Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Systematic review of family and pediatric constipation: An overlooked piece of the puzzle

The objective of this review is to summarize pertinent literature looking at family dynamics and/or adherence to treatment in pediatric functional constipation. A structured systematic literature search was conducted on MEDLINE, Embase, and Web of Science core collection libraries from the years 2000 to 2023 using specific search terms: constipation, treatment adherence, family dynamics, parenting style, and pediatrics. Seventy-one publications were identified and included for review. After screening based on alignment to the review, 20 publications remained. These publications were placed into three categories depending on their intent and findings: (1) recommendations to further increase adherence, (2) studies analyzing factors of adherence, and (3) studies stating a need for a better understanding of family factors. A future area of research is identifying the associations between family factors on adherence to constipation treatment regimens. Results from such studies would increase the amount of positive treatment outcomes and decrease unnecessary healthcare costs.

Development and survey of a questionnaire to measure parental perceptions of childhood defecation and constipation

BACKGROUND

There are insufficient data and measuring tools for parental perception of defecation and constipation in Thai children. The primary objective of this study was to develop a tool to measure parental perceptions towards defecation and constipation in children. The secondary objective was to identify parental understanding and misconceptions about these issues.

METHODS

The authors developed a questionnaire in three domains: knowledge, attitude, and practice. Content validity was evaluated using the item-objective congruence index (IOC) by five experts. The reliability of the measure was assessed based on both internal consistency and test-retest reliability. Then, a descriptive cross-sectional survey was conducted on Thai parents at pediatric outpatient clinics and wards in Bhumibol Adulyadej Hospital.

RESULTS

The authors developed a first draft questionnaire consisting of 31 items, which were categorized into three domains of knowledge, attitude, and practice. During expert validation, five items were disqualified. To assess the questionnaire's reliability, Cronbach's alpha value was calculated and found to be 0.229 for the original questionnaire. However, after removing irrelevant questions, Cronbach's alpha value increased to 0.511 for an 18-item questionnaire. The adjusted questionnaire demonstrated excellent test-retest reliability (Intraclass correlation coefficient, ICC = 0.91). The survey with 306 parents revealed parental misconceptions about the pathophysiology of stool withholding, stool soiling indicating constipation, toilet training after meals, and monitoring bowel movements.

CONCLUSION

The developed questionnaire helps to assess parental perception regarding defecation and constipation in Thai children. Based on the survey results, the authors suggest that parental education on these issues is still necessary.

Diagnosis and management of food allergy-induced constipation in young children-An EAACI position paper

The recognition of constipation as a possible non-Immunoglobulin E (IgE)-mediated allergic condition is challenging because functional constipation (unrelated to food allergies) is a common health problem with a reported worldwide prevalence rate of up to 32.2% in children. However, many studies in children report challenge proven cow's milk allergy and constipation as a primary symptom and have found that between 28% and 78% of children improve on a cow's milk elimination diet. Due to the paucity of data and a focus on IgE-mediated allergy, not all food allergy guidelines list constipation as a symptom of food allergy. Yet, it is included in all cow's milk allergy guidelines available in English language. The Exploring Non-IgE-Mediated Allergy (ENIGMA) Task Force (TF) of the European Academy for Allergy and Clinical Immunology (EAACI) considers in this paper constipation in the context of failure of standard treatment and discuss the role of food allergens as culprit in constipation in children. This position paper used the Delphi approach in reaching consensus on both diagnosis and management, as currently published data are insufficient to support a systematic review.

Psychiatric Features of Children with Chronic Functional Constipation: Focusing on Individuals with Autism Spectrum Disorder

PURPOSE

The present study aimed to assess the psychiatric characteristics of children with chronic functional constipation using the Aberrant Behavior Checklist-Japanese version and the Pervasive Developmental Disorders/Autism Society Japan Rating Scale, and to examine the frequency of autism spectrum disorder in children with chronic functional constipation. We also investigated differences in treatment duration between children with and without autism spectrum disorder.

METHODS

Treatment outcomes were examined retrospectively for 55 participants (chronic functional constipation group: n = 30, mean age 3.4 years; control group: n = 25, mean age, 4.5 years). The association between chronic functional constipation and autism spectrum disorder was evaluated using multivariable logistic regression analysis.

RESULTS

The mean Aberrant Behavior Checklist score and frequency of individuals with autism spectrum disorder were significantly higher in the chronic functional constipation group. After adjusting for age and sex, chronic functional constipation was significantly associated with autism spectrum disorder. In the chronic functional constipation group, the frequency of onset was significantly higher in children with autism spectrum disorder under 1 year of age. When treated, the mean duration of constipation was significantly longer in children with autism spectrum disorder.

CONCLUSION

Pediatricians, pediatric surgeons, and child psychiatrists should work closely to ensure appropriate treatment of chronic functional constipation in children with autism spectrum disorder.

Fifteen-minute consultation: Management of constipation in childhood

Constipation is common in childhood. It is a frequent presentation to primary care and common reason for referral to secondary and tertiary care. In the majority of cases, childhood constipation is idiopathic, with no significant underlying cause, but still presents a significant issue to patients, families and healthcare providers. We consider a case of idiopathic constipation, review the current evidence base for investigations and treatment and suggest practical management strategies.

Efficacy of transcutaneous posterior tibial nerve stimulation in functional constipation

Most children with functional constipation (FC) improve with conventional treatments. However, a proportion of children have poor treatment outcomes. Management of intractable FC may include botulinum toxin injections, transanal irrigation, antegrade enemas, colonic resections, and in some cases sacral nerve stimulation (SNS). SNS is surgically placed, not readily available and expensive. Posterior tibial nerve stimulation (PTNS) allows transmission of electronic impulses and retrograde stimulation to the sacral nerve plexus in a portable, simple and non-invasive fashion. To assess the efficacy and safety of transcutaneous PTNS for the treatment of FC in children. Single-center, prospective interventional study. Children 4-14 years with Rome IV diagnosis of FC received ten daily PTNS (30 min/day) sessions. Electrodes placed over skin of ankle. Strength of stimulus was below pain threshold. Outcomes were assessed during treatment and 7 days after. Twenty-three subjects enrolled. Two children excluded (acute gastroenteritis, COVID-19 contact). Twenty completed the study (4-14 years), (8.4 ± 3.2 years, 71.4% female). We found significant improvement in the consistency of bowel movements (BM) (p = 0.005), fecal incontinence (FI) (p = 0.005), abdominal pain presence (p = < 0.001) and intensity (p = 0.005), and a significant for improvement in blood in stools (p = 0.037). There was 86.3% improvement in abdominal pain. 96.7% reported treatment satisfaction. Only one child required rescue therapy.

CONCLUSION

We found significant improvement in stool consistency, FI, abdominal pain, and hematochezia. This suggests that transcutaneous PTNS could be a promising noninvasive treatment for FC in children. Large studies are needed.

WHAT IS KNOWN

• Functional constipation is one of the most common disorders in children. • Current management of functional constipation consists of an integrative approach that includes medications, diet and behavioral strategies.

WHAT IS NEW

• Posterior tibial nerve stimulation is a novel noninvasive and easy to use therapy that can improve stool consistency, fecal incontinence and blood in stools.

Providing a Constipation Action Plan to Families of Children With Constipation Decreases Health Care Utilization

OBJECTIVES

To evaluate whether providing a constipation action plan (CAP) to families of children with constipation at outpatient gastroenterology (GI) visits affects health care utilization of the GI department.

METHODS

We created a CAP to be included in the after visit summary of children seen in our GI Clinic. We compared the number of patient telephone calls, electronic messages, and urgent care (UC) visits, emergency department (ED) visits, and hospitalizations within 3 months after the visit of patients who received the CAP compared to those who did not using inverse probability treatment weighting (IPTW) analysis. For families who received the CAP at a follow-up visit, we compared these variables in the 3 months before and after the CAP was provided using paired t test and McNemar's test as appropriate.

RESULTS

We included 336 patients who received the CAP and 2812 who did not. After IPTW adjustment, there were fewer patient telephone calls for patients who received the CAP (P = 0.0006). The difference in patient electronic messages was not statistically significant (P = 0.09). For the 45 patients who received the CAP at a follow-up visit, there were on average 1.8 more patient telephone calls made prior to receiving the CAP than after (95% confidence interval (CI) = 0.8-2.8; P = 0.0007) and 2.3 more patient electronic messages received (95% CI = 0.1-4.5; P = 0.04). There were no differences in UC/emergency department visits or hospitalizations.

CONCLUSIONS

We found that providing a CAP to families of children with constipation decreases health care utilization. Further studies are needed to determine whether this impacts patient outcomes.

Rectal measurements and their correlation with bowel habits: Evaluation by trans-abdominal ultrasound in children with functional constipation

AIM

Constipation is one of the most common complaints in childhood affecting the quality of life of both children and parents. This study intends to investigate rectal measurements on ultrasound and their relationship with bowel habits.

METHODS

In this cross-sectional study, 100 children with functional constipation (FC) referred to a single hospital between 2018 and 2019 were enrolled. After obtaining informed consent, a questionnaire including demographic and constipation characteristics was completed, and a physical examination including digital rectal examination (DRE) was performed. Complete abdominopelvic ultrasound was then performed. Target measurements included rectal transverse diameter (RTD), rectal anterior wall thickness (RAWT) and the presence of faecal impaction.

RESULTS

One hundred children with a mean age of 7.68 ± 3.30 years were present in the study. The mean duration of constipation was 15.86 ± 13.34 months. In 14% of children, painful defaecation was reported. 88% of children had some degree of faecal incontinence. According to the ultrasound findings, the mean RTD and RAWT were 3.39 ± 0.73 cm and 2.77 ± 0.68 mm, respectively, and faecal impaction was present in 70% of cases. There was a positive correlation between RTD and RAWT with age, duration of constipation and the presence of hard stools, and there was a negative correlation with frequency of defecation (P < 0.05).

CONCLUSION

RTD and RAWT increased with increasing constipation duration and the presence of hard stools and decreased with increasing frequency of defaecation. DRE could be omitted from the initial clinical assessment if you had access to reliable ultrasound data.

Management Approach of Pediatric Constipation

Constipation is a common challenge in pediatrics. Abdominal radiographs are frequently taken in the pediatric emergency department for diagnosis despite their inadequate reliability to detect the pathology or the degree of constipation. Misdiagnosis of constipation may cause multiple vague physician visits, deployment of emergency medical services, use of radiation, unnecessary laboratory tests, and even surgical procedures. The primary evidence-based suggestions are based on published guidelines that include management of constipation in children divided into three stages of therapy: (1) disimpaction, (2) maintenance therapy, and (3) behavior modification, and special care should be given to neonates and to children with pre-existing medical problems.

Impact of Infant Milk-Type and Childhood Eating Behaviors on Functional Constipation in Preschool Children

OBJECTIVE

To investigate the association between functional constipation, infant feeding in early infancy and eating behavior in preschool children.

METHODOLOGY

A cross-sectional study was undertaken in public and private schools in the state of Sergipe (Northeast of Brazil). The sample calculation was based on a 25% estimate of constipation prevalence in Brazilian children, resulting in a sample size of 1051 children. Functional constipation was assessed using Rome IV criteria. Eating behavior was assessed using the Children's Eating Behavior Questionnaire. Adjusted odds ratios were estimated using a multivariate model.

RESULTS

The prevalence of functional constipation was 23%. After adjusting for water intake, children with food fussiness were >6 times likely to have constipation (odds ratio [OR] = 6.65; 95% confidence interval [CI] 5.19-8.52). Children who were fed with cow's milk in the first 6 months of age were up to 15.2 times more likely to have functional constipation. Bottle feeding at 0-6 months of age increased the risk of functional constipation at preschool age (whole cow's milk: OR = 17.02; 95% CI 7.33-39.51, infant formula: OR = 6.35; 95% CI 3.42-11.79, mixed breastfeeding: OR = 10.83; 95% CI 4.57-25.69).

CONCLUSION

Food fussiness and the use of cow's milk-based feeding bottles at 0-6 months of age were associated with functional constipation in preschool children.

Clinical Efficacy of Infantile Massage in the Treatment of Infant Functional Constipation: A Meta-Analysis

Background: Functional constipation in children is a common disease that causes a psychological burden on infants and young children across the world. It will greatly affect infant quality of life in early childhood and even affect their psychological and physical health. At present, infant functional constipation is treated with western drugs alone, but this can produce drug dependency. In recent years, Traditional Chinese Medicine (TCM) infant massage has been used as a complementary and alternative therapy, and its effectiveness and safety have been proven, attracting the attention of numerous researchers.

Objective: Our study aimed to compare the influence of infant massage intervention on defecation frequency and consistency, determine the effectiveness, and safety of infant massage in the treatment of infant functional constipation, and obtain high-quality clinical evidence.

Methods: Based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement, inclusion, and exclusion criteria were formulated. Randomized controlled trials (RCTs) on TCM infant massage for the treatment of infant functional constipation were found following a search of four mainstream medical databases. RCTs found to meet the study's requirement were included; data information was then extracted, and the quality was assessed using the Cochrane bias risk assessment tool. Through RevMan software, a meta-analysis was carried out for overall effective rate, stool form, defecation frequency, defecation difficulty, and constipation symptom scoring index. The relative risk (RR) and 95% confidence interval (95% CI) were calculated, heterogeneity was tested and its source was found, and publication bias was assessed through the Egger's and Begg's tests and by means of funnel plots.

Results: A total of 23 RCTs and 2,005 patients were included. The results of the meta-analysis showed that compared to drug therapy alone, TCM infant massage had a superior effect on the treatment of infant functional constipation. This difference was statistically significant (p < 0.05) and evaluated according to the overall effective rate (RR = 1.25; 95% CI = 1.17, 1.33), defecation frequency [mean difference (MD) = −0.72; 95% CI = −0.80, −0.65], and constipation symptom score (MD = −0.81; 95% CI = −1.20, −0.43), showing that TCM infant massage is indeed superior to drug therapy alone in the treatment of infant functional constipation. TCM infant massage was found to be equivalent to drug therapy alone in terms of the stool form score [−0.30 (−0.38, −0.22)] and the defecation difficulty score [−0.73 (−0.81, −0.65)], since the difference was not statistically significant (p > 0.05). The source of heterogeneity might be related to the state of patient, manipulation of the massages, efficacy of drugs in the control group, and difference in judgment criteria for efficacy. The Egger's test and Begg's test showed that publication bias did not occur in our study.

Conclusion: TCM infant massage can increase defecation frequency and reduce the symptoms of constipation in children suffering from functional constipation; in addition, the clinical trial showed beneficial effects. Since some of the RCTs featured a very small sample size, the reliability and validity of our study's conclusion may have been affected as well; therefore, the explanation should be treated with some caution. In the future, a large number of higher-quality RCTs are still needed to confirm the results of our study.

Evaluation of Fecal Incontinence in Pediatric Functional Constipation: Clinical Utility of Anorectal and Colon Manometry

OBJECTIVES

The aim of the study is to evaluate the utility of motility studies in pediatric functional constipation with/without fecal incontinence.

PATIENTS AND METHODS

Patients with functional constipation and failure to conventional therapy undergoing colonic manometry (CM) and/or anorectal manometry (ARM) manometry were classified as functional constipation without fecal incontinence (FC) or with fecal incontinence (FCI). Clinical data, motility parameters, and treatment outcomes were compared.

RESULTS

A total of 280 were included, and all patients underwent CM (229 FC and 51 FCI) and 219 ARM. We found no difference in CM interpretation and presence of normal high amplitude propagating contractions (HAPCs) between groups; however, patients with FCI had higher frequency and presence of HAPCs and normal gastrocolonic meal response (GC). No CM parameter predicted outcomes. In FC, more patients with an abnormal CM responded to therapy compared to those with a normal study (79% vs 65% respectively, P = 0.04). FCI patients had lower median anal resting pressure compared to FC (49 vs 66 mmHg, respectively, P = 0.03); no other ARM parameter differentiated FC from FCI. We found no association between therapy response and ARM interpretation (P = 0.847) or any ARM parameter. A multivariate analysis found only male gender was associated with FCI (P < 0.001).

CONCLUSIONS

FCI patients have higher frequency of normal CM parameters compared to FC, but overall interpretation was no different. CM helped predict response to therapy in FC but not in FCI. ARM demonstrated no added benefit in the evaluation of functional constipation with/without soiling. Patients with both normal ARM and CM had a lower response to therapy than those with abnormal studies.

Preparing Nurses for Palliative Care in the NICU

BACKGROUND

Neonatal intensive care unit (NICU) nurses require knowledge and skill to meet the unique needs of infants and families. Increasingly, principles of palliative care are being integrated into the NICU setting to improve the quality of care.

PURPOSE

The purpose of this article is to describe the efforts of the End-of-Life Nursing Education Consortium (ELNEC) project and its Pediatric Curriculum, which began in 2003 to provide this education, and to also describe efforts by nurses to implement the training into their practice settings.

METHODS

The ELNEC Pediatric Palliative Care (ELNEC-PPC) project is a train-the-trainer educational program and evidence-based curriculum.

FINDINGS/RESULTS

Participants attend a course or receive online training and then apply the education to implement improved practices in areas such as symptom management, care at the time of death, and bereavement support for families.

IMPLICATIONS FOR RESEARCH

Experiences with ELNEC-PPC have demonstrated that nurses can implement the curriculum to improve care.

IMPLICATIONS FOR PRACTICE

Continued attention to palliative care in this setting is needed, and future research is needed to evaluate the outcomes of this education and practice change.

The Use of Peripheral μ-Opioid Receptor Antagonists (PAMORA) in the Management of Opioid-Induced Constipation: An Update on Their Efficacy and Safety

Peripherally acting μ-opioid receptor antagonists (PAMORAs) constitute a class of drugs which reverse opioid-induced constipation (OIC) with similar opioid analgesic effects. OIC differs from other forms of constipation in that it is an iatrogenic condition that occurs when an opioid acts on the dense network of μ-opioid receptors in the enteric system, which affect a variety of functions including gastrointestinal motility, secretion, and other factors that can cause bowel dysfunction. Unfortunately, laxative products, bowel regimens, dietary changes, and lifestyle modifications have limited effectiveness in preventing OIC, Opioid-associated adverse effect which occurs in 40% to 80% of opioid patients and may led to cessation of the treatment. PAMORAs are μ-receptor opioid antagonists specifically developed so that they have very limited ability to cross the blood-brain barrier and thus they are able to antagonize peripheral but not central μ-opioid receptors. PAMORAs are designed to have no effect on the analgesic benefits of opioid pain relievers but to relieve but antagonizing the effects of the opioid in the gastrointestinal system. The three main PAMORAS are methyltrexone (oral or parenteral), naldemedine (oral only), and naloxegol (oral only). Clinical studies demonstrate the safety and efficacy of these agents for alleviating constipation without diminishing the analgesic effect of opioid therapy. The aim of this narrative review to update the current status of PAMORAs for treating OIC in terms of safety and efficacy.

GUT MICROBIOTA AND THE USE OF PROBIOTICS IN CONSTIPATION IN CHILDREN AND ADOLESCENTS: SYSTEMATIC REVIEW

Objective:

To perform a systematic review of literature data on gut microbiota and the efficacy of probiotics for the treatment of constipation in children and adolescents.

Data source:

The research was performed in the PubMed, the Scientific Electronic Library Online (SciELO) and the Latin American and Caribbean Health Sciences Literature (LILACS) databases in English, Portuguese and Spanish. All original articles that mentioned the evaluation of the gut microbiota or the use of probiotics in children with constipation in their title and abstract were selected.

Data synthesis:

559 articles were found, 47 of which were selected for reading. From these, 12 articles were included; they studied children and adolescents divided into two categories: a gut microbiota evaluation (n=4) and an evaluation of the use of probiotics in constipation therapy (n=8). The four papers that analyzed fecal microbiota used different laboratory methodologies. No typical pattern of gut microbiota was found. Regarding treatment, eight clinical trials with heterogeneous methodologies were found. Fifteen strains of probiotics were evaluated and only one was analyzed in more than one article. Irregular beneficial effects of probiotics have been demonstrated in some manifestations of constipation (bowel frequency or consistency of stool or abdominal pain or pain during a bowel movement or flatulence). In one clinical trial, a complete control of constipation without the use of laxatives was obtained.

Conclusions:

There is no specific pattern of fecal microbiota abnormalities in constipation. Despite the probiotics’ positive effects on certain characteristics of the intestinal habitat, there is still no evidence to recommend it in the treatment of constipation in pediatrics.

Emergency Provider Use of Plain Radiographs in the Evaluation of Pediatric Constipation

BACKGROUND

More than half of children evaluated as outpatients for abdominal pain are diagnosed with constipation. X-ray use in this scenario is variable: less than 5% in clinic settings, greater than 70% in emergency departments. X-rays increase misdiagnosis rate, remain costly, and involve radiation exposure.

OBJECTIVES

The aim of this study was to assess the use of plain radiographs by pediatric emergency medicine (PEM) providers in the diagnostic evaluation and management of pediatric constipation.

METHODS

A cross-sectional survey of PEM providers was performed. Survey participants were subscribers to the American Academy of Pediatrics Section on Emergency Medicine Listserv. To assess diagnostic and therapeutic approaches, participants were presented a case of pediatric constipation meeting Rome III clinical criteria. Participants also categorized frequency of x-ray use, reasons for obtaining, estimated diagnostic utility, and elements of institutional standard approach. Descriptive statistical analyses were performed.

RESULTS

Three hundred five of 1272 Listserv members (24%) responded. Ninety-nine percent elected to treat for constipation in a case meeting Rome III clinical criteria; one third (31%) would obtain plain radiographs for this same scenario. Plain radiographs were viewed as somewhat (59%) or minimally (29%) value-added in the evaluation of suspected pediatric constipation. Obtaining family buy-in (44%) was the most common reason for utilizing plain radiographs. Frequency of use varied across geographic regions and with participant and hospital characteristics.

CONCLUSIONS

This survey suggests that many PEM providers obtain radiographs to convince families of the diagnosis of constipation. This is not a viable management plan given the risks of radiation as well as costs. There remains room for improvement as we attempt to reduce use of radiation in the evaluation of common pediatric illnesses.

Lactulose versus polyethylene glycol for disimpaction therapy in constipated children, a randomized controlled study

Faecal disimpaction is very important for successful management of the constipation in children. Lactulose is cheap and widely available medicine compared to other polyethylene glycol (PEG) preparations. From our experience, lactulose is effective and safe medicine for both disimpaction and maintenance therapy in constipated children. The purpose of the present study was to evaluate the safety and efficacy of lactulose in faecal impaction management in children with constipation. We conducted a prospective controlled trial in children with functional constipation, who presented with faecal impaction to Queen Rania Hospital for Children from April 15, 2018 until October 15, 2018. Two randomised matched groups; group A included 33 constipated children treated for disimpaction with higher dose lactulose (10 g/15 ml) 4-6 ml/kg/day (max. 120 ml/day) and group B included 32 children treated for disimpaction with macrogol (PEG 4000) 1-1.5 g/kg (max. 30 g/day). Both groups received treatment until resolution or up to 6 days. Patients were followed over 1 week and success of disimpaction was observed. Moreover, any adverse events were recorded. All the patients in both groups achieved successful disimpaction by seventh day of the therapy, group B showed significant faster response. Both therapies were tolerated and no significant adverse events were reported. Both agents were safe, effective and well tolerated. Lactulose may be a good alternative to PEG in the treatment of faecal impaction in constipated children.

Nutrition Management in Pediatric Gastrointestinal Motility Disorders

Gastrointestinal (GI) motility disorders are associated with suboptimal nutrition in children, mainly because of malabsorption and symptoms limiting dietary intake. Apart from medical therapy, nutrition support has a crucial role in maintaining growth and improving clinical outcomes in children. Based on recent data and guidelines, this review provides an overview of nutrition assessment and specific interventions for common pediatric GI disorders including gastroesophageal reflux disease, esophageal motility disorders, gastroparesis, chronic intestinal pseudo-obstruction, and constipation. Several approaches including diet modification, enteral nutrition (gastric vs post-pyloric, temporary vs permanent access, bolus vs continuous), and parenteral nutrition need to be tailored based on patient's nutrition and clinical assessment.

Chronic Functional Constipation in Infants and Children

Functional constipation is a common problem among children. The prevalence worldwide is about 3% and it is accounting for about 3-5% of all visits to pediatricians implicating a significant impact on health care cost. In most children presenting with the symptom constipation no underlying medical disease responsible for the symptom can be found; this is the so-called functional constipation. Functional constipation is characterized by infrequent bowel movements, hard and/or large stools, painful defecation, sometimes in combination with fecal incontinence, and is often accompanied by abdominal pain, without evidence of a structural or biochemical explanation.The recommendation for the management of FC includes a normal intake of fibers and fluids, normal physical activity, and an additional pharmacologic treatment for fecal disimpaction followed by a pharmacologic maintenance therapy.In infants constipation is treated somewhat differently as compared with children. When constipation presents early in life, the risk of an underlying organic disease is increased compared to older children.

Implementing a Standardized Constipation-Management Pathway to Reduce Resource Utilization

OBJECTIVE

Constipation is commonly diagnosed in our pediatric emergency department (ED). Care has varied significantly, with a heavy reliance on abdominal radiography (AR) for the diagnosis of and inpatient management for bowel cleanout. We implemented a standardized approach to caring for patients presenting to a pediatric ED with symptoms consistent with constipation, emphasizing clinical history, physical examination, less reliance on AR, and standardized home management.

METHODS

Using quality improvement (QI) methodology, a multidisciplinary group developed an ED constipation management pathway, encouraging less reliance on AR for diagnosis and promoting home management over inpatient bowel cleanout. The pathway included a home management "gift basket" containing over-the-counter medications and educational materials to promote successful bowel cleanout. Outcome measures included pathway utilization, AR rate, ED cost and length of stay, and ED admission rate for constipation.

RESULTS

Within 3 months, >90% of patients discharged home with an ED disposition diagnosis of constipation left with standardized educational materials and home medications. Staff education and feedback, pathway and gift basket changes, and a higher threshold for inpatient management led to significant decreases in AR rate (73.3%-24.6%, P < .001), average per-patient cost ($637.42-$538.85), length of stay (223-196 minutes, P < .001), and ED admission rate (15.3%-5.4%, P < .001), with no concerning missed diagnoses or increases in ED revisit rate.

CONCLUSIONS

An ED QI project standardizing the care of pediatric constipation was implemented successfully, leading to a sustainable decrease in resource utilization. The next phase of the project will focus on collaborating with community providers to reduce ED utilization.

Yield and Examiner Dependence of Digital Rectal Examination in Detecting Impaction in Pediatric Functional Constipation

OBJECTIVES

Guidelines on functional constipation recommend digital rectal examination (DRE) when constipation is doubtful or with a suspicion of organic etiology. The guidelines do not clarify if DRE is mandatory to diagnose impaction. This study aims to determine the frequency of impaction detectable only on DRE among children satisfying Rome III criteria without requiring DRE and also the inter-observer influences on impaction detection by DRE.

METHODS

Children between 6 months to 13 years of age, presenting with history suggestive of constipation were assessed. After excluding those with suspicion of organic etiology, those who needed DRE for diagnosis of constipation and those who do not satisfy Rome III criteria without DRE, the rest who satisfied Rome III criteria were assessed for impaction by palpable fecoliths or constipation-associated fecal incontinence. Those without such impaction were randomized to 2 examiners for DRE to diagnose impaction, in the absence of contraindications.

RESULTS

Two hundred and thirty-three children were assessed. One hundred and sixty-nine satisfied Rome III without needing DRE. Forty-eight (28.4%) had impaction detectable without DRE. Among the rest, 28 (30.1%) had impaction by DRE. There was no difference between the frequency of impaction detected by the 2 examiners. Clinical characteristics were similar (P > 0.05) between those with impaction detectable by DRE and those without.

CONCLUSIONS

DRE does detect cases of impaction not discernible by other means. Such a finding may be comparable between examiners. These children may be identified by other clinical characteristics. The clinical significance of such a finding needs more understanding from the standpoint of therapeutic choices.

PROPOSALS TO APPROXIMATE THE PEDIATRIC ROME CONSTIPATION CRITERIA TO EVERYDAY PRACTICE

BACKGROUND

Acceptance of the prevailing pediatric Rome constipation criteria, by primary care physician, is still low. Even for research purposes they have not been universally adopted. Thus, it has been indicated that some re-evaluation of these criteria would be welcome.

OBJECTIVE

The authors aimed to look at the timing of diagnosis and the dietary treatment recommendations in the criteria, to make proposals trying to approximate them to everyday practice.

METHODS

The literature cited in the Rome criteria was reviewed and the publications pertinent to the subject, searched by Medline up to January 2018, were included.

RESULTS

An early diagnosis is fundamental to avoid evolution to bothersome complications and possibly to 'intractable' constipation, but the inclusion of two items of the criteria might hamper it. Thus, one constipation sign/symptom should suffice, usually the easily observable 'painful or hard bowel movements'. Details about dietary fiber recommendations are missing in the criteria, although its increase is usually the first approach in primary care, and overall the data about dietary fiber supplements point to beneficial effects.

CONCLUSION

For diagnosis and treatment of pediatric constipation in primary care, one constipation sign/symptom should suffice. The recommended daily dietary fiber intake, according to the American Health Foundation, should be detailed as a treatment measure, and also for prevention, from weaning on.

Comparison of Hirschsprung-associated enterocolitis following Soave and Duhamel procedures

BACKGROUND

Hirschsprung-associated enterocolitis (HAEC) represents the primary cause of high morbidity and mortality in Hirschsprung disease (HSCR) patients. The most common surgical methods for HSCR are the Soave and Duhamel procedures. Therefore, we aimed to compare the HAEC frequency following the Soave and Duhamel procedures.

METHODS

Medical records were retrospectively analyzed for patients who underwent the Soave and Duhamel pull-through at Dr. Sardjito Hospital, Indonesia from 2010 to 2015. The diagnosis of HAEC was determined using a HAEC scoring system.

RESULTS

One hundred patients were involved (Soave: 52 males and 19 females vs. Duhamel: 23 males and 6 females, p=0.62). There was significant difference in mean age at pull-through (Soave: 29.9±45.2 vs. Duhamel: 50.8±47.5months, p=0.04), whereas mean age of HSCR diagnosis and pre-operative enterocolitis frequency did not differ significantly between groups (Soave: 25.4±41.0 vs. Duhamel: 43.7±48.1months, p=0.06, and Soave: 7% vs. Duhamel: 14%, p=0.44, respectively). The HAEC frequency after pull-through was significantly higher in the Duhamel than the Soave group (28% vs. 10%, respectively, p=0.03). Furthermore, pre-operative enterocolitis showed a significant association with HAEC following pull-through (p=2.0×10-4) and the risk of HAEC after Soave pull-through was increased in long-segment aganglionosis compared to short-segment HSCR (p=0.015).

CONCLUSIONS

The frequency of HAEC was significantly higher after the Duhamel than the Soave procedure. Moreover, patients with pre-operative enterocolitis are prone to have HAEC following pull-through.

LEVEL OF EVIDENCE

III.

The Role of Non-invasive Testing in Evaluation and Diagnosis of Pediatric Lower Urinary Tract Dysfunction

PURPOSE OF REVIEW

The symptoms of lower urinary tract dysfunction (LUTD) including urinary incontinence, frequency, and urgency are among the most common reasons children are referred to pediatric urologists. Despite this, the workup for LUTD is often time consuming and a source of frustration for patients, parents, and clinicians alike. In the current review, we summarize the important role non-invasive testing plays in the diagnosis and management of children with LUTD and to show how use of these tests can help avoid the need for more invasive testing in the majority of children.

RECENT FINDINGS

Non-invasive tests such urine studies, uroflowmetry ± simultaneous electromyography, assessment of post-void residual, renal/bladder ultrasound, and pelvic ultrasound when used appropriately can provide valuable information to facilitate decision making during the evaluation of children with LUTD. While these tests should be employed prior to more invasive testing such as urodynamic studies, they can often act as a surrogate for the more invasive tests. Non-invasive tests can help us in our goal of improving diagnostic ability to better classify the child's LUTD into an actual condition which allows targeted treatment in the hope of better outcomes and more satisfied patients and families.

Fructose Intolerance: Cause or Cure of Chronic Functional Constipation

Functional constipation is a common occurrence in the pediatric population. The link between fructose ingestion and constipation is obscure due to a lack of published data. In this article, we discuss the relationship of fructose tolerance and the development of constipation via a literature review and our single-center experience. A literature review of constipation and fructose ingestion was performed using PubMed. A retrospective chart review from the pediatric gastroenterology clinic, January 2012 to December 2015, was completed, with attention to the relationship of fructose intolerance and its clinical presentations. There were 367 patients who underwent the fructose breath hydrogen test (FBHT), out of which 208 patients had fructose intolerance. Clinical presentations included chronic abdominal pain, chronic diarrhea, chronic constipation, emesis, and nausea. Statistical significance was reached for chronic constipation, emesis, and nausea, being less likely to be found in FBHT-positive patients. Thus, fructose intolerance may help resolve symptoms in patients with chronic functional constipation.

Constipation-Related Health Care Utilization in Children Before and After Hospitalization for Constipation

We studied constipation-related health care among children before and after constipation admission. Index admissions for constipation in 2010-2011 were identified in the Truven Marketscan Database, which includes children receiving Medicaid in 10 states. We measured number of and spending for outpatient constipation visits 12 months before and after index hospitalizations. We also measured spending for constipation hospitalizations and rehospitalization rate. There were 780 index constipation admissions. The median number of outpatient constipation visits was 1 (interquartile range [IQR] = 0, 3) in the 12 months before and 2 (IQR [0, 4]) after admission ( P = .001). Median outpatient spending for constipation was $110 (IQR [0, 429]) before and $132 (IQR [0, 431]) after admission ( P = .2). Median spending for index constipation admissions was $5295 (IQR [2756, 8267]); 78 children (10%) were rehospitalized for constipation within 12 months. Constipation-related health care utilization increased after constipation admission. Median spending for one constipation admission was 50 times the median spending for 12 months of outpatient constipation visits.

Role of ano rectal myomectomy in children with chronic refractory constipation

BACKGROUND

Chronic refractory constipation (CRC) is an uncommon type of constipation. These children have persistent symptoms even after treatment with high dose laxatives, which may cause abdominal distension, vomiting, cramping and bloating. We conducted this study to assess the diagnostic and therapeutic role of anorectal myomectomy in children with CRC.

MATERIALS AND METHODS

This study includes 107 patients who fit the criteria of CRC. Complete bowel preparation with polyethylene glycol solution, enemas and antibiotics was carried out before surgery in all patients. The anorectal myomectomy was carried out under general anaesthesia with the patient in the high lithotomy position. The patients were followed up from 6 months to 13 years postoperatively. The success of myomectomy was based on the daily and complete passage of stools without the need for medication or enemas.

RESULTS

A total of 99 patients were included in the study, of which, 86 (86.86%) patients showed a good response to anorectal myomectomy. Of these, 32 patients had normal histology, 14 had histology suggestive of Hirschsprung's disease, 8 had hypoganglionosis, 10 had ultra-short segment Hirschsprung's disease and 22 had hypertrophic nerves with immature ganglia. Poor response was seen in 13 (13.13%) patients of whom 5 had normal histology, 5 had Hirschsprung's disease, 2 had hypoganglionosis and 1 had ultra-short segment Hirschsprung's disease.

CONCLUSION

Anorectal myomectomy is an effective and technically simple procedure in selected patients with CRC for both diagnostic and therapeutic purposes.

An 8-Year-Old Boy With Treatment-Resistant Encopresis

Paul is an 8-year-old boy with a long-standing history of encopresis and enuresis. Potty training was initiated when he was 2 years old. At this time, his mother was absent from the home for 6 weeks when she cared for her ill father in a different city. The process of teaching Paul to use the bathroom was described as "inconsistent" due to multiple caretakers.Paul never successfully mastered bowel and bladder control. He continues to wet and soil his clothes on a daily basis at home and school. According to his parents, he does not accept responsibility and comments about his soiling such as, "I didn't do it; someone else must have put it there." One of Paul's teachers commented that she could tell at the beginning of the school day whether he would maintain bowel and bladder control. If he was "agitated and talkative" in the early morning, he would often soil that day.He had a pediatric gastroenterological evaluation at the age of 5 years when he was having daily episodes of stool soiling. Physical examination revealed normal anal tone, normal placement of the anus, and moderate stool in the rectal vault. An abdominal radiograph revealed moderate stool throughout the colon. He was treated with Miralax and instructed to sit on the toilet twice daily. Paul did not respond to these interventions and was diagnosed with "overflow incontinence secondary to stool withholding." When he was taking Miralax, he had a normal barium enema radiograph. He was admitted to the hospital for a cleanout with a polyethylene glycol/electrolyte solution.Although abdominal radiographs demonstrated absence of colonic stool for the following 5 months, he continued to soil his clothing. Play therapy and biofeedback did not change the chronic soiling and wetting pattern. An evaluation at the Continence Clinic resulted in a rigorous program including stooling after each meal, wearing a vibrating watch reminding him to void every 2 hours, drinking 60 ounces of water per day, tracking elimination patterns on a calendar, and a daily laxative (polyethylene glycol). A neuropsychological evaluation revealed a superior aptitude associated with unresolved early childhood issues of self-control, self-care, and frustration tolerance. Family therapy was initiated. However, daily fecal soiling and wetting persisted.Paul was born full-term without prenatal or perinatal complications. He was breast fed for 1 year and described as an easy baby. He achieved motor, social, and language milestone on time. Paul had difficulty with separation and aggression in preschool (e.g., biting). In school, teachers report inattention, fidgetiness, and difficulty following directions. He has been obese since age 3 years; his current body mass index is 29.

The overlap of gastroesophageal reflux disease and functional constipation in children: the efficacy of constipation treatment

OBJECTIVES

This study was designed to investigate the frequency of gastroesophageal reflux disease (GERD) in children with functional constipation (FC). It was structured to assess the improvement level in reflux symptoms by measuring the acid reflux in these patients after they had received FC treatment.

METHODS

Ninety-four children who suffered from constipation were evaluated prospectively. Data forms were completed to assess the GERD symptoms in all the cases. Twenty-four-hour pH meter monitoring was performed in 55 of the patients with GERD symptoms. The cases with abnormal acid reflux were treated by conventional therapy for FC. These cases were re-evaluated for GERD symptoms and weekly defecation frequency, and 24-h pH meter monitoring was performed at the end of a 3-month period.

RESULTS

An abnormal level of acid reflux was determined in 23 of the 55 cases. After the constipation treatment, a significant improvement was achieved in the acid reflux index and GERD symptoms, whereas the weekly defecation frequency increased.

CONCLUSION

GERD is a frequent problem in children with FC. Treatment of the constipation can improve the reflux symptoms and abnormal acid reflux in these cases. Physicians should bear in mind the co-occurrence of these two prevalent problems for better disease management.

Motility disorders in infants

Gastrointestinal motility disorders are common in the pediatric population and may affect the entire gastrointestinal tract and can vary from mild to severe conditions. They may clinically manifest as gastro-esophageal reflux symptoms, feeding difficulties and failure to thrive, constipation and diarrhea amongst others. This review first highlights the embryologic development of the gastrointestinal tract, after which the prenatal and neonatal development of gastrointestinal motility is discussed. Normal motility patterns as seen in (preterm) infants are described as a background for the discussion of the most common congenital and acquired motility disorders in infancy. This review specifically focuses on the role of preterm birth on the development of these disorders.

Acute Abdominal Pain: Recognition and Management of Constipation in the Emergency Department

OBJECTIVE

The main aim of the study was to investigate the incidence and the clinically relevant features of functional constipation in patients evaluated for acute abdominal pain in a tertiary care pediatric emergency department.

METHODS

This is a retrospective study. We analyzed 4394 medical records and recorded the information (demographics, triage code, symptoms, medical history, physical evaluation, laboratory tests, radiological studies, procedures, and treatments) of all patients admitted for acute abdominal pain to the emergency department of the IRCCS Burlo Garofolo, Trieste, during 2010 to 2013.

RESULTS

In this study, a quarter of patients (1020) presenting in the emergency department with acute abdominal pain were affected by functional constipation. Acute pain associated with functional constipation is generally rated from moderate to severe, and the location of the pain on physical evaluation was not a sufficient criterion to guide diagnosis. Isolated vomiting may be present in a minority of cases. Digital rectal exploration was never performed; the majority of patients were treated by means of an enema with prompt relief. Six percent of patients with constipation underwent radiological studies.

CONCLUSIONS

This study confirms that the medical history provides a pivotal role in the diagnosis of functional constipation. Digital rectal exploration and x-rays should be avoided in this setting, whereas an enema plays a useful diagnostic and therapeutic role in our study patients.

Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric Emergency Department

OBJECTIVES

Constipation is a common diagnosis in the pediatric emergency department (ED). Children diagnosed with constipation may undergo an abdominal radiograph (AXR) as part of their diagnostic workup despite studies that suggest that an AXR in a patient suspected of being constipated is unnecessary and potentially misleading. We aimed to decrease the percentage of low-acuity patients aged between 6 months and 18 years diagnosed with constipation who undergo an AXR in our pediatric ED from 60% to 20% over 12 months.

METHODS

We conducted an interventional improvement project at a large, urban pediatric ED by using the Institute for Healthcare Improvement's Model for Improvement. The primary outcome was the proportion of patients ultimately diagnosed with constipation who had an AXR during their ED visit. Analysis was performed by using rational subgrouping and stratification on statistical process control (SPC) charts.

RESULTS

Process analysis was performed by using a cause-and-effect diagram. Four plan-do-study-act cycles were completed over 9 months. Interventions included holding Grand Rounds on constipation, sharing best practices, metrics reporting, and academic detailing. Rational subgrouping and stratification on SPC charts were used to target the interventions to different ED provider groups. Over 12 months, we observed a significant and sustained decrease from a mean rate of 62% to a mean rate of 24% in the utilization of AXRs in the ED for patients with constipation.

CONCLUSIONS

The use of rational subgrouping and stratification on SPC charts to study different ED provider groups resulted in a substantial and sustained reduction in the rate of AXRs for constipation.

Water and fluid intake in the prevention and treatment of functional constipation in children and adolescents: is there evidence?

OBJECTIVE

To study the evidence on the role of water and fluid intake in the prevention and treatment of functional intestinal constipation in children and adolescents.

SOURCE OF DATA

A search was carried out in the Medline database (between 1966 and 2016) for all published articles containing the following words: constipation, water, and fluids, published in Portuguese, English, and Spanish. All original articles that assessed children and adolescents were selected by title and abstract. The references of these articles were also evaluated.

SYNTHESIS OF DATA

A total of 1040 articles were retrieved. Of these, 24 were selected for reading. The study included 11 articles that assessed children and adolescents. The articles were divided into two categories, those that evaluated water and fluid intake as a risk factor for intestinal constipation and those that evaluated their role in the treatment of intestinal constipation. Five articles were included in the first category. The criteria for assessing fluid intake and bowel rhythm were different in each study. Three studies demonstrated an association between low fluid intake and intestinal constipation. Regarding treatment, five articles with heterogeneous methodologies were found. None of them clearly identified the favorable role of fluid intake in the treatment of intestinal constipation.

CONCLUSION

There are few articles on the association between fluid intake and intestinal constipation. Epidemiological evidence indicates an association between lower fluid intake and intestinal constipation. Further clinical trials and epidemiological studies that consider the international recommendations for fluid intake by children and adolescents are required.

Constipation and paediatric emergency department utilization

Background

Constipation is a common condition in children. Little is known about the acute health care utilization of constipated children, including how many present to the paediatric emergency department (ED), the spectrum of presenting complaints, investigations and treatments used.

Methods

We conducted a cross-sectional chart review of all 42,875 visits to British Columbia Children's Hospital ED between August 31, 2012 and September 1, 2013. All visits were assessed for a potential diagnosis of constipation and a total of 913 patients were included. We recorded the chief complaints, tests performed and therapies administered in the ED and measures of flow/efficiency including waiting time (WT), length of stay (LOS) and disposition.

Results

Constipation-related visits comprised 2.1% of overall visits. Abdominal pain was found to be the most common presenting complaint in 65.6% of patients; however, 11.9% of patients presented with complaints unrelated to the gastrointestinal tract. Abdominal radiographs were obtained in nearly one-third of patients and almost half of the patients received a fleet enema in the ED. Only a quarter of patients were discharged home on longer-term management. Measures of ED flow were similar between groups, with no meaningful difference in WT or LOS. The vast majority of children (99.7%) were discharged home.

Conclusions

Constipation can be treated as an out-patient, rather than burdening the paediatric ED unnecessarily. This study demonstrates over utilization of radiologic tests and invasive ED treatments and an under utilization of outpatient medication and dietary counselling that may contribute to unnecessary return ED visits.

Positive Effect of Probiotics on Constipation in Children: A Systematic Review and Meta-Analysis of Six Randomized Controlled Trials

Context: Constipation in children is a prevalent, burdensome, and psychologically important pediatric issue, the treatment of which remains a global challenge. The use of probiotics has been reported for management of the gastrointestinal microbiota. Objective: This study reviewed the existing literatures of 6 Randomized Control Trials (RCTs) to ascertain some baseline understanding and available information for the effects of probiotics on stool frequency and consistency in children with constipation. Data Sources: PubMed, Springer, Elsevier Science, Cochrane Library, Scopus, Ovid (Medline, EMBASE, PsycINFO), Orbis, and Web of Science from the earliest record in each database to 15 September, 2016. Study selection: Eligible studies were randomized controlled trials that compared the effect of probiotics interventions to any control intervention on stool frequency and consistency. Data Extraction: Studies were identified by searching electronic databases. The meta-analysis was performed by Review Manager 5.3 software using a randomized model. Results: Six studies were identified. The use of probiotics significantly increased the stool frequency [mean difference (MD), 0.73; 95% confidence interval (CI), 0.14-1.31; P = 0.02]. Subgroup assessment showed a significantly increased stool frequency in Asian patients (MD, 1.18; 95% CI, 0.33-2.02; P = 0.006), but no significant difference in stool consistency (MD, -0.07; 95% CI, -0.21-0.06; P = 0.27). Limitations: Only six RCTs met the criteria and were included. Each RCT in this study was performed in a different country, and some of the included studies had a small sample size, which might have influenced the reliability and validity of the conclusions. Conclusion: The present study shows that probiotics increase stool frequency and have beneficial effects in Asian children. However, caution is needed when interpreting these outcomes because of the existence of heterogeneity. Evidence from larger samples and more adequately powered RCTs with results obtained by standardized measurements are necessary to determine which species and dosage of probiotics and what length of treatment are most efficacious for constipation in children.

DIAGNOSTIC ACCURACY OF BARIUM ENEMA FINDINGS IN HIRSCHSPRUNG'S DISEASE

Background:

Hirschsprung's disease is the most common cause of pediatric intestinal obstruction. Contrast enema is used for evaluation of the patients with its diagnosis.

Aim:

To evaluate sensitivity, specificity, positive predictive value, and negative predictive value of radiologic findings for diagnosis of Hirschsprung in patients underwent barium enema.

Methods:

This cross sectional study was carried out in Imam Khomeini Hospital for one year starting from 2012, April. Sixty patients were enrolled. Inclusion criteria were: neonates with failure to pass meconium, abdominal distention, and refractory constipation who failed to respond with medical treatment. Transitional zone, delay in barium evacuation after 24 h, rectosigmoid index (maximum with of the rectum divided by maximum with of the sigmoid; abnormal if <1), and irregularity of mucosa (jejunization) were evaluated in barium enema. Biopsy was obtained at three locations apart above dentate line. PPV, NPV, specificity , and sensitivity was calculated for each finding.

Results:

Mean age of the cases with Hirschsprung's disease and without was 17.90±18.29 months and 17.8±18.34 months respectively (p=0.983). It was confirmed in 30 (M=20, F=10) of cases. Failure to pass meconium was found in 21(70%) cases. Sensitivity, specificity, PPV, and NPV were 90%, 80%, 81.8% and 88.8% respectively for transitional zone in barium enema. Sensitivity, specificity, PPV, and NPV were 76.7%, 83.3%, 78.1% and 82.1% respectively for rectosigmoid index .Sensitivity, specificity, PPV, and NPV were 46.7%, 100%, 100% and 65.2% respectively for irregular contraction detected in barium enema. Sensitivity, specificity, PPV, and NPV were 23.3%, 100%, 100% and 56.6% respectively for mucosal irregularity in barium enema.

Conclusion:

The most sensitive finding was transitional zone. The most specific findings were irregular contraction, mucosal irregularity, and followed by cobblestone appearance.

Approach to Constipation in Children

PURPOSE

There is a scarcity of literature, and prevalent misconceptions about constipation in India.

METHODS

A literature search in PubMed was conducted with regard to epidemiology, clinical features, and management of constipation. Special emphasis was paid to functional constipation and refractory constipation. English language studies available full text over the last 25 years were considered and relevant information was extracted.

CONCLUSIONS

Estimated prevalence of constipation is 3% among toddlers and pre-school children worldwide and 95%, of them are considered functional. A careful history and thorough physical examination is all that is required to diagnose functional constipation. Management includes disimpaction followed by maintenance therapy with oral laxative, dietary modification and toilet training. A close and regular follow-up is necessary for successful treatment. In most of the cases laxative needs to be continued for several months and sometimes years. Early withdrawal of laxative is the commonest cause of recurrence. Refractory constipation is less common in primary care set up. Radiological colon transit study is useful in picking up Slow transit constipation. Antegrade continence enema plays an important role in the management of slow transit constipation.

Pediatrician's knowledge on the approach of functional constipation

OBJECTIVE

To evaluate the pediatrician's knowledge regarding the diagnostic and therapeutic approach of childhood functional constipation.

METHODS

A descriptive cross-sectional study was performed with the application of a self-administered questionnaire concerning a hypothetical clinical case of childhood functional constipation with fecal incontinence to physicians (n=297) randomly interviewed at the 36th Brazilian Congress of Pediatrics in 2013.

RESULTS

The majority of the participants were females, the mean age was 44.1 years, the mean time of professional practice was 18.8 years; 56.9% were Board Certified by the Brazilian Society of Pediatrics. Additional tests were ordered by 40.4%; including abdominal radiography (19.5%), barium enema (10.4%), laboratory tests (9.8%), abdominal ultrasound (6.7%), colonoscopy (2.4%), manometry and rectal biopsy (both 1.7%). The most common interventions included lactulose (26.6%), mineral oil (17.5%), polyethylene glycol (14.5%), fiber supplement (9.1%) and milk of magnesia (5.4%). Nutritional guidance (84.8%), fecal disimpaction (17.2%) and toilet training (19.5%) were also indicated.

CONCLUSIONS

Our results show that pediatricians do not adhere to current recommendations for the management of childhood functional constipation, as unnecessary tests were ordered and the first-line treatment was not prescribed.