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Bautista-Casasnovas A, Argüelles-Martín F, Martín-Martínez B, Domínguez-Otero MJ, Tavares M, Amil-Dias J. Multicentre Study Into the Use of Polyethylene Glycol With Electrolytes Over at Least 6 Months to Treat Constipation in Paediatric Populations. JPGN REPORTS 2023; 4:e353. [PMID: 38034437 PMCID: PMC10684192 DOI: 10.1097/pg9.0000000000000353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 12/02/2023]
Abstract
Background Constipation is a common clinical problem in children, for which the first-line therapeutic options are osmotic laxatives, mainly polyethylene glycol (PEG). These treatments are often prescribed for short or limited periods, with progressive treatment withdrawal often resulting in relapses. However, there are a few studies into the long-term use (≥6 months) of PEG 3350 with electrolytes (PEG+E) in terms of the patients' clinical evolution. Objectives To assess bowel movement and other relevant symptoms in children with constipation receiving PEG+E (≥6 months), as well as parent/caregiver satisfaction with this treatment. Methods A retrospective, observational, descriptive, longitudinal, and multicentre study was carried out on 74 children diagnosed with functional constipation (ROME IV criteria) who had received PEG+E (≥6 months). Bowel control was assessed using the Bristol stool scale, and the parent's/caregiver's perception of the treatment was also evaluated employing a nonvalidated questionnaire. Results Children with an average duration of constipation >1 year experienced a significant improvement in bowel movements and stool consistency when using PEG+E. The mean duration of use was 18.6 (±13.4) months, without the need to adjust the dose for weight. All clinical symptoms improved significantly except bloating, and all the parents/caregivers confirmed these clinical improvements. Conclusions Children treated with PEG+E (≥6 months) normalised their bowel movements, improving the clinical symptoms related to constipation in the absence of serious advert events or the need for dosage adjustments due to weight gain. Parents/caregivers reported good satisfaction with PEG+E treatment.
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Affiliation(s)
| | | | | | | | - Marta Tavares
- Pediatric Gastroenterology Unit, Centro Infantil do Norte, Oporto
| | - Jorge Amil-Dias
- Pediatric Gastroenterology Department, Hospital Sao Joao, Oporto
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Sodero CEO, da Silva EAW, de Castro Rezende Júnior D, Tiveron GRC, Zago AFR, de Oliveira RA, Souza BRE, Pelegrinelli LR. Idiopathic megacolon in a teenager treated by laparoscopic rectosigmoidectomy. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2016.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AbstractChronic constipation in children and adolescents is relatively common and a reason for consultation with pediatricians and proctologists. Most cases respond to medical treatment. Advanced cases of megacolon and megarectum can be treated surgically by Duhamel technique.This case report describes a 15-year-old patient with chronic intestinal constipation refractory to clinical treatment associated with megacolon and megarectum, which was surgically treated.
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Affiliation(s)
| | | | | | | | | | | | - Bernardo Rosae e Souza
- Universidade Federal do Triângulo Mineiro (UFTM), Hospital de Clínicas, Uberaba, MG, Brazil
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Mattheus HK, Wagner C, Becker K, Bühren K, Correll CU, Egberts KM, Ehrlich S, Fleischhaker C, Föcker M, Hahn F, Hebebrand J, Herpertz-Dahlmann B, Jaite C, Jenetzky E, Kaess M, Legenbauer PhD T, Pfeiffer PhD JP, Renner Md TJ, Roessner V, Schulze U, Sinzig J, Wessing I, von Gontard A. Incontinence and constipation in adolescent patients with anorexia nervosa-Results of a multicenter study from a German web-based registry for children and adolescents with anorexia nervosa. Int J Eat Disord 2020; 53:219-228. [PMID: 31617610 DOI: 10.1002/eat.23182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 09/06/2019] [Accepted: 09/13/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) are common disorders in childhood and are frequently accompanied by comorbid psychiatric disorders. Despite a high association between urinary and fecal incontinence with psychiatric and neurodevelopmental disorders, research on comorbidity between incontinence and anorexia nervosa (AN) remains scarce. Yet, it is well known that somatic consequences of AN include metabolic and gastrointestinal disorders. The study sought to assess the prevalence of incontinence and constipation in children and adolescents with AN and to examine associations of these two symptoms with body weight at admission and with BMI changes during inpatient treatment. METHODS Data collected between 2015 and 2017 by a multicenter German web-based registry for AN were analyzed. Three hundred and forty-eight patients with AN (96.3% female, mean age = 15.1 ± 1.8 years) were assessed regarding AN subtype, psychiatric comorbidity, body weight, incontinence, and constipation. RESULTS Overall, 27.6% of patients had constipation, 1.8% had NE and 1.8% DUI. Prevalence of constipation did not significantly differ between AN subtypes. Constipation did not lead to any significant differences in weight/BMI changes during inpatient treatment. DISCUSSION This is the largest study of incontinence and constipation in patients with AN, so far. Our results indicate that constipation is highly prevalent in adolescent patients with AN and reflects a clinically relevant condition. Despite, patients with AN do not have an increased prevalence of incontinence compared with the general population. Future studies should include medical examinations like ultrasound and physical examination of the lower abdomen to evaluate the severity of constipation.
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Affiliation(s)
- Hannah K Mattheus
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
| | - Catharina Wagner
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
| | - Katja Becker
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps University Marburg and University Hospital Marburg, Marburg, Germany.,Center for Mind, Brain and Behavior (CMBB), Philipps-University Marburg, Marburg, Germany
| | - Katharina Bühren
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, Aachen, Germany
| | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Psychiatry and Molecular Medicine, Hofstra Northwell School of Medicine, Hempstead, New York.,Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
| | - Karin M Egberts
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Ehrlich
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universitaet Dresden, Dresden, Germany
| | - Christian Fleischhaker
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany
| | - Manuel Föcker
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Hospital Essen, University of Duisburg-Essen, Duisburg, Germany
| | - Freia Hahn
- Department of Child an Adolescent Psychiatry, Psychosomatics and Psychotherapy, LVR - Hospital Viersen, Viersen, Germany
| | - Johannes Hebebrand
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Hospital Essen, University of Duisburg-Essen, Duisburg, Germany
| | - Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital, RWTH Aachen, Aachen, Germany
| | - Charlotte Jaite
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ekkehart Jenetzky
- Department of Child and Adolescent Psychiatry, University Medicine of the Johannes Gutenberg-University, Mainz, Germany.,Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Michael Kaess
- Clinic of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany.,University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Tanja Legenbauer PhD
- LWL University Hospital Hamm for Child and Adolescent Psychiatry, Ruhr University Bochum, Bochum, Germany
| | - Jens P Pfeiffer PhD
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps University Marburg and University Hospital Marburg, Marburg, Germany
| | - Tobias J Renner Md
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Veit Roessner
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Technische Universitaet Dresden, Dresden, Germany
| | - Ulrike Schulze
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital, University of Ulm, Ulm, Germany
| | - Judith Sinzig
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, LVR-Klinik Bonn, Bonn, Germany
| | - Ida Wessing
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Münster, Münster, Germany
| | - Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
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MOMENI M, MOMEN-GHARIBVAND M, KULOUEE N, JAVAHERIZADEH H. ULTRASONOGRAPHY IN DETERMINING THE RECTAL DIAMETER AND RECTAL WALL THICKNESS IN CHILDREN WITH AND WITHOUT CONSTIPATION: A CASE-CONTROL STUDY. ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:84-87. [DOI: 10.1590/s0004-2803.201900000-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 03/13/2019] [Indexed: 12/12/2022]
Abstract
ABSTRACT BACKGROUND: Ultrasonography has shown to be useful in the diagnosis of constipation. OBJECTIVE: The aim of this study was to compare the rectal diameter and rectal wall thickness in children with and without constipation. METHODS: Children with the diagnosis of constipation according to Rome III criteria were included in the study. The children underwent transabdominal sonography for the evaluation of rectal diameter and rectal wall thickness. Ultrasonography was performed with a full bladder. Children without constipation who underwent abdominal sonography were assigned to the control group. RESULTS: The rectal diameter was larger in children with constipation than in children without constipation (31.72±9.63 mm vs 19.85±4.37 mm; P=0.001). The rectal wall was thinner in children with constipation than in children without constipation (1.75±0.33 mm vs 1.90±0.22 mm; P=0.032). There was no significant difference between boys and girls with constipation in terms of rectal diameter (31.02±8.57 mm 32.77±11.35 mm; P=0.63). CONCLUSION: Transabdominal rectal diameter measurement may be useful in the diagnosis of constipation.
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Poddar U, Singh S, Pawaria A, Srivastava A, Yachha SK. Aetiological spectrum, clinical differentiation and efficacy of polyethylene glycol over lactulose in children with constipation: Experience of 316 cases. J Paediatr Child Health 2019; 55:162-167. [PMID: 29943871 DOI: 10.1111/jpc.14099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 04/02/2018] [Accepted: 05/27/2018] [Indexed: 01/02/2023]
Abstract
AIM To find the aetiological spectrum, clinical features to differentiate organic from functional constipation (FC) and the efficacy of polyethylene glycol (PEG) over lactulose in the treatment of childhood constipation. METHODS From January 2007 to December 2014, 316 consecutive children (up to 18 years) with constipation were included in this study. FC was defined as per Rome III criteria. Standard treatment protocol (disimpaction with PEG followed by laxatives) was followed in FC. Lactulose was used in the first 4 years of study and PEG in the last 4 years. Success of therapy was assessed at 3 months. RESULTS The median age was 44 (25.00-78.00) months, and 227 (72%) were boys. The majority, 245 (77.5%), had FC, while Hirschsprung disease was the most common organic cause (39.4%). On multivariate analysis, delayed passage of meconium, growth failure, absence of retentive posturing and absent faecal impaction significantly (P < 0.05) determined an organic aetiology. In FC, successful outcome at 3 months was achieved equally with PEG and lactulose (81 vs. 76%, respectively). However, more children in lactulose group had to be switched over to PEG due to lack of efficacy (P = 0.0002). CONCLUSIONS FC is the most common cause of constipation in children. Presence of delayed passage of meconium, growth failure and absence of retentive posturing and absent faecal impaction raise the suspicion of an organic cause. Both lactulose and PEG are equally effective. PEG has an edge over lactulose as the need for switch over was uncommon.
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Affiliation(s)
- Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Sumit Singh
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Arti Pawaria
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Surender K Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Abstract
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.
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Devitt P, Thornley E, Hinks M. An evaluation of an inter-disciplinary constipation clinic for childhood constipation. J Res Nurs 2016. [DOI: 10.1177/1744987107079589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Childhood constipation is a common chronic condition that has considerable implications for both the children who suffer from it and their families. The complex nature of the condition requires an multi-faceted response. Recognising this, a multidisciplinary clinic was set up in a hospital in the north-west of England. This article reports the process and outcomes of an evaluation of the clinic. The evaluation combined data from a number of sources and both qualitative and quantitative data were collected. Questionnaires and one-to-one interviews were employed. The sample included both service users and medical consultants. Families reported on the impact that the condition had on their perceived quality of life. The multidisciplinary `joined-up' approach was valued by both service users and medical consultants.
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Affiliation(s)
- Patric Devitt
- Salford Centre for Nursing Midwifery and Collaborative Research, School of Nursing, University of Salford, Salford,
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8
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Abstract
PURPOSE OF REVIEW Constipation is a very common problem in pediatrics with both the severity of presentations and treatments varying across a broad spectrum. The majority of children with functional constipation are managed successfully without the need for specialized testing and surgical intervention. Those who present with intractable constipation, with or without fecal soiling, require referrals for motility testing that helps determine both medical and surgical management, and interventions. The literature was reviewed for publications on surgical approaches to children with severe constipation, including assessing the quality and levels of evidence and the use of objective measures to determine outcomes. RECENT FINDINGS There is very little in the way of recent studies evaluating surgical indications or treatment approaches for functional constipation, apart from one systematic review and one recent expert review. Although the systematic review was published in the last year, most of the studies it analyzes are older. The vast majority of studies comprise level 4 and 5 evidence. SUMMARY The indication for most surgical procedures is 'failed' medical management, yet no standardized definition for this exists. Many surgical procedures are proposed with little evidence to show outcomes. We recommend that the surgical evaluation and treatment of children with constipation needs to be protocolized and studied in a prospective manner using validated outcomes measures. Our center's current protocol is described.
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Is rectal disimpact always necessary in children with chronic constipation? Evaluation with pelvic ultrasound. Pediatr Surg Int 2010; 26:601-6. [PMID: 20414661 DOI: 10.1007/s00383-010-2602-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of study was to evaluate if pelvic ultrasound can be useful in managing children with chronic idiopathic constipation. METHODS A total of 270 children with idiopathic chronic constipation were enrolled in the study. At baseline and at monthly checkups children were evaluated by clinical score and pelvic ultrasound (US). Patients have been divided in 2 groups, based on pelvic US results: group A with a rectal diameter >3 cm, group B with a rectal diameter <3 cm or rectum not visualized. Both groups were subsequently randomly divided in two subgroups (A1, A2, B1, B2) on the basis of the prescribed treatment (disimpaction for the first week and daily laxative or only daily laxative). RESULTS After 1 month of therapy all clinical features improved in group A1 and at pelvic US, rectal size reduced and became not visualized; group A2 showed poor clinical response and transverse diameter of rectum did not modify significantly; B1 and B2 groups showed significant improvement only after 2-3 months. CONCLUSIONS Rectal disimpaction is necessary only in presence of MR. Pelvic US is a useful to diagnose MR and to set up the most appropriate treatment protocol for different chronic constipation cases.
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Khanna V, Poddar U, Yachha SK. Etiology and clinical spectrum of constipation in Indian children. Indian Pediatr 2010; 47:1025-30. [PMID: 20453267 DOI: 10.1007/s13312-010-0175-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 12/30/2009] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To analyze the etiology, clinical spectrum and outcome of constipation in children. SETTING Tertiary care teaching hospital. DESIGN Retrospective chart review. PARTICIPANTS Consecutive children with constipation from 2001 to 2006. INCLUSION CRITERIA Functional constipation was designated when there was no objective evidence of any causative pathologic condition while the rest were termed as organic constipation. INTERVENTION Lactulose was started after disimpaction with polyethyleneglycol in functional constipation cases. OUTCOME MEASURES Clinical and etiological profile, management, and follow-up data. RESULTS 137 children (boys, 90); 117 (85%), had functional constipation while the remaining 15% had an associated organic disorder. Hirschsprungs disease accounted for 6% of all patients. Children in organic group more commonly had delayed passage of meconium (50.0% vs 1.7%), symptoms since first month of life (40.0% vs 1.7%), and abdominal distension (50% vs 5%) as compared to functional group, while fecal impaction was less common (69% vs 20%). Besides fecal impaction, straining (35%), withholding behaviour (27.4%), and fecal incontinence (30.8%) were other main clinical characteristics of the functional group. In the functional group, successful outcome to laxatives was obtained in 95% of patients while 10% needed rescue disimpaction. CONCLUSIONS Functional constipation is the most common cause of constipation in Indian children. History of delayed passage of meconium, presence of abdominal distension, and absence of fecal impaction point to an organic pathology.
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Affiliation(s)
- Vikrant Khanna
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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12
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Abstract
PURPOSE Pelvic ultrasound (US) has been used in various different ways to assess severity of constipation. We evaluated the use of a new US scoring system to determine if there is any correlation between symptom severity and US findings. METHODS Data were collected prospectively on all children attending the constipation clinic from January 2007 to July 2008. All patients completed a standardised symptom severity score sheet (SSS) for constipation. US was done with the probe placed 2 cm above the pubic symphysis. A new US scoring system designed to assess the faecal loading and its effect on the bladder was used. Patients with severe symptoms were followed up with few patients requiring as many as four follow up visits. During each follow-up visit SSS and US scoring was completed. RESULTS A total of 500 patients were studied (male 317, female 183) with a median age of 8 years (8 months, 18 years). Statistical analysis was done using SPSS software (version 15.0). Pearson's correlation was used to assess the correlation between SSS and US score. P value <0.05 was considered to represent a statistically significant correlation between symptoms and ultrasound findings. CONCLUSION US is an easy and quick tool that can be used in the out-patient setting to assess severity of constipation. The new US scoring system is a reliable method that can be used in conjunction with clinical examination for assessing the long-term improvement of children who are undergoing treatment for chronic constipation.
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Chao HC, Lai MW, Kong MS, Chen SY, Chen CC, Chiu CH. Cutoff volume of dietary fiber to ameliorate constipation in children. J Pediatr 2008; 153:45-9. [PMID: 18571534 DOI: 10.1016/j.jpeds.2007.12.044] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2007] [Revised: 11/19/2007] [Accepted: 12/18/2007] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the proper ingested volume of dietary fiber for relieving constipation in children. STUDY DESIGN During a 3-year period, we prospectively evaluated the correlation of intake volume of dietary fiber with improvement of constipation in children. Patients were categorized into younger (3-7 years) and older (8-14 years) children. The evaluation period lasted 12 weeks. A good improvement was defined as the child exhibiting at least 60% relief of the constipation symptoms during the observation period. Freedom from constipation was observed during the last 4 weeks. RESULTS The study population consisted of 422 patients (213 younger, 209 older), with a mean age of 7.89 +/- 4.71 years. Baseline daily dietary fiber intake of the younger and older groups was 5.97 +/- 2.35 g and 9.83 +/- 3.51 g, respectively. 227 cases (53.8 %) showed improvement of constipation, and 49.1 % of the patients had relief of constipation. Greater intake of dietary fiber was positively associated with good improvement of constipation in both groups (P = .002, and P < .001). Cutoff volumes of daily dietary fiber intake in the relief of constipation were 10 g in the younger group and 14.5 g in the older group. CONCLUSION The cutoff of dietary fiber intake needed to relieve constipation increased with age, achievable in a 12-week intervention.
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Affiliation(s)
- Hsun-Chin Chao
- Division of Gastroenterology, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Lee WTK, Ip KS, Chan JSH, Lui NWM, Young BWY. Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant foods: A community-based study. J Paediatr Child Health 2008; 44:170-5. [PMID: 17854410 DOI: 10.1111/j.1440-1754.2007.01212.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To evaluate consumption of foods rich in dietary fibre and its relation to the prevalence of constipation in pre-school children. METHODS In total, 368 children aged 3-5 years were randomly selected from kindergartens in Hong Kong. Constipation was confirmed by Rome-criteria. Children with normal bowel habits served as non-constipated controls. Consumption of vegetables, fruits, whole-grain cereals and fluid were determined using a 3-day food record. RESULTS A total of 28.8% children were reported to have constipation. Median dietary fibre intake of constipated children was significantly lower than non-constipated children (3.4 g/d (inter-quartile range (IQR): 2.3-4.6 g/d) vs. 3.8 g/d (IQR: 2.7-4.9 g/d); P = 0.044) corresponding to 40% reference dietary fibre intake. Constipated children also had significantly lower intakes of vitamin C (P = 0.041), folate (P = 0.043) and magnesium (P = 0.002). Fruit intake and total plant foods intake were significantly lower in the constipated than non-constipated children: (61 g/d (IQR: 23.8-115 g/d) vs. 78 g/d (IQR: 41.7-144.6 g/d); P = 0.047) and (142.5 g/d (IQR: 73.7-214.7 g/d) vs. 161.1 g/d (IQR: 98.3-233.3 g/d); P = 0.034), respectively. Total fluid intake did not differ between groups but milk intake among the constipated children was marginally higher than the non-constipated children (P = 0.055) CONCLUSION Insufficient dietary fibre intake is common in Hong Kong pre-school children. Constipated children had significantly lower intakes of dietary fibre and micronutrients including vitamin C, folate and magnesium than non-constipated counterparts which was attributable to under-consumption of plant foods. However, milk intake was marginally higher in the constipated children. More public education is necessary for parents to help develop healthy dietary habit and bowel habit in early life in order to prevent childhood constipation.
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Affiliation(s)
- Warren T K Lee
- Division of Nutritional Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK.
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Guest JF, Candy DCA, Clegg JP, Edwards D, Helter MT, Dale AK, Fell J, Cosgrove M, Debelle G. Clinical and economic impact of using macrogol 3350 plus electrolytes in an outpatient setting compared to enemas and suppositories and manual evacuation to treat paediatric faecal impaction based on actual clinical practice in England and Wales. Curr Med Res Opin 2007; 23:2213-25. [PMID: 17692152 DOI: 10.1185/030079907x210462] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To estimate the clinical and economic impact of using macrogol 3350 plus electrolytes (macrogol 3350; Movicol; Movicol Paediatric Plain) in an outpatient setting compared to enemas and suppositories and manual evacuation to treat paediatric faecal impaction. METHODS A chart review was undertaken to extract clinical outcomes and resource use from the case notes of a cohort of children aged 2-11 years with faecal impaction who initially received either macrogol 3350 (in an outpatient setting) or enemas and suppositories or manual evacuation for initial disimpaction. Five centres across England and Wales participated in the study. These data were used to inform a decision model which depicted the management of children during the disimpaction phase and for a period of 12 weeks following initial disimpaction. Unit resource costs at 2005/2006 prices were applied to the resource utilisation estimates within the model, enabling the incremental costs and consequences of using macrogol 3350 in an outpatient setting, compared to the other treatments, to be estimated. RESULTS 112 patients treated with macrogol 3350, 101 who received enemas and suppositories and 11 who underwent a manual evacuation were eligible for analysis. Ninety-seven per cent of children treated with macrogol 3350 were successfully disimpacted within 5 days, compared to 73% of those who received enemas and suppositories and 89% of those who underwent a manual evacuation (p < 0.001). There were no significant differences in reported adverse events between the different treatments for disimpaction, with the exception of vomiting which was significantly higher among those who underwent a manual evacuation (18% versus 2% with the other treatments; p < 0.01). There were no significant differences in the number of clinician outpatient visits between treatments. However, macrogol 3350-treated patients had significantly fewer hospital admissions than those who received the other interventions (0.1 versus 1.4 and 1.0 for enemas and suppositories and manual evacuation respectively; p < 0.05) and occupied fewer bed days. The total NHS cost of disimpaction and subsequent maintenance of children initially treated with macrogol 3350 was estimated to be 694 pounds sterling (95% CI: 496 pounds sterling; 892 pounds sterling). This compared with 2759 pounds sterling (95% CI: 1266 pounds sterling; 4252 pounds sterling) and 2333 pounds sterling (95% CI: 1609 pounds sterling; 3058 pounds sterling) for those who initially received enemas and suppositories or underwent a manual evacuation, respectively. Hence, using macrogol 3350 instead of enemas and suppositories and manual evacuation to disimpact the whole annual cohort of faecally impacted children aged 2-11 years in England could potentially reduce annual NHS expenditure on this condition by 59% (5 million pounds sterling) and reduce the annual number of paediatric hospital admissions for this condition by 92% (4330). CONCLUSION Within the limitations of our model, macrogol 3350 affords the NHS a clinically effective and cost-effective treatment for the disimpaction of children suffering from faecal impaction compared to enemas and suppositories or a manual evacuation, and has the potential to release healthcare resources for alternative use within the system.
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Affiliation(s)
- Julian F Guest
- Catalyst Health Economics Consultants, Northwood, Middlesex, UK.
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Abstract
Chronic functional constipation is a common problem in childhood, with soiling a significant issue. The morbidity is high and the treatment is complex. There is a very poor evidence base for the drug treatments used and there are considerable differences in practice in different units. The key to successful management is early diagnosis and prompt treatment with an emphasis on holistic care with multidisciplinary support where needed. For example, the practical approach in our unit at the Southampton General Hospital, Southampton, England emphasizes the non-drug aspects including patient education and behavioral modification and uses stimulant laxatives, usually in a high dose as first-line therapy. There is an urgent need for prospective comparative studies to investigate different treatment regimens and for longitudinal studies to examine the long-term outcome of chronic constipation and the factors that determine it. The lack of a significant evidence base for the use of the most widely used agents proves a significant challenge in the production of evidence-based guidelines and highlights the paucity of data for most of the widely used treatments for childhood constipation.
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Affiliation(s)
- Adrian Plunkett
- Paediatric Medical Unit, Southampton General Hospital, Southampton, UK
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Hardikar W, Cranswick N, Heine RG. Macrogol 3350 plus electrolytes for chronic constipation in children: a single-centre, open-label study. J Paediatr Child Health 2007; 43:527-31. [PMID: 17635680 DOI: 10.1111/j.1440-1754.2007.01116.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM A Macrogol 3350-based, iso-osmotic laxative has become available for the treatment of chronic constipation in adults. This open-label, non-randomised study aimed to evaluate the safety and efficacy of this preparation in the treatment of chronic constipation in children. METHODS Seventy-eight children, aged 2-11 years, with chronic constipation for greater than 3 months were enrolled. All children received Macrogol 3350 plus electrolytes for 12 weeks. The primary efficacy variable was the number of spontaneous defaecations per week. Secondary efficacy variables were faecal form, abdominal pain, rectal bleeding, pain on defaecation, straining, soiling, amount of stool, stool withholding and assessments of efficacy by the investigators and parents. Safety and compliance were also assessed. RESULTS The mean number of spontaneous defaecations per week increased from 1.4 +/- 0.55 (SD) at baseline to 6.8 +/- 3.45 after 14 days, and 7.1 +/- 3.45 at 12 weeks (P < 0.001). Similar improvements were found in the secondary efficacy variables. There was a significant reduction in reported abdominal pain from 53 (69%) children at baseline to 3 (4%) at the final visit (P < 0.0001). Similarly, 61 (79%) children had pain on defaecation at baseline, compared with 7 (9%) at the final visit (P < 0.0001). Treatment was well tolerated. Of 318 adverse events, 262 (82%) were considered mild, and 241 (76%) were deemed unrelated to treatment. Only 3 (4%) children were withdrawn because of poor compliance. CONCLUSIONS Macrogol 3350 plus electrolytes is a safe and effective treatment for constipation in children aged 2-11 years.
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Affiliation(s)
- Winita Hardikar
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Victoria, Australia.
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18
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Collis DR, Norton LN, Wallis MC. Childhood chronic constipation: An innovative community-based parent education group program. Aust Occup Ther J 2007. [DOI: 10.1111/j.1440-1630.2007.00638.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Vasconcelos M, Lima E, Caiafa L, Noronha A, Cangussu R, Gomes S, Freire R, Filgueiras MT, Araújo J, Magnus G, Cunha C, Colozimo E. Voiding dysfunction in children. Pelvic-floor exercises or biofeedback therapy: a randomized study. Pediatr Nephrol 2006; 21:1858-64. [PMID: 16967285 DOI: 10.1007/s00467-006-0277-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Revised: 06/19/2006] [Accepted: 07/10/2006] [Indexed: 11/24/2022]
Abstract
Fifty-six patients 5.9-15.2 years old with dysfunctional elimination syndrome (DES) unimproved by previous therapies were randomly distributed into two voiding training programs: group 1 contained 26 patients submitted to 24 training sessions over a 3-month period; group 2 contained 30 patients submitted to 16 sessions over a 2-month period. Both groups adhered to a voiding and drinking schedule, received instruction on adequate toilet posture, were reinforced through the maintenance of voiding diaries, and went through proprioceptive and pelvic floor muscle training (Kegel exercises). Group 2 patients also received biofeedback therapy. Clinical evaluation was carried out before each program's initiation and 1, 6, and 12 months after each program's termination. All patients were submitted to renal ultrasonography and dynamic ultrasonography before and 6 months after each program's conclusion. Millivoltage recordings of pelvic floor muscles were compared before and after training. Urinary continence was improved after completion of either training program. Only those patients who received biofeedback training showed a significant decrease in postvoiding residual (PVR) urine as detected by dynamic ultrasonography. Our results show that either training regime can reduce episodic urinary incontinence and urinary tract infection but that further study is required to identify the optimal training duration.
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Affiliation(s)
- Mônica Vasconcelos
- Pediatric Nephrourology Unit, Hospital das Clínicas, Federal University of Minas Gerais, Belo Horizonte, Brazil.
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20
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Candy DCA, Edwards D, Geraint M. Treatment of faecal impaction with polyethelene glycol plus electrolytes (PGE + E) followed by a double-blind comparison of PEG + E versus lactulose as maintenance therapy. J Pediatr Gastroenterol Nutr 2006; 43:65-70. [PMID: 16819379 DOI: 10.1097/01.mpg.0000228097.58960.e6] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To assess the efficacy of polyethylene glycol 3350 plus electrolytes (PEG + E; Movicol) as oral monotherapy in the treatment of faecal impaction in children, and to compare PEG + E with lactulose as maintenance therapy in a randomised trial. PATIENTS AND METHODS An initial open-label study of PEG + E in the inpatient treatment of faecal impaction (phase 1), followed by a randomised, double-blind comparison between PEG + E and lactulose for maintenance treatment of constipation over a 3-month period (phase 2) in children aged 2 to 11 years with a clinical diagnosis of faecal impaction. RESULTS Disimpaction on PEG + E was achieved in 58 (92%) of 63 of children (89% of 2-4 year olds and 94% of 5-11 year olds) without additional interventions. A maximum dose of 4 sachets (for 2-4 year olds) or 6 sachets (for 5-11 year olds) was required; median time to disimpaction was 6 days (range, 3-7 days). Seven children (23%) reimpacted whilst taking lactulose, whereas no children reimpacted while taking PEG + E (P = 0.011). The total incidence rate of adverse events seen was higher in the lactulose group (83%) than in the PEG + E group (64%). CONCLUSIONS PEG + E is safe and highly effective in the management of childhood constipation. It allows a single orally administered laxative to be used for disimpaction without recourse to invasive interventions. It is significantly more effective than lactulose as maintenance therapy, both in efficacy in treating constipation and efficacy in preventing the recurrence of faecal impaction.
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Affiliation(s)
- David C A Candy
- Paediatric Gastroenterology Service, Royal West Sussex NHS Trust, Chichester, UK.
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21
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Dupont C, Leluyer B, Amar F, Kalach N, Benhamou PH, Mouterde O, Vannerom PY. A dose determination study of polyethylene glycol 4000 in constipated children: factors influencing the maintenance dose. J Pediatr Gastroenterol Nutr 2006; 42:178-85. [PMID: 16456412 DOI: 10.1097/01.mpg.0000189349.17549.a9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To determine the doses of polyethylene glycol (PEG) 4000 without additional salts allowing normal bowel habits in childhood functional constipation. METHODS This multicenter noncomparative study allocated children to 4 groups: 6-12 months, 13 months-3 years, 4-7 years, and 8-15 years. Constipation was defined as <1 stool/d for more than 1 month in children aged 6-12 months and <3 stools/w for more than 3 months in older children. Children randomly received either a nominal or a double starting dose. Treatment scheduled for 3 months could be adapted. Data were collected daily by the parents and rated at each visit by the investigator. RESULTS In the 96 children included, the median (interquartile) effective daily doses were by groups; 3.75 (2.50-5.00) g, 6.00 (4.00-7.43) g, 11.71 (7.00-16.00) g, and 16.00 (16.00-24.00) g, respectively, i.e., around 0.50 g/day/kg with a potential increment of the maintenance dose with higher initial dosages. More children had a final dosage identical to the initial one when started on the nominal dose (73%) than with the double one (42%, P < 0.003). More than 90% of children recovered normal bowel habits. Fecal soiling ceased in >60% of children with this symptom at enrolment. Fecal mass in the rectum and abdominal pain were markedly reduced and appetite improved. CONCLUSIONS A daily dose of PEG 4000 around 0.50 g/day/kg in children aged 6 months to 15 years is effective in more than 90% of constipated children and 60% of those with fecal soiling.
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Affiliation(s)
- Christophe Dupont
- Service de Neonatologie, Hôpital Cochin-Saint-Vincent-de-Paul, bât. Marcel Lelong, 74-82 Avenue Denfert Rochereau, 75674 Paris Cedex 14, France.
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22
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Guest JF, Clegg JP. Modelling the costs and consequences of treating paediatric faecal impaction in Australia. Curr Med Res Opin 2006; 22:107-19. [PMID: 16393437 DOI: 10.1185/030079905x65583] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the costs and consequences of using oral macrogol 3350 plus electrolytes (macrogol 3350; Movicol) compared to enemas/suppositories, manual evacuation and naso-gastric administration of macrogol (NGA-PEG) lavage solution in treating paediatric faecal impaction in Australia. METHOD A decision model was constructed using published clinical outcomes, utilities and clinician-derived resource utilisation estimates. The model was used to determine the expected Commonwealth and parent costs associated with each treatment over the period of disimpaction and 12 weeks post-disimpaction, in Australian dollars at 2003/2004 prices. RESULTS 92% of oral macrogol 3350-treated patients are expected to be disimpacted within 6 days following initial treatment, compared with 79% of patients treated with enemas and suppositories who are expected to be disimpacted within 8 days. All patients are expected to be disimpacted within 5 days following a manual evacuation and within 2 days following NGA-PEG. The level of health gain at 12 weeks post-disimpaction irrespective of treatment for disimpaction and subsequent maintenance is expected to be the same; the expected quality-adjusted life years (QALYs) being 0.20 (95% CI: 0.17; 0.23). Starting treatment with oral macrogol 3350 in an outpatient setting is expected to lead to a Commonwealth cost of $758, compared to $1838 with NGA-PEG, $2125 with enemas and suppositories, $3931 with oral macrogol 3350 in an inpatient setting and $4478 with manual evacuation. Resource use associated with maintenance following initial disimpaction is expected to be broadly similar, irrespective of initial laxative. Hence, the expected Commonwealth cost is primarily affected by the treatment used to initially disimpact a patient. Expected parents' costs are expected to be comparable irrespective of treatment ranging from $89 to $112 per patient. CONCLUSION Within the limitations of our model, using oral macrogol 3350 in an outpatient setting for treating faecally impacted children affords a cost effective alternative compared to the other treatments investigated.
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Affiliation(s)
- Julian F Guest
- CATALYST Health Economics Consultants, Northwood, Middlesex, UK.
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Singh SJ, Gibbons NJ, Vincent MV, Sithole J, Nwokoma NJ, Alagarswami KV. Use of pelvic ultrasound in the diagnosis of megarectum in children with constipation. J Pediatr Surg 2005; 40:1941-4. [PMID: 16338324 DOI: 10.1016/j.jpedsurg.2005.08.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE It has not been possible so far to differentiate slow transit constipation from functional fecal retention because the existing medical literature lacks data on rectal dimensions for healthy children or children with chronic idiopathic constipation (CIC). We, for the first time, describe the use of pelvic ultrasound (US) to achieve this. METHODS A pelvic US was carried out on 82 children with a full or partially full bladder and with no history of bowel problems and on 95 children with CIC. The rectal crescent seen behind the bladder was measured. All children also had documentation of their age, weight, and height. RESULTS The median age, weight, and height for the healthy children were comparable with those of the children with CIC. The median rectal crescent size in children with constipation was 3.4 cm (range, 2.10-7.0; IQR, 1.0), as compared with 2.4 cm (range, 1.3-4.2; IQR, 0.72) in the healthy children, and this difference is statistically significant on multiple regressions of log for rectal diameter, adjusted for height, weight, and age (P value< .001). CONCLUSION Pelvic US is a quick child-friendly investigation, which can be used to document the presence of megarectum. It should be the first line investigation for all the children with CIC.
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Affiliation(s)
- Shailinder Jit Singh
- Department of Paediatric Surgery, University Hospital, Queen's Medical Centre, NG7 2UH Nottingham, UK.
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24
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Chiarioni G, de Roberto G, Mazzocchi A, Morelli A, Bassotti G. Manometric assessment of idiopathic megarectum in constipated children. World J Gastroenterol 2005; 11:6027-30. [PMID: 16273619 PMCID: PMC4436729 DOI: 10.3748/wjg.v11.i38.6027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: Chronic constipation is a frequent finding in children. In this age range, the concomitant occurrence of megarectum is not uncommon. However, the definition of megarectum is variable, and a few data exist for Italy. We studied anorectal manometric variables and sensation in a group of constipated children with megarectum defined by radiologic criteria. Data from this group were compared with those obtained in a similar group of children with recurrent abdominal pain.
METHODS: Anorectal testing was carried out in both groups by standard manometric technique and rectal balloon expulsion test.
RESULTS: Megarectum patients displayed discrete abnormalities of anorectal variables and sensation with respect to controls. In particular, the pelvic floor function appeared to be impaired in most patients.
CONCLUSION: Constipated children with megarectum have abnormal anorectal function and sensation. These findings may be helpful for a better understanding of the pathophysiological basis of this condition.
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Affiliation(s)
- Giuseppe Chiarioni
- Clinica di Gastroenterologia ed Epatologia Via Enrico Dal Pozzo, Padiglione W, Perugia 06100, Italy
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Soares ACF, Lederman HM, Fagundes-Neto U, de Morais MB. Breath hydrogen test after a bean meal demonstrates delayed oro-cecal transit time in children with chronic constipation. J Pediatr Gastroenterol Nutr 2005; 41:221-4. [PMID: 16056103 DOI: 10.1097/01.mpg.0000167499.40074.d7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate oro-cecal transit time in children with chronic constipation. METHODS 34 patients with chronic functional constipation age 3 to 13 years and 15 controls without constipation. Oro-cecal transit time was evaluated using the hydrogen breath test after ingestion of lactulose and after a standard meal of cooked beans. Total and segmental colonic transit times were measured with radiopaque markers. RESULTS Of 34 patients with chronic constipation 61.8% had increased total colonic transit time (>62 hours). Oro-cecal transit time measured with lactulose as substrate was similar (p=0.727) in constipated patients with increased colonic transit time (63.8+/-16.3 minutes), in constipated patients with normal colonic transit time (66.9+/-22.9 minutes), and in controls (65.3+/-15.5 minutes). Using a test meal of beans, the hydrogen breath test showed that oro-cecal transit time of constipated patients with increased total colon transit time was higher (252.4+/-23.2 minutes) than oro-cecal transit time of constipated patients with normal colonic transit time (227.7+/-39.6 minutes) or controls (205.3+/-23.3 minutes) (p<.05). CONCLUSION Hydrogen excretion in breath after a bean test meal showed delayed oro-cecal transit time in children with chronic constipation with abnormal total colonic transit time.
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Affiliation(s)
- Ana Cristina Fontenele Soares
- Pediatric Gastroenterology Division and the Medical Imaging Department, Federal University of Sao Paulo, Sao Paulo, Brazil
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Abstract
Constipation defined as changes in the frequency, volume, weight, consistency and ease of passage of the stool occurs in any age group. The most important factors known to promote constipation are reduced physical activity and inadequate dietary intake of fibres, carbohydrates and fluids. Fluid losses induced by diarrhoea and febrile illness alter water balance and promote constipation. When children increase their water consumption above their usual intake, no change in stool frequency and consistency was observed. The improvement of constipation by increasing water intake, therefore, may be effective in children only when voluntary fluid consumption is lower-than-normal for the child's age and activity level. In the elderly, low fluid intake, which may be indicative of hypohydration, was a cause of constipation and a significant relationship between liquid deprivation from 2500 to 500 ml per day and constipation was reported. Dehydration is also observed when saline laxatives are used for the treatment of constipation if fluid replacement is not maintained and may affect the efficacy of the treatment. While sulphate in drinking water does not appear to have a significant laxative effect, fluid intake and magnesium sulphate-rich mineral waters were shown to improve constipation in healthy infants. In conclusion, fluid loss and fluid restriction and thus de-or hypohydration increase constipation. It is thus important to maintain euhydration as a prevention of constipation.
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Keshtgar AS, Ward HC, Clayden GS. Diagnosis and management of children with intractable constipation. Semin Pediatr Surg 2004; 13:300-9. [PMID: 15660324 DOI: 10.1053/j.sempedsurg.2004.10.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
AIM To assess the outcome at one year of a cohort of patients referred to outpatient clinics with soiling. METHOD Retrospective case note audit of 34 children referred to hospital outpatients over a four month period with soiling stated as the main problem in the referral letter. RESULTS After one year, 29% of the 34 children studied were discharged to patient satisfaction, 38% defaulted from follow up, 24% were still attending outpatient clinics and 9% had been referred back to source. Coexisting pathologies, in particular enuresis and family stress, were found in several of the children. At the time of referral, 44% of new patients and 89% of re-referrals bad symptoms present for longer than 12 months. Only 18% of the children were receiving treatment at the time referral was made. CONCLUSION Constipation is often undiagnosed until the problem is well established with soiling present, which makes treatment a long and often difficult process. It is necessary to consider the wider social and family issues when managing a child with constipation and soiling. Hospital based general medical and surgical outpatient clinics may not be the ideal setting in which to deal with these problems.
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Affiliation(s)
- L A B McDonald
- Department of Community Child Health, Royal Hospital for Sick Children, Yorkhill NHS Trust, Glasgow
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Burnett CA, Juszczak E, Sullivan PB. Nurse management of intractable functional constipation: a randomised controlled trial. Arch Dis Child 2004; 89:717-22. [PMID: 15269068 PMCID: PMC1720020 DOI: 10.1136/adc.2002.025825] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To evaluate the effectiveness of a nurse led clinic (NLC) compared with a consultant led paediatric gastroenterology clinic (PGC) in the management of chronic constipation. METHODS Children (age 1-15 years) with functional constipation were randomised following a detailed medical assessment to follow up in either the NLC or PGC. An escalating algorithm of treatment was used as the basis of management in both the NLC and PGC. Main outcome measures were: time to cure at last visit or later confirmed by telephone; time to cure at last visit; and time to prematurely leaving the study. RESULTS A total of 102 children were recruited, of whom 52 were randomly assigned to NLC and 50 to PGC. Outcome assessment showed that 34 children in the NLC and 25 children in the PGC were confirmed cured at their last visit or later confirmed by telephone. The median time to cure was 18.0 months in the NLC and 23.2 months in the PGC. The probability of being cured was estimated as 33% higher in the NLC compared to PGC (hazard ratio 1.33). Attending the NLC hastened time to cure by an estimated 18.4%. CONCLUSION Children who attend an NLC are equally as, if not more likely to be cured of intractable constipation, than those attending a PGC and on average their cure will occur sooner. Results suggest that an NLC can significantly improve follow up for children with intractable constipation and highlight the important role for clinic nurse specialists in management of children with gastrointestinal disease.
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Affiliation(s)
- C A Burnett
- University of Oxford, Department of Paediatrics, John Radcliffe Hospital, Oxford, UK
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Rawat DJ, Haddad M, Geoghegan N, Clarke S, Fell JM. Percutaneous endoscopic colostomy of the left colon: a new technique for management of intractable constipation in children. Gastrointest Endosc 2004; 60:39-43. [PMID: 15229423 DOI: 10.1016/s0016-5107(04)01286-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The antegrade colonic enema is accepted as effective for management of intractable constipation in children when conventional bowel management has failed. This study describes experience with a new, minimally invasive technique, the distal antegrade colonic enema, which involves percutaneous endoscopic colostomy of the left colon. METHODS Fifteen children with refractory constipation and soiling who had radiographic evidence of megarectum and/or distal colonic delay were selected for the procedure. The junction of the descending and the sigmoid colon was identified colonoscopically, and the percutaneous endoscopic colostomy tube, through which antegrade distal colonic enema are administered, was inserted. RESULTS Fourteen children underwent distal percutaneous endoscopic colostomy insertion. The median time required for the procedure was 30 minutes (20-50 minutes). Excluding one child (technical difficulties with percutaneous endoscopic colostomy placement), median post-procedural hospital stay was 4 days (2-27 days). Thirteen children were no longer soiling, and improvement in quality of life was reported at 2 months' follow-up. At 6 months' follow-up, 90% of children were clean during intervals between enemas. All children evaluated at 12 months' follow-up remained clean. Median duration of follow-up was 12.5 months (2-51 months). CONCLUSIONS The distal percutaneous endoscopic colostomy is a simple alternative to established methods for delivery of antegrade enemas. It is less invasive and on reversal leaves only minor scarring.
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Affiliation(s)
- David J Rawat
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, London, UK
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Abstract
The notes of 214 children who, over a period of 7 years, had been referred after an allegation or a suspicion of any form of child abuse, were examined retrospectively to establish the pattern of injury found, especially with regard to anal fissures or scars. These were all children who had had their genitalia examined at the time of their referral. In 81 children (Group A) who had no history or evidence of sexual abuse, two fissures were found, both with medical explanations for their presence. In 83 (Group B) who alleged sexual abuse but denied anal abuse, nine (11%) had fissures or scars, and in four of the nine there was a history of significant constipation at some time. In 50 children (Group C) who had a strong history of anal abuse, 41 (84%) had fissures or scars. The diagnosis in 13 of these cases was considered definite because there was a confession or guilty plea from the abuser; in the remainder, the diagnosis was "not proven" despite a strong history or gross anal signs and regardless of the verdict in court proceedings. The significance of the findings was discussed with a view to clarifying the relative importance of anal fissures in children with a strong history of anal abuse.
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Loening-Baucke V, Miele E, Staiano A. Fiber (glucomannan) is beneficial in the treatment of childhood constipation. Pediatrics 2004; 113:e259-64. [PMID: 14993586 DOI: 10.1542/peds.113.3.e259] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Constipation and encopresis are common problems in children. Still today, the role of fiber in the treatment of chronic constipation in childhood is controversial. The aim of our study was to evaluate whether fiber supplementation is beneficial in the treatment of children with functional constipation with or without encopresis. We used glucomannan as the fiber supplement. METHODS We evaluated the effect of fiber (glucomannan, a fiber gel polysaccharide from the tubers of the Japanese Konjac plant) and placebo in children with chronic functional constipation with and without encopresis in a double-blind, randomized, crossover study. After the initial evaluation, the patients were disimpacted with 1 or 2 phosphate enemas if a rectal impaction was felt during rectal examination. Patients continued with their preevaluation laxative. No enemas were given during each treatment period. Fiber and placebo were given as 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg for 4 weeks each. Parents were asked to have children sit on the toilet 4 times daily after meals and to keep a stool diary. Age, frequency of bowel movements into the toilet and into the undergarment, presence of abdominal pain, dietary fiber intake, medications, and the presence of an abdominal and/or a rectal fecal mass were recorded on a structured form at the time of recruitment and 4 weeks and 8 weeks later. Children were rated by the physician as successfully treated when they had > or =3 bowel movements/wk and < or =1 soiling/3 weeks with no abdominal pain in the last 3 weeks of each 4-week treatment period. Parents made a global assessments to whether they believed that the child was better during the first or second treatment period. RESULTS Forty-six chronically constipated children were recruited into the study, but only 31 children completed the study. These 31 children (16 boys and 15 girls) were 4.5 to 11.7 years of age (mean: 7 +/- 2 years). All children had functional constipation; in addition, 18 had encopresis when recruited for the study. No significant side effects were reported during each 4-week treatment period. Significantly fewer children complained of abdominal pain and more children were successfully treated while on fiber (45%) as compared with placebo treatment (13%). Parents rated significantly more children (68%) as being better on fiber versus 13% as being better on placebo. The initial fiber intake was low in 22 (71%) children. There was no difference in the percentage of children with low fiber intake living in the United States (70%) and Italy (71%). Successful treatment (physician rating) and improvement (parent rating) were independent of low or acceptable initial fiber intake. The duration of chronic constipation ranged from 0.6 to 10 years (mean: 4.0 +/- 2.5 years). Duration of constipation did not predict response to fiber treatment. Children with constipation only were significantly more likely to be treated successfully with fiber (69%) than those with constipation and encopresis (28%). CONCLUSION We found glucomannan to be beneficial in the treatment of constipation with and without encopresis in children. Symptomatic children who were already on laxatives still benefited from the addition of fiber. Therefore, we suggest that we continue with the recommendation to increase the fiber in the diet of constipated children with and without encopresis.
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Schimpl G, Uray E, Ratschek M, Höllwarth ME. Constipation and intestinal neuronal dysplasia type B: a clinical follow-up study. J Pediatr Gastroenterol Nutr 2004; 38:308-11. [PMID: 15076632 DOI: 10.1097/00005176-200403000-00015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Intestinal neuronal dysplasia type B (IND B) is one of the gastrointestinal motility disorders with a defined malformation of the parasympathetic submucous and myenteric ganglia. The clinical presentation of IND B is variable, ranging from intestinal obstruction in the neonatal period to acute or chronic constipation in childhood. METHODS Between 1993 and 1996, 105 patients (49 females and 56 males) were treated for constipation, and in all of them an IND type B was confirmed histopathologically. Twenty-two neonates, 42 infants to 6 months of age (38% of them were premature, and 5% had additional malformations), and 41 patients to the age of 4 years were included in this study. All 105 patients had been treated conservatively. Treatment consisted of diet in all patients, cisapride in 70% of them, laxatives in 52%, and repeated anal dilatations in 12% of the patients. The mean duration of their treatment lasted from 3 months to 10 months (mean, 6 months). RESULTS The clinical follow-up 5 to 9 years later in 89 of the 108 (85%) patients showed daily defecation in 80% of them and every second day in 14% of them. Only 5 (6%) patients experience recurrent constipation, which responds well to diet and laxatives. CONCLUSIONS In young patients, constipation related to IND B can be treated successfully by conservative treatment regimens, including diet, laxatives, and prokinetic drugs.
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Affiliation(s)
- Guenther Schimpl
- Department of Paediatric Surgery, University of Graz, Medical School, Graz, Austria.
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Abstract
Functional constipation is a common condition. In the majority of cases the constipation develops as a result of a complex weave of factors including specific triggers, e.g. reduced fluid intake following a viral infection or periods of restricted access to the toilet. The passage of large painful stools perpetuates the problem when the child begins to associate pain with defecation. The management of constipation can often be a challenge in children, who initially may be reluctant to sit on the toilet. This article will discuss the contributory factors to the cause of constipation and identify the keys to successful treatment, including ensuring a holistic child-focused approach with effective initial evacuation and appropriate maintenance therapy.
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Affiliation(s)
- June Rogers
- Knowsley PCT, and PromoCon - Disabled Living Centre, Manchester.
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35
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Abstract
BACKGROUND Constipation in childhood is common and places a burden on child health services. Whilst constipation can have a variety of causes, for most children it is usually non-organic and requires limited intervention. It has been suggested that health professionals can resent consultations for such a common problem, believing them to be inappropriate. However, they can underestimate the impact of this condition, leading to adverse clinical effects, as well as parental dissatisfaction. Little research has explored parents' experiences of consulting health professionals about the management of childhood constipation. AIM To explore parents' experiences of consulting health professionals about management of childhood constipation and to use the findings to inform more effective therapeutic encounters when responding to parental concerns. METHODS A phenomenological approach was adopted, using in-depth interviews with parents of 14 children receiving health interventions for constipation. FINDINGS Six themes emerged from analysis including: 'enduring and extreme constipation', which reflected the substantial and sustained impact of the child's constipation; 'dismissed and fobbed off', which captured parents' feelings that their concerns were frequently dismissed by health professionals; 'asserting the need for action', a perception that they had reached a point at which they had to demand some intervention; and 'validation and acknowledgement', which reflected acknowledgment that, finally, their concerns for their child had been taken seriously and acted on. DISCUSSION The findings indicate a failure by some health professionals to appreciate fully the significance of childhood constipation, thereby appearing to be unconcerned and insensitive to the needs of child and family. The impact of this is a potential loss of trust in health professionals by parents, which can then have implications for how they perceive and access health services for management of this common childhood problem. The findings offer an insight into parental experiences and indicate the need for a more sensitive approach during health consultations.
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Affiliation(s)
- Mike Farrell
- Formerly Lecturer/Practitioner, Alder Hey - Royal Liverpool Children's NHS Trust and Department of Nursing, University of Liverpool, Liverpool, UK.
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Khan AR, Vujanic GM, Huddart S. The constipated child: how likely is Hirschsprung's disease? Pediatr Surg Int 2003; 19:439-42. [PMID: 12698267 DOI: 10.1007/s00383-002-0934-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2002] [Indexed: 10/26/2022]
Abstract
The incidence of Hirschsprung's disease (HD) was determined in children who presented with constipation to a specialist paediatric surgical unit. During a 5-year period, 355 rectal biopsies were performed on 182 neonates, infants and children presenting with chronic constipation or intestinal obstruction: 25 (14%) were diagnosed HD. One hundred and four patients had suction and 78 had full-thickness rectal biopsies. Haematoxylin-eosin (HE) staining and acetylcholinesterase (AChE) histochemistry was used. In 13 cases (8%) of suction and 2 cases (2.5%) of full thickness rectal biopsies, specimens were inadequate to diagnose HD. The mean age of all patients was 2.9 years and that of patients diagnosed with HD was 3.64 months. Nineteen patients with HD were diagnosed in the first month, 5 in 1-12 months and 1 at 4 years of age (Fig. 1). The authors found that along with onset of constipation convincing indications for rectal biopsy to exclude HD were as follows: those infants and children who do not pass meconium within 48 hours, have low intestinal obstruction of unknown cause, severe constipation, chronic abdominal distension and failure to thrive. A diagnostic accuracy of 94% was achieved with AChE histochemistry for suction rectal biopsy. After this review, referring paediatricians were advised that screening of other common organic causes of constipation with the least invasive investigations, including laboratory, dietary and paediatric gastroenterology advice, should be undertaken to avoid unnecessary rectal biopsy to exclude HD and related disorders.
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Affiliation(s)
- A R Khan
- Department of Pediatric Surgery, College of Medicine and King Khalid University Hospital, P.O. 2925, 11461 Riyadh, Saudi Arabia.
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Speridião PGL, Tahan S, Fagundes-Neto U, Morais MB. Dietary fiber, energy intake and nutritional status during the treatment of children with chronic constipation. Braz J Med Biol Res 2003; 36:753-9. [PMID: 12792705 DOI: 10.1590/s0100-879x2003000600011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present prospective study was carried out to determine dietary fiber and energy intake and nutritional status of children during the treatment of chronic constipation. Twenty-five patients aged 2 to 12 years with chronic constipation were submitted to clinical evaluation, assessment of dietary patterns, and anthropometry before and after 45 and 90 days of treatment. The treatment of chronic constipation included rectal disimpaction, ingestion of mineral oil and diet therapy. The standardized diet prescribed consisted of regular food without a fiber supplement and met the nutrient requirements according to the recommended daily allowance. The fiber content was 9.0 to 11.9 g for patients aged less than 6 years and 12.0 to 18.0 g for patients older than 6 years. Sixteen patients completed the 90-day follow-up and all presented clinical improvement. The anthropometric variables did not change, except midarm circumference and triceps skinfold thickness which were significantly increased. Statistically significant increases were also found in percent calorie intake adequacy in terms of recommended daily allowance (55.5 to 76.5% on day 45 and to 68.5% on day 90; P = 0.047). Percent adequacy of minimum recommended daily intake of dietary fiber (age + 5 g) increased during treatment (from 46.8 to 52.8% on day 45 and to 56.3% on day 90; P = 0.009). Food and dietary fiber intake and triceps skinfold thickness increased during follow-up. We conclude that the therapeutic program provided a good clinical outcome.
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Affiliation(s)
- P G L Speridião
- Programa de Pós-Graduação em Nutrição, Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Procter E, Loader P. A 6-year follow-up study of chronic constipation and soiling in a specialist paediatric service. Child Care Health Dev 2003; 29:103-9. [PMID: 12603355 DOI: 10.1046/j.1365-2214.2003.00319.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Constipation and soiling is a relatively common condition in childhood and its course is often chronic. This study investigated long-term outcome of children with chronic constipation and soiling by following up a cohort of children 6 years after their presentation to a specialist paediatric gastroenterology clinic with chronic constipation and soiling. DESIGN Retrospective postal survey. SETTING/SAMPLE All children referred in 1991 to a specialist paediatric gastroenterology clinic accepting both secondary and tertiary referrals. MEASURES A semi-structured postal questionnaire was sent to all families, and the Strengths and Difficulties Questionnaire (SDQ) was sent to a random sample. RESULTS The response rate (of those who could be traced) was 89%. Of these, over a third (36%) still had a problem with constipation and soiling and 17% were using regular laxatives. Three people still having problems with constipation and soiling in the sample were aged over 18 years. No significant difference was found with regard to age, sex or age at referral between the group that improved and the group that did not. Both groups felt they had suffered a high degree of distress because of the problem, with parents highlighting their powerlessness to help their child and the child identifying the embarrassment caused by the problem. CONCLUSIONS A significant number of children presenting to a specialist paediatric clinic continue to have problems for several years. Further research is needed to identify these cases and to identify which factors promote resolution of the problem.
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Affiliation(s)
- E Procter
- Canada House, Barnsole Road, Gillingham, Kent, ME7 4JL, UK.
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40
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Abstract
A careful history and physical examination will help to differentiate between encopresis with or without constipation and fecal incontinence caused by anatomic or organic disease. Most children with encopresis with or without functional constipation require no or minimal laboratory workup. Successful treatment of encopresis requires a combination of parent and child education, behavioral intervention, medical therapy, and long-term compliance with the treatment regimen. The conventional treatment approach consists of behavior modification and laxative for children with encopresis with constipation and behavior modification alone for the few children with encopresis without constipation. Almost every patient will experience dramatic improvement in encopresis. Recovery rates are 30% to 50% after 1 year and 48% to 75% after 5 years.
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Affiliation(s)
- Vera Loening-Baucke
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of Iowa, Iowa City, 52242-1083, USA.
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41
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Haddad M, Clarke S, Fell J. Percutaneous Endoscopic Colostomy of the Left Colon: A New Technique for the Management of Intractable Chronic Constipation. ACTA ACUST UNITED AC 2002. [DOI: 10.1089/10926410260338924] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Abstract
The anatomic and functional elements contributing to fecal continence and defecation are explored. The high incidence and importance of chronic idiopathic constipation as an entity in itself and a contributing factor to fecal incontinence are emphasized, and its management is discussed. The importance of a proper clinical history and examination is highlighted, and investigative modalities including radiology, transit studies, and anorectal manometry are described and placed in the context of practical clinical management.
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Affiliation(s)
- D M Griffiths
- Wessex Regional Centre for Paediatric Surgery, Southampton University Hospitals NHS Trust, England
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Abstract
BACKGROUND Children with functional constipation and encopresis benefit from behavior modification and from long-term laxative medication. Polyethylene glycol without electrolytes has become the first option for many pediatric gastroenterologists. METHODS Twenty-eight children treated with polyethylene glycol without electrolytes were compared with 21 children treated with milk of magnesia to evaluate the efficiency, acceptability, side effects, and treatment dosage of polyethylene glycol in long-term treatment of functional constipation and encopresis. Children were rated as "doing well," "improved," or "not doing well," depending on resolution of constipation and encopresis. RESULTS At the 1-, 3-, 6-, and 12-month follow-ups, bowel movement frequency increased and soiling frequency decreased significantly in both groups. At the 1-month follow-up, children on polyethylene glycol were soiling more frequently (P < 0.01) and fewer were improved (P < 0.01). At the 3- and 6-month follow-ups, both groups had similarly improved. At the 12-month visit, 61% of children on polyethylene glycol and 67% of children on milk of magnesia were doing well. Children on polyethylene glycol soiled more frequently (P < 0.01). None refused polyethylene glycol, but 33% refused to take milk of magnesia. The mean initial treatment dosage of polyethylene glycol was 0.6 +/- 0.2 g/kg daily. Polyethylene glycol had no taste, and no loss of efficacy occurred. Polyethylene glycol did not cause clinically significant side effects. CONCLUSIONS Polyethylene glycol without electrolytes is an alternative for long-term management of children with constipation and encopresis.
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Borowitz SM, Cox DJ, Sutphen JL, Kovatchev B. Treatment of childhood encopresis: a randomized trial comparing three treatment protocols. J Pediatr Gastroenterol Nutr 2002; 34:378-84. [PMID: 11930093 DOI: 10.1097/00005176-200204000-00012] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To compare short- and long-term effectiveness of three additive treatment protocols in children experiencing chronic encopresis. METHODS Children, 6 to 15 years of age, who experienced at least weekly fecal soiling for 6 months or longer were eligible for the study. Children were randomly assigned to a group that received intensive medical therapy (IMT), a group that received intensive medical therapy plus a behavior management program called enhanced toilet training (ETT), or a group that received intensive medical therapy with enhanced toilet training and external anal sphincter electromyographic biofeedback (BF). Data concerning toileting habits were collected for 14 consecutive days before an initial visit, and at 3, 6, and 12 months after initiation of therapy. All data were collected using a computerized voice-mail system that telephoned the families each day. At 12 months, children were classified as significantly improved (reduction in soiling, P < 0.001) or cured (<one fecal accident in 2 weeks). RESULTS Eighty-seven children participated in the study, 72 boys and 15 girls. Mean age at enrollment was 8.6 +/- 2.0 years, and mean duration of symptoms was 58.2 +/- 38.5 months. At 12 months, the cure rates for the IMM, ETT, and BF groups were 36, 48, and 39, respectively (not significant). The improvement rates for these three groups were 45, 78, and 54, respectively (P < 0.05). These results were very stable over time (r > 0.90, P < 0.001 in each case). Response to treatment during the first 2 weeks of therapy was highly predictive of outcome at 3, 6, and 12 months (P < 0.0001). Children in the ETT group used less laxative medication (P < 0.04) and required fewer treatment contacts (P = 0.08) than children in the IMM group. All three treatments resulted in significant increases in daily bowel movements passed in the toilet and self-initiated toileting, and resulted in decreases in average daily soiling at 3, 6, and 12 months (P < 0.05). CONCLUSIONS Enhanced toilet training is somewhat more effective in treating childhood encopresis than either intensive medical therapy or anal sphincter biofeedback therapy. Although similar total cure rates at 1 year can be expected with these three forms of therapy, enhanced toilet training results in statistically significant decreases in the daily frequency of soiling for the greatest number of children.
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Affiliation(s)
- Stephen M Borowitz
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia 22908, USA.
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Lee SL, DuBois JJ, Montes-Garces RG, Inglis K, Biediger W. Surgical management of chronic unremitting constipation and fecal incontinence associated with megarectum: A preliminary report. J Pediatr Surg 2002; 37:76-9. [PMID: 11781991 DOI: 10.1053/jpsu.2002.29431] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND/PURPOSE Functional constipation with associated fecal incontinence responds poorly to medical management once megarectum has developed. The authors describe resecting the dilated rectum and inserting a cecostomy button for antegrade enemas in this difficult condition. METHODS Four children, ages 9 to 15 years, with a history of unremitting constipation and fecal incontinence were referred for evaluation after not responding to medical management. All patients had exhibited normal lumbosacral magnetic resonance images (MRI) and open rectal biopsies; however, all 4 patients had a megarectum on contrast enema. In addition, anorectal manometry was consistent with functional fecal retention. The dilated rectum was resected by anastamosing the nondilated sigmoid colon to the distal rectum, and a standard gastrostomy button was inserted into the cecum for antegrade enemas. Mean follow-up was 35 months (range, 8 to 60 months). RESULTS Constipation and incontinence resolved within 6 months in all patients, and all children remained continent without the aid of cathartic agents. There were no postoperative episodes of fecal impaction. The only complication was antibiotic-associated diarrhea in 1 patient. Cecostomy buttons were removed at 1 year postplacement in all 4 patients with continued success. Three patients underwent repeat anorectal manometry; all 3 had normal rectal sensory threshold volumes and anorectal inhibitory reflexes. Barium studies also were obtained in the 3 patients without evidence of recurrent rectal dilation. CONCLUSIONS Refractory constipation and incontinence associated with megarectum may be amenable to surgical intervention in selected patients. The authors' limited experience suggests that proctectomy and button cecostomy is an effective treatment option that improves the quality of life in these patients. Furthermore, proctectomy alone may be curative.
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Affiliation(s)
- Steven L Lee
- Department of Surgery, University of California, Davis Health System, Sacramento, CA, USA
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Böhmer CJ, Taminiau JA, Klinkenberg-Knol EC, Meuwissen SG. The prevalence of constipation in institutionalized people with intellectual disability. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2001; 45:212-218. [PMID: 11422645 DOI: 10.1046/j.1365-2788.2001.00300.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Constipation is a common problem in people with intellectual disability (ID). Laxatives are frequently prescribed with disappointing results. The prevalence of constipation was investigated in a random population of 215 people with ID (IQ < 50) and constipation was correlated with clinical symptoms. All subjects were scored for bowel habits. Constipation was defined as having a bowel movement less than three times a week or the necessity of using laxatives more than three times a week. Further possible accompanying factors were evaluated. The control subjects were defined as individuals who did not use laxatives. Subjects with constipation were defined as patients and were compared to subjects without constipation (controls). One hundred and forty-nine out of 215 cases (69.3%) showed constipation. Constipation was significantly correlated with non-ambulancy, cerebral palsy, the use of anticonvulsive medication or benzodiazepines, H2-receptor antagonists or proton pump inhibitors, food refusal, and an IQ < 35. Fifty-eight per cent of the patients used bisacodyl or magnesium oxide, 39% lactulose, 13% sodiumlaurylsulphoacetate/sodium citrate/sorbitol and only 10% were given sodium phosphate enemas. Faecal soiling was found in 15% of subjects, while manual evacuation of faeces was performed in nearly 7% of cases. Constipation was randomly demonstrated in almost 70% of the population with ID. Subjects with the above-mentioned accompanying factors are especially at risk for constipation. Contrary to the general population, constipation in people with ID is associated with little use of phosphate enemas, microlax, a low incidence of faecal soiling and manual evacuation of faeces, suggesting an aetiology without distal faecal impaction. The regimen and effect of therapy has to be studied to define adequate treatment schedules.
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Affiliation(s)
- C J Böhmer
- Academic Hospital Vrije Universiteit, Department of Gastroenterology, 1007 MB Amsterdam, the Netherlands.
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Brooks RC, Copen RM, Cox DJ, Morris J, Borowitz S, Sutphen J. Review of the treatment literature for encopresis, functional constipation, and stool-toileting refusal. Ann Behav Med 2001; 22:260-7. [PMID: 11211851 DOI: 10.1007/bf02895121] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
This review summarizes the literature on randomized, controlled, published studies involving medical, behavioral, psychological, and biofeedback treatments for encopresis/functional constipation and stool-toileting refusal in preschool-age and school-age children. Nine such studies were located in the literature involving school-age children. No randomized, controlled treatment studies involving preschool-age children have been published. This review revealed no evidence to support the routine use of psychotherapy or anal sphincter biofeedback in the treatment of pediatric fecal elimination dysfunctions, beyond those benefits derived from a comprehensive medical-behavioral intervention. Further, this review indicated that paradoxical constriction of the External Anal Sphincter does not influence the treatment outcome of either biofeedback or medical-behavioral interventions. There are remarkably few controlled treatment outcome studies in this most important clinical area. More research is needed that employs standard treatment outcome variables.
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Affiliation(s)
- R C Brooks
- Behavioral Medicine Center, Box 223, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA
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van der Plas RN, Benninga MA, Staalman CR, Akkermans LM, Redekop WK, Taminiau JA, Buller HA. Megarectum in constipation. Arch Dis Child 2000; 83:52-8. [PMID: 10869000 PMCID: PMC1718400 DOI: 10.1136/adc.83.1.52] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Faecal impaction is frequently observed in children with chronic constipation. The term megarectum is often used to describe this finding. AIM To evaluate rectal functioning and rectal measures in constipated children with a filled rectum, in order to define the terms faecal impaction, enlarged rectum, and megarectum. METHODS All children underwent radiological investigation, colonic transit time study, anorectal manometry, and rectal volume and rectal wall compliance measurements. Patients with faecal impaction were compared with controls, who had an empty rectum on digital rectal examination. RESULTS A total of 31 patients and six controls were included in the study. The mean duration of complaints was 4.2 years and all had faecal incontinence. The colonic transit times in the patients showed a distinct delay in the rectosigmoid segment. Anorectal manometry was not significantly different between patients and controls. The rectal width in patients was 0.68 and in controls 0.52 with an upper limit of 0.61. The pressure-volume curve in patients showed significant less relaxation at a distension of 50 ml. The slope of the curve (corresponding with rectal wall compliance) was comparable for patients and controls. CONCLUSIONS We suggest that faecal impaction is a filled rectum found on digital rectal examination; an enlarged rectum is defined by a rectopelvic ratio greater than 0.61; and megarectum is defined in those with significant abnormalities found with anorectal manometry, pressure-volume curves, or rectal compliance investigation. A diminished relaxation of the rectum on rectal distension could be the first sign of megarectum in children with chronic constipation.
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Affiliation(s)
- R N van der Plas
- Department of Paediatric Gastroenterology and Nutrition, Academic Medical Center, G8-245, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands.
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Nurko S, Garcia-Aranda JA, Worona LB, Zlochisty O. Cisapride for the treatment of constipation in children: A double-blind study. J Pediatr 2000; 136:35-40. [PMID: 10636971 DOI: 10.1016/s0022-3476(00)90046-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To determine whether cisapride is effective in the treatment of children with constipation. STUDY DESIGN Double-blind, placebo-controlled study in which children with chronic constipation were randomly assigned to treatment with cisapride or placebo for 12 weeks. RESULTS Forty children were enrolled, and 36 completed the therapy. Treatment successes occurred in 13 of 17 (76%) subjects in the cisapride group and 8 of 19 (37%) subjects in the placebo group (P <.03). The odds ratio for response after cisapride administration was 8.2 times higher (95% CI 1.3 to 49.4). During cisapride therapy, there was a significant improvement in number of spontaneous bowel movements per week (from 0.9 +/- 0.1 to 4.1 +/- 1.1), and there was a significant decrease in number of fecal soiling episodes per day (1.8 +/- 0.5 to 0.08 +/- 0.4), percent with encopresis (82% vs 23%), number of laxative doses per week (from 10.3 +/- 2.6 to 0.8 +/- 0.6), percent using laxatives (77% to 24%), and total gastrointestinal transit time (from 115.0 +/- 3.7 hours to 77.0 +/- 11.1 hours). With placebo, there were no significant changes in the number of spontaneous bowel movements (from 1.0 +/- 0.8 to 2.2 +/- 0.6), percent with encopresis (74% vs 47%), or total gastrointestinal transit time (from 112.5 +/- 4.9 hours to 95.4 +/- 9.8 hours); but there was a significant decrease in number of fecal soiling episodes per day (from 1.3 +/- 0.4 to 0.4 +/- 0.2) and number of laxative doses used per week (from 11.5 +/- 2.9 to 2.05 +/- 0.7). The final number of spontaneous bowel movements, fecal soiling episodes, laxatives used, or percent patients with encopresis was not different when patients receiving cisapride were compared with those receiving placebo. CONCLUSION Cisapride was effective in the treatment of children with constipation.
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Affiliation(s)
- S Nurko
- Department of Gastroenterology and Nutrition Hospital Infantil De Mexico "Federico Gomez," Mexico City, Mexico
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