Constipation, antiepileptic drugs, and gingivitis in children and adolescents with cerebral palsy

Poo Matters! A scoping review of impact of constipation on epilepsy

BACKGROUND

Epilepsy is a common neurological disorder which frequently presents with co-morbid physical health conditions, including constipation. However, the nature of the relationship between the two conditions has not been well defined.

AIM

To quantify constipation's relationship with epilepsy and anti-seizure medication (ASM).

METHOD

A scoping review registered on PROSPERO (CRD42022320079) with suitable search terms was conducted and reported in accordance with PRISMA guidance. CINAHL, Embase, PsycInfo and MEDLINE electronic databases were searched by an information specialist. The Joanna Briggs Institute (JBI) critical appraisal tools alongside the Oxford Centre for Evidence Based Medicine (OCEBM) levels of evidence were used to assist in assessing relevance, quality, and results of the included publications.

RESULTS

Nine articles selected for inclusion in the review. The prevalence of irritable bowel syndrome (including constipation) was reported to be up to five times more frequent in people with epilepsy (PWE). Functional constipation was reported in 36% of PWE. Constipation was found to be the second most common co-morbid condition in children with epilepsy. Two studies found constipation to precede seizures. Constipation was reported as a common side effect of ASMs in PWE. Two studies rated OCEBM level 2 the remaining level 3.

CONCLUSION

Our findings suggest a higher prevalence of constipation in PWE. Co-occurring multimorbidity and resulting polypharmacy adds further complexity to the process of establishing aetiology of constipation in PWE. Potential contributory aetiological factors for constipation such as neurodevelopmental and genetic disorders, ASM side effects and the epilepsy itself require better understanding and research.

Optical spectral diagnostics of the oxygenation level in periodontal tissues and photodynamic therapy using methylene blue in children with cerebral palsy

Dental diseases occur in children with cerebral palsy three times higher than in healthy children. Low values of the unstimulated salivation rate (<0.3 ml per minute), pH and buffer capacity, changes in enzyme activity and sialic acid concentration, as well as increased saliva osmolarity and total protein concentration, which indicates impaired hydration, are the factors in the development of a gingiva disease in case of cerebral palsy. This leads to increased bacterial agglutination and the formation of acquired pellicle and biofilm, leading to the formation of dental plaque. There is a tendency toward an increase in the concentration of hemoglobin and a decrease in the degree of hemoglobin oxygenation, as well as an increase in the generation of reactive oxygen and nitrogen species. Photodynamic therapy (PDT) with the use of photosensitizer methylene blue improves blood circulation and the degree of oxygenation in periodontal tissues, as well as eliminates a bacterial biofilm. Analysis of back diffuse reflection spectra makes it possible to conduct non-invasive monitoring determine tissue areas with a low level of hemoglobin oxygenation for precision photodynamic exposure.

Aim

To improve the effectiveness of phototheranostics methods using, namely PDT with simultaneous optical-spectral control, for the treatment of gingivitis in children with complex dental and somatic status (cerebral palsy).

Methods

The study involved 15 children (6-18 y.o.) with various forms of cerebral palsy, in particular, spastic diplegia and atonic-astatic form and with gingivitis. The degree of hemoglobin oxygenation was measured in tissues before PDT and on the 12th day. PDT was performed using laser radiation (λ = 660 nm) with a power density of 150 mW/cm² with a five-minute application of 0.01% MB. The total light dose was 45 ± 15 J/cm². For statistical evaluation of the results, a paired Student's t-test was used.

Results

The paper presents the results of phototheranostics using methylene blue in children with cerebral palsy. An increase in the level of hemoglobin oxygenation from 50 to 67% (p < 0.001) and a decrease in blood volume in the microcirculatory bed of periodontal tissues were shown.

Conclusion

Photodynamic therapy methods with application of methylene blue make it possible to assess the state of the gingival mucosa tissue diseases objectively in real time, and to provide effective targeted therapy for gingivitis in children with cerebral palsy. There is a prospect that they can become widely used clinical methods.

Detection of periodontal disease activity based on histatin degradation in individuals with cerebral palsy

Objectives

This proof-of-concept study aimed at evaluating the proteolytic profile of histatin 1 and 5 in saliva of adolescents with spastic cerebral palsy (CP) with gingivitis.

Methods

This cross-sectional study included 24 individuals allocated into three groups: G1 (CP with gingivitis; n = 8), G2 (without CP and without gingivitis; n = 8), and G3 (without CP and with gingivitis; n = 8). The gingival index (GI) and simplified oral hygiene index (OHI–S) were evaluated. Whole saliva was collected and used to assess the rate and mode of histatin 1 and 5 at different times. The degradation products were visualized after cationic PAGE and the protein band densities (BDs) were compared with a protein standard. Fragmentation products were collected from the gel, pooled by group and characterized by mass spectrometry. BDs and gingival health parameters were analyzed by One-Way ANOVA or Kruskal Wallis tests, whereas poisson multilevel regression was used to the factors that influenced histatin degradation (α = 5%).

Results

Groups G1 and G3 differed significantly on OHI–S, visible biofilm, oral calculus and GI (p < 0.001). Poisson Regression showed that: 1) CP and gingivitis influenced the degradation of histatin 1 and 5 (p < 0.05); 2) The degradation of histatin 5 was influenced by age and male sex (p < 0.05); and 3) GI influenced significantly the degradation of histatin 1 (p < 0.001). Unique histatin degradation peptides were identified in individuals with gingivitis.

Conslusions

These data demonstrated that both the kinetics and pattern of histatins degradation differ according to the gingival health or disease conditions.

Dental health status and hygiene in children with cerebral palsy: A matched case-control study

BACKGROUND

Children with cerebral palsy (CP) are at risk for oral pathology and parafunctional habits, and are reliant on caregivers for oral hygiene.

AIM

To evaluate oral hygiene habits and oral examination findings among a group of children with CP and a healthy age- and gender-matched control group.

DESIGN

A comparative, cross-sectional study, consisting of a questionnaire component and a standard dental examination component, each applied to both groups.

RESULTS

Eighty-three children with CP and 84 healthy children were included. Parents of children with CP were more likely to be of low educational level and lack a professional line of occupation (P < .05). Children with CP were less likely to be responsible for oral hygiene maintenance, adhere to toothbrushing, or receive procedural dental care (P < .001). Food packing and drooling were significantly more likely in children with CP. Malocclusion type III was more prevalent among children with CP, as was higher gingival index and gingival enlargement index-horizontal component (P < .001). There were no differences in caries experience between the CP and control groups.

CONCLUSIONS

Children with CP have suboptimal oral hygiene habits, limited access to procedural dental care, higher parafunctional habits, and increased periodontal pathology.

Caries prevalence using ICDAS visual criteria and risk assessment in children and adolescents with cerebral palsy: A comparative study

AIMS

To compare the dental caries prevalence using the International Caries Detection and Assessment System (ICDAS) and the caries risk by Caries Management by Risk Assessment (CAMBRA) in individuals with cerebral palsy (CP) and normoactives (NAs).

METHODS AND RESULTS

Sixty children and adolescents aged 6-12 years (30 CP/30 NA) were clinically evaluated by one calibrated examiner using two-digit ICDAS criteria and converted into components of dmf/DMF indices: d2mf2/D2MF2 (enamel and dentin lesions) and d3mf3/D3MF3 (dentin lesions). An adapted CAMBRA was used for risk classification. The mean d2mf2s/d2mf2t and D2MF2S/D2MF2T for CP were 17.0 ± 16.8/7.5 ± 4.3 and 10.7 ± 17.6/5.3 ± 5.8, respectively, and for NA were 17.2 ± 16.9 /6.9 ± 4.8 and 11.1 ± 11.7/5.5 ± 4.7, respectively. The mean d3mf3s/d3mf3t and D3MF3S/D3MF3T for CP were 10.1 ± 16.7/3.0 ± 4.1 and 4.9 ± 15.6/0.2 ± 0.4, respectively, while for NA the mean values were 9.8 ± 13.0/3.5 ± 3.8 and 2.1 ± 5.7/0.9 ± 2.0, respectively. There were no statistically differences for caries prevalence and risk in both groups (p > 0.05).

CONCLUSIONS

Dental caries was highly prevalent in CP and NA children and adolescents. Enamel and dentin lesions and high caries risk were the most common condition.

The Impact of Oral-Gut Inflammation in Cerebral Palsy

Background: Oral-gut inflammation has an impact on overall health, placing subjects at risk to acquire chronic conditions and infections. Due to neuromotor disturbances, and medication intake, cerebral palsy (CP) subjects present intestinal constipation, impacting their quality of life (QOL). We aimed to investigate how oral inflammatory levels predicted gut phenotypes and response to therapy.

Methods: A total of 93 subjects aging from 5 to 17 years were included in the study, and assigned into one of the 4 groups: CP with constipation (G1, n = 30), CP without constipation (G2, n = 33), and controls without CP with constipation (G3, n = 07) and without CP and without constipation (G4, n = 23). In addition to characterizing subjects' clinical demographics, medication intake, disease severity levels, salivary cytokine levels [TNF-α, interleukin (IL)-1β, IL-6, IL-8, IL-10], and Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD). Statistical significance was evaluated by Shapiro-Wilks, Student's T-Test, ANOVA, and ANCOVA analysis.

Results: Salivary proinflammatory cytokines were highly correlated with the severe form of gut constipation in G1 (P < 0.001), and out of all cytokines IL-1β levels demonstrated highest correlation with all gut constipation (P < 0.05). A significant relationship was found between the type of medication, in which subjects taking Gamma-Aminobutyric Acid (GABA) and GABA+ (GABA in association with other medication) were more likely to be constipated than the other groups (P < 0.01). Cleary salivary inflammatory levels and gut constipation were correlated, and impacted QOL of CP subjects. G1 presented a lower QOL mean score of CPCHILD (49.0 ± 13.1) compared to G2 (71.5 ± 16.7), when compared to G3 (88.9 ± 7.5), and G4 (95.5 ± 5.0) (P < 0.01). We accounted for gingival bleeding as a cofounder of oral inflammation, and here were no differences among groups regarding gender (P = 0.332) and age (P = 0.292).

Conclusions: Collectively, the results suggest that saliva inflammatory levels were linked to gut constipation, and that the clinical impact of medications that controlled gut was reliably monitored via oral cytokine levels, providing reliable and non-invasive information in precision diagnostics.

Efficacy of oral magnesium therapy in the treatment of chronic constipation in spastic cerebral palsy children: a randomized controlled trial

BACKGROUND

Constipation is a common problem in children with spastic cerebral palsy (sCP) with a prevalence that reaches 75%. We hypothesized that treating constipation in those children will improve their health and shorten time spent in daily care. Our aim was to evaluate the efficacy and safety of oral magnesium sulfate for treating chronic constipation in children with sCP.

METHODS

A prospective, double-blinded randomized control trial was carried out involving 100 children aged 2-12 years with sCP (level III-V of the Gross Motor Functional Classification system) and chronic constipation. They were followed up in the Pediatric neurology clinic, Children's hospital, Ain Shams University, May 2017- January 2019. The intervention group (O-Mg) received oral magnesium sulfate 1 mL/kg/day daily for 1 month compared to the placebo. Outcome measures were constipation improvement and decrease in bowel evacuation time after 1 month.

RESULTS

Initially, weekly bowel movements, constipation scores and stool consistency were comparable in both groups. After 1 month of regular administration of oral magnesium sulfate, the constipation score, stool frequency and consistency improved compared to the placebo group (P < 0.001). Effective safe treatment was achieved in 31 (68%) and 4 (9.5%) patients in the O-Mg and placebo groups, respectively (RR, 2.95; 95% CI 2.0-4.5) (P < 0.001). Painful bowel evacuation attempts spent by mothers decreased from 25 (55.6%) of the cases initially to 10 (22%) cases after one month in the O-Mg group (P = 0.001). In contrast, in the placebo group, the decrease went from 21 (50%) cases initially to 18 (42.9%) after 1 month and was not significant (P = 0.5).

CONCLUSIONS

Oral magnesium sulfate seems effective in alleviating chronic constipation and pain experience in children with sCP. Consequently, saving maternal time spent in daily bowel evacuation attempts.

Factors associated with the stool characteristics of children with cerebral palsy and chronic constipation

BACKGROUND

chronic constipation is a common gastrointestinal problem in children with cerebral palsy and several factors can influence the stool frequency, consistency and pH in these cases.

AIM

to identify the association of dietary factors, use of anticonvulsants and family history of constipation with the stool characteristics of children with cerebral palsy and chronic constipation.

METHODS

an analytical cross-sectional study was performed of 45 children with cerebral palsy and chronic constipation that included 19 females and 26 males, aged 37 ± 13 months. Dietary factors, the use of anticonvulsants and family history were analyzed. Stool frequency, consistency (Bristol Stool Form Scale) and pH (using a pH-meter) were also determined.

RESULTS

there was a positive correlation between stool frequency and the consumption of oilseeds (r = 0.339, p = 0.023). There was a negative correlation between hard stools and fluid intake (r = -0.336, p = 0.042) and between stool pH and the consumption of cereals rich in insoluble fiber, high soluble fiber vegetables, carrots and potatoes (r = -0.339, p = 0.030; r = -0.308, p = 0.044; r = -0.336, p = 0.027; r = -0.307, p = 0.045, respectively). An association was also identified between the use of anticonvulsant polytherapy and hard stools (OR = 14.2 [95% CI 1.16-174], p = 0.038). There was no association between family history and constipation.

CONCLUSIONS

rich-fiber food consumption, fluids intake and anticonvulsant polytherapy were associated with the stool characteristics of children with cerebral palsy and chronic constipation.