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Quitadamo P, Tambucci R, Mancini V, Campanozzi A, Caldaro T, Giorgio V, Pensabene L, Isoldi S, Mallardo S, Fusaro F, Staiano A, Salvatore S, Borrelli O. Diagnostic and therapeutic approach to children with chronic refractory constipation: Consensus report by the SIGENP motility working group. Dig Liver Dis 2024; 56:406-420. [PMID: 38104028 DOI: 10.1016/j.dld.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 11/15/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Abstract
Constipation is a common problem in children, accounting for about 3% of all primary care visits and up to 25% of referrals to paediatric gastroenterologists. Although polyethylene glycol often proves effective, most children require prolonged treatment and about 50% of them have at least one relapse within the first 5 years after initial recovery. When conventional treatment fails, children are considered to have refractory constipation. Children with refractory constipation deserve specialist management and guidance. Over the last decades, there has been a remarkable increase in our knowledge of normal and abnormal colonic and anorectal motility in children, and a number of different techniques to measure transit and motility have been developed. The present review analyses the possible diagnostic investigations for children with refractory constipation, focusing on their actual indications and their utility in clinical practice. Moreover, we have also analytically reviewed medical and surgical therapeutic options, which should be considered in selected patients in order to achieve the best clinical outcome.
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Affiliation(s)
- Paolo Quitadamo
- Pediatric Gastroenterology and Epatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy.
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, San Carlo Hospital, Milan, Italy
| | - Angelo Campanozzi
- Pediatrics, Department of Medical and Surgical Sciences, University of Foggia
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Giorgio
- UOC Pediatria, Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Sara Isoldi
- Pediatric Gastroenterology and Epatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy; Maternal and Child Health Department, Sapienza - University of Rome, Santa Maria Goretti Hospital, Polo Pontino, Latina, Italy
| | - Saverio Mallardo
- Maternal and Child Health Department, Sapienza - University of Rome, Santa Maria Goretti Hospital, Polo Pontino, Latina, Italy
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Newborn Surgery Unit, Digestive and Endoscopic Surgery, Gastroenterology and Nutrition, Intestinal Failure Rehabilitation Research Group, Bambino Gesù Children's Hospital Research Institute, Rome, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University "Federico II", Naples, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
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de Geus A, Koppen IJN, Flint RB, Benninga MA, Tabbers MM. An Update of Pharmacological Management in Children with Functional Constipation. Paediatr Drugs 2023; 25:343-358. [PMID: 36941393 PMCID: PMC10097737 DOI: 10.1007/s40272-023-00563-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/23/2023]
Abstract
Functional constipation is a common problem in childhood worldwide and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. It is a clinical diagnosis based on the Rome IV criteria. Non-pharmacological treatment involves education, demystification, lifestyle advice, and toilet training. Pharmacological treatment consists of disimpaction, maintenance treatment, and eventually weaning if possible. Polyethylene glycol is considered as the first choice of laxative for both disimpaction and maintenance treatment. Different osmotic laxatives, stimulant laxatives, lubricants, and enemas are available as alternative pharmacological treatment options. Novel drugs are emerging but evidence to support the widespread application of these drugs in the pediatric population is often lacking and more high-quality research is needed in this field. If children remain symptomatic despite optimal pharmacological treatment, botulinum toxin injections in the anal sphincter can be considered as an alternative, more invasive treatment option. This review provides an update on currently available literature concerning the pharmacologic treatment of functional constipation in children.
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Affiliation(s)
- Anna de Geus
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Robert B Flint
- Department of Clinical Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Merit M Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands.
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Sherburne E, Snethen J. Down There - Pediatric Nurses, Constipation, and Rectal Interventions. J Pediatr Nurs 2021; 61:364-371. [PMID: 34592678 DOI: 10.1016/j.pedn.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric nurses care for hospitalized children with constipation on a daily basis. However, very little is reported in the literature about the experiences of pediatric nurses when providing care to hospitalized children who are constipated. A rarely discussed aspect of pediatric care is that of sensitive touch which is required during rectal interventions such as enema and suppository administration. The purpose of this qualitative study was to investigate the experiences of pediatric nurses regarding the identification & management of constipation in hospitalized children. A theme, "down there," emerged from the larger study and revealed pediatric nurses' experiences with sensitive touch in hospitalized children with constipation. METHODS This phenomenological investigation utilized in depth interviews with 21 pediatric nurses to explore their experiences of caring for hospitalized children with constipation. RESULTS The concept sensitive touch, a touch that is applied to an intimate area of the body, emerged as a theme from the interviews. There were several subthemes. Nurses discussed assessment as "I would not automatically do a rectal check;" and incorporated development as "an infant is totally different from a 5 or 6-year-old; developing a "trustful rapport" during interventions; ensuring "comfort and privacy" as strategies during rectal interventions; and performing a "dress rehearsal" when teaching orientees about rectal interventions. CONCLUSIONS Pediatric nurses describe a variety of experiences when using sensitive touch in children. Although there is high awareness of the need for comfort and privacy, pediatric nurses' hesitation to intervene using rectal maneuvers could contribute to ongoing constipation in hospitalized children.
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Affiliation(s)
- Eileen Sherburne
- Children's Wisconsin, Nursing Research,WI, United States of America.
| | - Julia Snethen
- University of Wisconsin-Milwaukee College of Nursing, WI, United States of America.
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What is the Evidence for Over the Counter Laxatives to Treat Childhood Constipation? Curr Gastroenterol Rep 2021; 23:19. [PMID: 34637057 DOI: 10.1007/s11894-021-00818-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Functional constipation is a common pediatric GI disorder that is responsible for a significant portion of pediatric office visits each year. It presents a significant stressor for patients, their families, and providers alike. There are a variety of over the counter agents available for treatment of pediatric constipation. RECENT FINDINGS Osmotic laxatives, such as polyethylene glycol 3350 (PEG 3350) and lactulose, remain the most effective and safe therapy for both long and short term treatment of pediatric functional constipation. Stimulant laxatives, like Senna and Bisacodyl, probiotics, fiber preparations, enemas, and suppositories make excellent choices for adjunct therapies in specific clinical scenarios. There are multiple over the counter pharmacologic agents with various mechanisms of action that have demonstrated efficacy in pediatric functional constipation. These therapies are generally safe and well tolerated by patients.
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Kim MJ, Choi YJ, Lee JH, Kwon H, Suh D. The Appropriateness of Glycerin Enema in Pediatric Patients Visiting the Emergency Department. CHILDREN-BASEL 2021; 8:children8050364. [PMID: 34063250 PMCID: PMC8147433 DOI: 10.3390/children8050364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 11/16/2022]
Abstract
Objectives: We determined whether glycerin enemas were appropriately prescribed in pediatric fecal impaction patients using the Leech score and identified factors that influenced the prescription of glycerin enemas in the pediatric emergency department (PED). Methods: We included patients who received a glycerin enema at the PED of a tertiary teaching hospital. We divided the study subjects into two groups on the basis of their Leech scores: an appropriate enema group (Leech score ≥ 8), and an inappropriate enema group (Leech score < 8). Logistic regression was performed to determine the factors associated with glycerin enema administration. Results: The data of 998 patients, including 446 patients in the inappropriate enema group (Leech score 5.2 ± 1.7) and 552 patients in the appropriate enema group (Leech score 10.1 ± 1.7), were analyzed. A discharge diagnosis of fecal impaction was observed significantly more frequently (57.1%) in the appropriate enema group, and nonspecific abdominal pain (8.3%) and acute gastroenteritis (40.8%) were diagnosed significantly more frequently in the inappropriate enema group (p < 0.05). Constipation (2.8%) and irritability (3.0%) were slightly more common in the appropriate enema group than in the inappropriate enema group (p < 0.05). According to multiple logistic regression, subjects aged 2–8 years (2–4 years, OR 4.24; 4–8 years, OR 2.83), with vomiting (OR 1.72), with irritability (OR 4.52), and with a prolonged last defecation day (OR 1.2) were most likely to receive appropriate enema administration (p < 0.05). Conclusion: The results showed that in those aged 2–8 years, with vomiting and irritability, and with a prolonged last defecation day, an enema was generally administered appropriately.
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Affiliation(s)
- Min-Jung Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Gyeonggi-do 13496, Korea;
| | - Yoo-Jin Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Gyeonggi 16499, Korea;
| | - Jin-Hee Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi 13620, Korea; (H.K.); (D.S.)
- Correspondence: or ; Tel.: +82-31-787-7586
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi 13620, Korea; (H.K.); (D.S.)
| | - Dongbum Suh
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi 13620, Korea; (H.K.); (D.S.)
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Anderson J, Furnival RA, Zhang L, Lunos SA, Sadiq Z, Strutt JR, Kaila R, Hendrickson MA. A Comparison of the Efficacy of Enema Solutions in Pediatric Emergency Department Patients. J Emerg Med 2019; 57:461-468. [PMID: 31594739 DOI: 10.1016/j.jemermed.2019.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/03/2019] [Accepted: 07/11/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection. OBJECTIVE Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the "pink lady," a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate. METHODS We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus. RESULTS There were 768 records included. Median age was 6.2 years (interquartile range 3.3-10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain. CONCLUSIONS There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.
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Affiliation(s)
- Julie Anderson
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Ronald A Furnival
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Lei Zhang
- Clinical and Translational Science Institute/Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota
| | - Scott A Lunos
- Clinical and Translational Science Institute/Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota
| | - Zujaja Sadiq
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Jonathan R Strutt
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Rahul Kaila
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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Diagnostic approach to constipation impacts pediatric emergency department disposition. Am J Emerg Med 2017; 35:1490-1493. [DOI: 10.1016/j.ajem.2017.04.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 02/03/2023] Open
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