Prevalence of Functional Constipation and Relationship with Dietary Habits in 3- to 8-Year-Old Children in Japan

The ten "hard" questions in pediatric functional constipation

Functional constipation is a common problem in childhood and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. No organic cause of the constipation can be found in approximately 95% of children, defining the "so-called" chronic functional constipation. Its prevalence has been reported to range from 0.7 to 29.6%, with a median of 12%. The diagnosis of functional constipation is exclusively clinical based on the pediatric diagnostic Rome criteria for functional gastrointestinal disorders and does not routinely require laboratory and/or radiological investigations. In case of alarm signs and symptoms that may suggest organic diseases, further investigations can be required. The therapeutic management is based on non-pharmacological and pharmacological approaches. Education, demystification of constipation and reward-based toilet training represent the cornerstones of nonpharmacological management. Disimpaction, maintenance treatment and weaning of medication are all elements of pharmacological treatment. Osmotic laxatives, mainly polyethylene glycol (PEG), are considered the first-choice laxative for both disimpaction and maintenance treatment. The aim of this review is to provide pediatric gastroenterologists with a practical tool to support the clinical and therapeutic management of children and adolescents affected by chronic functional constipation.

Urodynamic findings in children with primary refractory nocturnal enuresis: 10 years' experience of a tertiary center

Background/Aim

To identify correlations between urodynamic study (UDS) findings and urinary symptoms in children with refractory monosymptomatic and nonmonosymptomatic primary nocturnal enuresis.

Materials and Methods

A total of 96 neurologically normal children were enrolled, 44 consecutive boys and 51 consecutive girls, aged 5-18 years, of whom 41 (38.8%) had refractory monosymptomatic nocturnal enuresis (MNE) and 55 (61.2%) had refractory non-MNE (NMNE). We assessed the urodynamics of all children to detect any underlying bladder overactivity. A comparative analysis was carried out between the two groups of patients.

Results

Detrusor overactivity (DO), low bladder capacity, low compliance, and increased postvoid residual (PVR) were identified in 70 (72.9%), 35 (36.5%), 43, and 76 (79.2%) patients, respectively. The mean bladder compliance was 21.66 ± 14.52 mL/cmH2O (2-75 cmH2O). Of the NMNE patients, 50 (90.9%) had abnormal urodynamic findings, while 40 (97.5%) had abnormal urodynamic findings in the MNE group. There was a statistically significant relationship between NMNE and both increased PVR and abnormal voiding patterns. Both high PVR and DO were significantly associated with obstructive urinary symptoms. Constipation and history of urinary tract infection (UTI) did not significantly correlate with UDS abnormality (p = 1.0 and p = 0.49, respectively).

Conclusion

There was a high prevalence of bladder function disorders in both refractory MNE and NMNE patients in our study. This included small functional capacity, low bladder compliance, and marked DO. A nocturnal enuresis may be the only presenting symptom, however, it may be associated with bladder overactivity, UTI, and constipation; the UDS findings may aid in guiding the assessment and treatment of children suffering from primary refractory nocturnal enuresis and its association with bladder and bowel symptoms.

Relationship of constipation, body mass index increase and cigarette craving with nutrition in the smoking cessation process: A cross-sectional study from Turkey

This cross-sectional study was conducted to determine the complaints of constipation, increase in body mass index (BMI) and cigarette craving levels and their relationship with nutrition at the end of the 1st month following quit smoking. Individuals who applied to a Smoking Cessation Clinic in Izmir, Turkey were included in the study (N = 87, mean age 44.13 ± 12.67 years). Frequent constipation in daily life and greater than 30 g fat consumption increased constipation complaints, whereas increasing the number of cigarettes smoked before quitting decreased constipation complaints. BMI increase was higher in those who experienced severe constipation after quitting smoking. Cigarette cravings increased as the educational level of the participants increased. Individuals who were obese before quitting had lower levels of cigarette craving. During the smoking cessation process, it will be useful to question the situation of constipation in daily life. Studies examining types of fat and fatty acids should be planned.

Defecation Habits in Preschoolers Are Associated with Physical Activity: A Cross-Sectional and Isotemporal Substitution Analysis

There is a lack of research on the relationship between defecation habits (DF) and physical activity (PA) in preschoolers. This study aimed to clarify the relationship between sedentary behaviour (SB), PA time, and DF in preschoolers and to estimate the effect of DF replacement in an isotemporal substitution (IS) model. The participants included 166 children (aged 4-6 years) attending childcare facilities. PA was measured using an accelerometer to calculate the daily activity and wearing time for SB, light-intensity physical activity (LPA), and moderate-to-vigorous-intensity physical activity (MVPA). DF were classified based on defecation frequency and timing. A multinomial logistic regression analysis was used for the IS model. One-way analysis of variance detected significant differences in MVPA between the DF groups (F(2) = 3.12, p < 0.05). According to the analysis results of the IS model, replacing 5 min of SB with MVPA resulted in improved DF (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.81-0.97). Conversely, replacing 5 min of MVPA with SB worsened DF (OR, 1.13; 95% CI, 1.03-1.23). The findings suggest that PA is associated with DF among preschoolers. It also indicates that replacing SB with MVPA could help improve DF in children.

Overweight status, abdominal circumference, physical activity, and functional constipation in children

OBJECTIVE

The aim of this study was to assess the prevalence of functional constipation and its relationship with the food intake, overweight status, and physical activity of children.

METHODS

This cross-sectional study included students from two public schools in the municipality of Osasco, which is located in the metropolitan area of São Paulo. Functional constipation was diagnosed if the clinical manifestations of the Rome IV criteria were present for more than 2 months. A 24-h recall survey was used to determine the daily food intake. Weight, height, abdominal circumference, and bioelectrical impedance were used to evaluate the weight status. Active commuting to school and physical activity scores were assessed using a questionnaire that has been validated in Brazil.

RESULTS

A total of 452 children, aged 6-12 years, were evaluated. Functional constipation was observed in 22.3% of participants. A greater abdominal circumference was associated with functional constipation in girls (p=0.036) in the bivariate analysis but not in the logistic regression model. Boys with functional constipation consumed higher quantities of fats (p=0.041). There was no statistically significant relationship between functional constipation and overweight status (44.6 and 34.5% of children with and without constipation, respectively; p=0.083) and active commuting to school (48.5 and 56.7% of children with and without constipation, respectively; p=0.179).

CONCLUSION

Functional constipation was associated with a greater abdominal circumference in girls in the bivariate analysis, however, without association in the logistic regression model. Boys with functional constipation consumed higher quantities of fat. No association was found between functional constipation, overweight status, and physical activity.

Relationship of Functional Constipation and Growth Status: A Systematic Review and Meta-Analysis

OBJECTIVES

Functional constipation (FC) and malnutrition are 2 of the most common diseases affecting children worldwide with long-term consequences. We hereby performed a systematic review and meta-analysis to analyze the relationship between these 2 entities.

METHODS

We searched PubMed, American Academics of Pediatrics (AAP), Cochrane, ClinicalTrials.gov (from inception to December 11, 2021) using "constipation," "growth," and "children" as the keywords. Newcastle-Ottawa Scale was used as the risk of bias assessment tool. Meta-analysis using the random-effects model was done.

RESULTS

Eighteen studies involving 33,410 children were chosen in this study. Meta-analysis of all the studies showed statistically significant relationship between FC with both overweight/obesity [odds ratio (OR) = 1.75; 95% confidence interval (CI) = 1.11-2.76; P = 0.02], in Asian countries subgroup, and undernutrition (OR = 2.38; 95% CI = 1.43-3.97; P < 0.001) in Asian countries using ROME criteria's subgroup. Normal weight patients were also more prevalent in non-FC patients in Asia (OR = 0.54; 95% CI = 0.38-0.76; P < 0.001). The relationship between FC and short stature is still inconclusive.

CONCLUSIONS

FC is correlated with the prevalence of both overweight/obesity and undernutrition. Future studies should evaluate the causal relationship and whether FC treatment could help.

Saudi Experts Consensus on Diagnosis and Management of Pediatric Functional Constipation

Although functional gastrointestinal disorders (FGIDs) are very common in pediatric patients, there is a scarcity of published epidemiologic data, characteristics, and management patterns from Saudi Arabia, which is the 2nd largest Arabic country in terms of area and the 6th largest Arabic country in terms of population, with 10% of its population aged <5 years. Functional constipation (FC) is an FGID that has shown a rising prevalence among Saudi infants and children in the last few years, which urges us to update our clinical practices. Nine pediatric consultants attended two advisory board meetings to discuss and address current challenges, provide solutions, and reach a Saudi national consensus for the management of pediatric constipation. The pediatric consultants agreed that pediatricians should pay attention to any alarming signs (red flags) found during history taking or physical examinations. They also agreed that the Rome IV criteria are the gold standard for the diagnosis of pediatric FC. Different therapeutic options are available for pediatric patients with FC. Dietary treatment is recommended for infants with constipation for up to six months of age. When non-pharmacological interventions fail to improve FC symptoms, pharmacological treatment with laxatives is indicated. First, the treatment is aimed at disimpaction to remove fecal masses. This is achieved by administering a high dose of oral polyethylene glycol (PEG) or lactulose for a few days. Subsequently, maintenance therapy with PEG should be initiated to prevent the re-accumulation of feces. In addition to PEG, several other options may be used, such as Mg-rich formulas or stimulant laxatives. However, rectal enemas and suppositories are usually reserved for cases that require acute pain relief. In contrast, infant formulas that contain prebiotics or probiotics have not been shown to be effective in infant constipation, while the use of partially hydrolyzed formula is inconclusive. These clinical practice recommendations are intended to be adopted by pediatricians and primary care physicians across Saudi Arabia.

Polysaccharide Extracts Derived from Defloration Waste of Fruit Pitaya Regulates Gut Microbiota in a Mice Model

Flower thinning is often used during the planting of fruit trees to improve fruit quality and promote large fruit. Flower buds become an agricultural by-product of the planting process. Pitaya (Hylocereus undatus) is a popular fruit in many tropical regions, which is widely cultivated in Southeast Asian countries. Probiotics such as Lactobacillus plantarum have been shown to exhibit an anti-obesity effect by regulating gut microbiota. This study investigated the effect of polysaccharides from pitaya flower buds (PFW) extracted with water on the regulation of gut microbiota and body weight control in mice fed with a high-fat diet. The effects of PFW on the growth of L. plantarum were analyzed and the propagation of L. plantarum was promoted in an aqueous solution containing PFW. In an in vivo study, mice were fed with a high-fat diet supplemented with PFW for 12 weeks; PFW treatment effectively controlled body weight and reduced short bowel syndrome of mice induced by the high-fat diet. Gut microbiota sequencing revealed that Lachnospiraceae and Lactobacillaceae were the main bacteria targeted by PFW. Moreover, transcript analysis demonstrated that PFW alleviated obesity through amino acid metabolism, carbohydrate metabolism, and glycan metabolism. Overall, PFW is a valuable food supplement that can regulate gut microbiota and may have potential to ameliorate the physiological damage caused by a high-fat diet.

Association of dietary magnesium intake with chronic constipation among US adults: Evidence from the National Health and Nutrition Examination Survey

The association of dietary magnesium intake with chronic constipation has not been well-studied in general population. Therefore, the aim of this study was to examine whether increased intake of dietary magnesium is associated with the presence of chronic constipation. Data from the 2007-2010 National Health and Nutrition Examination Survey (NHANES) were used. A total of 9,519 participants (4,814 men and 4,705 women) aged ≥20 years were included. The individual's bowel habits (chronic constipation) were evaluated using the questionnaire on bowel health and two different definitions of constipation (stool consistency and stool frequency) were used. Dietary magnesium intake was obtained from 24-h dietary recall. Participants were categorized based on the quartiles of magnesium intake. Multivariable logistic regressions models were performed controlling for confounding factors. After multivariable adjustment, dietary magnesium intake was inversely associated with chronic constipation defined by stool frequency, and the ORs (95% CIs) across quartiles 2-4 compared with the lowest quartile were 0.71 (0.51-0.99), 0.78 (0.46-1.31), and 0.39 (0.16-0.95), respectively. In addition, there was a significant trend for the decreased prevalence of chronic constipation by quartiles of magnesium intake only among men (p for trend < .001). However, no statistically significant association between magnesium intake and prevalence of chronic constipation defined by stool consistency was observed. More evidence from longitudinal studies is needed to confirm these findings.

Influence of constipation on enuresis

INTRODUCTION

Constipation has classically been considered as a risk factor of enuresis, although there are increasingly more publications that report a similar prevalence of constipation in both enuretics and non-enuretics.

OBJECTIVE

To determine the influence of constipation in monosymptomatic and non-monosymptomatic enuresis, and to find out the prevalence of the three disorders, as well as the lower urinary tract dysfunction and bladder-bowel dysfunction in the population.

MATERIAL AND METHOD

A cross-sectional observational prevalence study on a representative population sample of 5-9 year-old school boys and girls of Galicia, Spain. A questionnaire was completed in the schools on urinary and bowel habits, which included questions from the Paediatric Lower Urinary Tract Scoring System (PLUTSS) diagnostic questionnaire and grading of the lower urinary tract dysfunctions. The enuresis was diagnosed using the International Children's Continence Society (ICSS), and if it was also associated with diurnal symptoms, it was also classified as non-monosymptomatic enuresis. The constipation was evaluated using the Rome III criteria and the adapted Bristol stool scale.

RESULTS

A total of 772 questionnaires were included in the study. The prevalence of constipation was 20% and that of enuresis was 9.1% (62.9% monosymptomatic enuresis and 37.1% non-monosymptomatic), with the prevalence of bladder-bowel dysfunction being 5.2%. It was observed that constipation had no influence on the presence of monosymptomatic enuresis, but it did have an influence on non-monosymptomatic enuresis and lower urinary tract dysfunctions, where it was a significant risk factor.

CONCLUSIONS

The differential diagnosis between monosymptomatic and non-monosymptomatic enuresis is essential in the initial evaluation of the patient with enuresis, since the therapeutic management and the characteristics of both disorders are different, with constipation only being a risk factor in cases of non-monosymptomatic enuresis.

Lifestyle Habits Associated with Poor Defecation Habit among Pupils in Japan

PURPOSE

Not enough attention has been paid to defecation habits in Japan. This study aimed to emphasize the importance of defecation habits on health and function in Japanese pupils.

METHODS

Using multiple regression analysis, 2,722 questionnaires obtained from pupils in grades 5 to 12 were analyzed to determine lifestyle habits associated with defecation frequency.

RESULTS

Significant regression formulae for defecation scores were obtained for all school types: elementary school (ES) (adjusted R2=0.08, p<0.001), junior high school (JHS) (0.09, p<0.001), and senior high school (SHS) (0.15, p<0.001). The following factors were associated with poorer defecation scores, according to school type: female gender (all 3 school types), breakfast skipping (elementary and JHSs), lower physical activity (JHSs and SHSs), and longer school-day screen time (elementary and SHSs). In addition, poorer self-reported academic performance scores in ES, less standardized body mass index (BMI) in JHS, and shorter non-school- day screen time scores in SHS, were associated with poorer defecation scores.

CONCLUSION

Poor defecation frequency showed significant associations with various lifestyle habits, such as breakfast skipping, physical activity, and screen time, among pupils. Academic performance and standardized BMI were also associated with defecation frequency. More attention should be paid to defecation frequency to sustain health and function in pupils.

Foot reflexology in the management of functional constipation: A systematic review and meta-analysis

BACKGROUND

Foot reflexology has been considered an important complementary therapy for many health-related symptoms, especially for some chronic conditions such as anxiety, stress, pain and fatigue. Some studies also showed that foot reflexology had a significant effect on functional constipation, whereas some studies did not. The effect of foot reflexology on functional constipation remains controversial. Therefore, an evidence-based systematic review and meta-analysis of randomised controlled trials were conducted to investigate the effect of foot reflexology on functional constipation.

METHODS

Randomised controlled trials were identified by searching five electronic databases and hand-searching eligible reference lists. Studies that reported the effect of foot reflexology on functional constipation were included. Two reviewers performed the study screening, quality assessment and data extraction. Any discrepancy was discussed with a third reviewer. Quantitative synthesis was conducted for the same outcome measurements by calculating weighted risk ratios.

RESULTS

A total of 203 records were identified, of which seven were eligible. Overall, foot reflexology significantly increased the curative ratio, with a pooled risk ratio of 1.27 (95% CI: 1.16, 1.40, p < 0.00001). Three trials compared the improvement of constipation-related symptoms after intervention in both the experimental and control groups by evaluating the constipation-related symptom scores. The results all showed that foot reflexology can effectively improve constipation-related symptoms. However, one trial reported that foot reflexology had no significant effect on stool frequency and stool consistency. Two studies indicated that foot reflexology significantly reduced the recurrence rate of functional constipation. One study reported the effect of foot reflexology on compliance with the toilet training, diet and motivation. Nevertheless, no significant improvement was detected.

CONCLUSION

Foot reflexology is an effective complementary therapy for treating functional constipation. However, because of the small number of included studies and their small sample sizes, the current evidence was insufficient to support the effectiveness of foot reflexology in reducing the recurrence rate, improving the constipation-related symptom, and compliance with toilet training, diet and motivation. Randomised controlled trials with long-term follow-up are needed for further investigation.

Pediatricians' perceptions and practice of the management of constipation in Thailand

BACKGROUND

Previous studies have shown that physicians' perception and practice can differ from proposed guidelines with regards to constipation. Most studies were performed in developed countries but only a few in developing nations. We therefore aimed to study Thai pediatricians' perceptions of the management of constipation.

METHODS

We performed a national survey using an 37-item online questionnaire that included questions about demographics, perceptions, and practice related to constipation in children. We used a five-point scale to determine perception in each aspect (5 = strongly agreed; 1 = strongly disagreed).

RESULTS

We received 275 responses (response rate of 11.0%). Most were female (69.1%), subspecialists (55.6%) and worked in a government-based setting (69.5%). We noted that only 51.8% considered disimpaction if physical examination is suggestive of fecal impaction. Most pediatricians used lactulose for both disimpaction and maintenance phases (83.4 and 91.9%, respectively); however, pediatricians perceived that the caregivers of constipated children were concerned about tolerance or dependence of most commonly used laxatives, ranged from 45.8 to 63.8%. We also found that recently graduated pediatricians were more likely than older individuals to provide advice on fluid intake, toilet training, and laxative use, and to consider polyethylene glycol for disimpaction (P = 0.003, 0.02, 0.004, and 0.02, respectively).

CONCLUSIONS

The proportion of pediatricians who consider disimpaction remained suboptimal. Providing appropriate knowledge on pharmacological management, especially disimpaction and issues regarding laxatives, may be helpful for pediatricians and caregivers. Education may also need to be tailored to various pediatricians' experience and work settings.