FI scores were significantly higher in the patients with encopresis who were methane producers (P < .01). SIBO was diagnosed in 21 of 50 (42%) patients with encopresis and 9 of 39 (23%) of control subjects (P = .06). Methane was produced in 56% of the patients with encopresis versus 23.1% of the control subjects in the gastrointestinal group (P < .01). Fasting methane level was elevated in 48% versus 10.3 %, respectively (P < .01).

CONCLUSIONS

Children with FI and encopresis had a higher prevalence of SIBO, elevated basal methane levels, and higher methane production. Methane production was associated with more severe colonic impaction. Further study is needed to determine whether methane production is a primary or secondary factor in the pathogenesis of SIBO and encopresis.

24-Hour colonic manometry in pediatric slow transit constipation shows significant reductions in antegrade propagation

BACKGROUND

The physiological basis of slow transit constipation (STC) in children remains poorly understood. We wished to examine pan-colonic motility in a group of children with severe chronic constipation refractory to conservative therapy.

METHODS

We performed 24 h pan-colonic manometry in 18 children (13 boys, 11.6 +/- 0.9 yr, range 6.6-18.7 yr) with scintigraphically proven STC. A water-perfused, balloon tipped, 8-channel, silicone catheter with a 7.5 cm intersidehole distance was introduced through a previously formed appendicostomy. Comparison data were obtained from nasocolonic motility studies in 16 healthy young adult controls and per-appendicostomy motility studies in eight constipated children with anorectal retention and/or normal transit on scintigraphy (non-STC).

RESULTS

Antegrade propagating sequences (PS) were significantly less frequent (P < 0.01) in subjects with STC (29 +/- 4 per 24 h) compared to adult (53 +/- 4 per 24 h) and non-STC (70 +/- 14 per 24 h) subjects. High amplitude propagating sequences (HAPS) were of a normal frequency in STC subjects. Retrograde propagating sequences were significantly more frequent (P < 0.05) in non-STC subjects compared to STC and adult subjects. High amplitude retrograde propagating sequences were only identified in the STC and non-STC pediatric groups. The normal increase in motility index associated with waking and ingestion of a meal was absent in STC subjects.

CONCLUSIONS

Prolonged pancolonic manometry in children with STC showed significant impairment in antegrade propagating motor activity and failure to respond to normal physiological stimuli. Despite this, HAPS occurred with normal frequency. These findings suggest significant clinical differences between STC in children and adults.

Treatment of encopresis and chronic constipation in young children: clinical results from interactive parent-child guidance

To describe the source of and treatment for encopresis in a series of 40 children under age 9 years. Referral for psychological based treatment followed upon limited success of standard gastroenterologic intervention. The treatment provided is defined as interactive parent-child family guidance. This includes a variety of specific psychologically based recommendations offered to parents, and, when indicated, direct interventions with the symptomatic child. These are different from various forms of behavioral corrective reward-punishment interventions frequently recommended for young children with encopresis. The pediatric and the psychological literature offer few reports of successful treatment of young children with this syndrome. Also, there are few specific descriptions of psychologically based interventions. The results reported here are of the successful treatment of 38 of 40 cases referred specifically for psychologically based intervention following the prior limited success of standard gastroenterologic treatment. The interactive parent-child family guidance intervention described in this report, differentiated from typical behavior therapies, is a notably successful mode of psychologically based therapy for these children. It offers an important alternative to standard pediatric gastroenterological treatment for encopresis, as well as to reward-punishment oriented behavioral therapies.

Colonic manometry via appendicostomy shows reduced frequency, amplitude, and length of propagating sequences in children with slow-transit constipation

BACKGROUND/PURPOSE

We wish to define colonic motor function in children with slow-transit constipation (STC) using manometry catheters introduced through appendiceal stomas, previously sited for controlling fecal retention by colonic irrigation.

METHODS

We undertook 24-hour pancolonic manometry of 6 children (5 boys; mean, 11.5 years; SD, 3.0) using a multilumen silastic catheter.

RESULTS

were compared to nasocolonic motility studies obtained in healthy young adults.

RESULTS

Antegrade propagating sequences (APSs) originated less frequently in the cecum compared to controls. There were fewer APS (mean +/- SEM: STC, 13 +/- 6 per 24 hours; controls, 52 +/- 6 per 24 hours; P < .01) and high-amplitude propagating contractions (HAPCs: STC, 5 +/- 2 per 24 hours; controls, 9.9 +/- 1.4 per 24 hours; P < .05). The amplitude of APS and HAPC was less in STC (APS, 39 +/- 9 mm Hg; controls, 54 +/- 3 per 24 hours; P < .05) (HAPC: STC, 94 +/- 10 mm Hg; control, 117 +/- 3 mm Hg; P < .01), whereas the amplitude of retrograde propagating sequences was greater in STC (43 +/- 6 mm Hg; control, 27 +/- 1 mm Hg; P < .01). The distances propagated by HAPC were significantly less in STC (36 +/- 4.5 vs 47 +/- 2.3 cm, controls; P < .05), and there was no evidence of a region-specific difference in propagation velocity of APS. Neither meal ingestion nor waking significantly increased colonic motor activity in patients with STC.

CONCLUSIONS

Despite the small numbers available to be studied, we found that children with STC in whom an appendicostomy had been placed show significant abnormalities in pancolonic motor function.

Pediatric Constipation Therapy Using Guidelines and Polyethylene Glycol 3350

OBJECTIVE

To review current guidelines on the treatment of functional constipation in pediatric patients, with an emphasis on the role of polyethylene glycol 3350 (PEG 3350).

DATA SOURCES

Primary medical literature published in English was identified by MEDLINE search (1980—May 2003).

STUDY SELECTION AND DATA EXTRACTION

Recently published treatment guidelines relating to pediatric functional constipation and its pharmacotherapy are assessed and compared. Published trials evaluating PEG 3350 in pediatric subjects are discussed and their results applied to the clinical role and use of this new agent.

DATA SYNTHESIS

Constipation is a common disorder among children. A number of factors may play a role. A variety of medications are commonly used for this disorder, although few treatments have undergone evaluation by controlled clinical trials. Consensus guidelines recommend either osmotic laxatives, mineral oil, or their combination for maintenance treatment in concert with patient and parental education and behavioral training. PEG 3350 solution (MiraLax) has been shown in recent clinical studies to be an effective maintenance treatment for pediatric constipation.

CONCLUSIONS

PEG 3350 is an effective and well-tolerated treatment choice for pediatric constipation, especially as an adjunct to education and behavioral training. PEG 3350 is an option for children with constipation who have failed or are intolerant of other pharmacotherapies. THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT ACPE UNIVERSAL PROGRAM NUMBER: 407-000-04-016-H01

Management of childhood constipation: parents’ experiences

BACKGROUND

Constipation in childhood is common and places a burden on child health services. Whilst constipation can have a variety of causes, for most children it is usually non-organic and requires limited intervention. It has been suggested that health professionals can resent consultations for such a common problem, believing them to be inappropriate. However, they can underestimate the impact of this condition, leading to adverse clinical effects, as well as parental dissatisfaction. Little research has explored parents' experiences of consulting health professionals about the management of childhood constipation.

AIM

To explore parents' experiences of consulting health professionals about management of childhood constipation and to use the findings to inform more effective therapeutic encounters when responding to parental concerns.

METHODS

A phenomenological approach was adopted, using in-depth interviews with parents of 14 children receiving health interventions for constipation.

FINDINGS

Six themes emerged from analysis including: 'enduring and extreme constipation', which reflected the substantial and sustained impact of the child's constipation; 'dismissed and fobbed off', which captured parents' feelings that their concerns were frequently dismissed by health professionals; 'asserting the need for action', a perception that they had reached a point at which they had to demand some intervention; and 'validation and acknowledgement', which reflected acknowledgment that, finally, their concerns for their child had been taken seriously and acted on.

DISCUSSION

The findings indicate a failure by some health professionals to appreciate fully the significance of childhood constipation, thereby appearing to be unconcerned and insensitive to the needs of child and family. The impact of this is a potential loss of trust in health professionals by parents, which can then have implications for how they perceive and access health services for management of this common childhood problem. The findings offer an insight into parental experiences and indicate the need for a more sensitive approach during health consultations.