Behavioral therapy for childhood constipation: a randomized, controlled trial

Functional urination or defecation disorders may be warning signs of attention-deficit/hyperactivity disorder among children in rural China

BACKGROUND

This study was designed to investigate the prevalence of attention-deficit/hyperactivity disorder (ADHD) and its association with functional urination and defecation disorders among children in rural China.

METHODS

A cross-sectional study was conducted with children aged 6-18 in rural schools in southwest China using a survey questionnaire. The Swanson, Nolan, and Pelham Questionnaire-IV (SNAP-IV) was used to measure ADHD symptoms, and standardized questions about urination and defecation were used to measure lower urinary tract symptoms (LUTS) and functional defecation disorders (FDDs). The association of ADHD with LUTS and FDDs was analyzed by matched logistic regression after propensity score matching was performed to minimize the influence of potential confounders, including demographic characteristics.

RESULTS

A total of 17,279 participants were included in the analyses. The prevalence of ADHD was 2 % mainly among boys before age 12, after which it showed a decreasing trend with age, resulting in a concomitant reduction in gender differences. The risk of ADHD was positively associated with the presence of enuresis, holding maneuvers, intermittency, and encopresis, with encopresis having the strongest association (P = 0.001). The presence of holding maneuvers, intermittency, excessive volitional stool retention, and encopresis were associated with a higher risk of ADHD at 6-15 years-old, with intermittency exhibiting an increasingly positive association with ADHD risk across ages 6-15.

CONCLUSIONS

ADHD was associated with LUTS and FDDs, which highlights that functional urination and/or defecation disorders could serve as warning signs for ADHD that should trigger screening, especially in relatively backward regions with little ADHD awareness.

Nonpharmacologic Treatment for Children with Functional Constipation: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the effectiveness and safety of nonpharmacologic interventions for the treatment of childhood functional constipation.

STUDY DESIGN

Randomized controlled trials (RCTs) evaluating nonpharmacologic treatments in children with functional constipation which reported at least 1 outcome of the core outcome set for children with functional constipation.

RESULTS

We included 52 RCTs with 4668 children, aged between 2 weeks and 18 years, of whom 47% were females. Studied interventions included gut microbiome-directed interventions, other dietary interventions, oral supplements, pelvic floor-directed interventions, electrical stimulation, dry cupping, and massage therapy. An overall high risk of bias was found across the majority of studies. Meta-analyses for treatment success and/or defecation frequency, including 20 RCTs, showed abdominal electrical stimulation (n = 3), Cassia Fistula emulsion (n = 2), and a cow's milk exclusion diet (n = 2 in a subpopulation with constipation as a possible manifestation of cow's milk allergy) may be effective. Evidence from RCTs not included in the meta-analyses, indicated that some prebiotic and fiber mixtures, Chinese herbal medicine (Xiao'er Biantong granules), and abdominal massage are promising therapies. In contrast, studies showed no benefit for the use of probiotics, synbiotics, an increase in water intake, dry cupping, or additional biofeedback or behavioral therapy. We found no RCTs on physical movement or acupuncture.

CONCLUSIONS

More well-designed high quality RCTs concerning nonpharmacologic treatments for children with functional constipation are needed before changes in current guidelines are indicated.

Functional Constipation and Dyssynergic Defecation in Children

Defecation is a complex physiological process, which relies on intricate mechanisms involving the autonomic and somatic nervous system, the pelvic floor muscles, and the anal sphincter complex. Anorectal dysfunction may result in constipation, a bothersome defecation disorder that can severely affect daily lives of children and their families. In this review, we focus on different mechanisms underlying anorectal dysfunction and specific treatment options aimed at improving defecation dynamics in children with functional constipation.

ACG Clinical Guidelines: Management of Benign Anorectal Disorders

Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

Emotional and behavioural problems in children and adolescents: The role of constipation

AIM

The functional constipation (FC) is a source of an expressive suffering in children, negatively affecting their emotional, social, and physical well-being. The objective of this study is to describe the clinical and behavioural characteristics of children/adolescents with FC.

METHODS

A cross-sectional, observational, analytical study was conducted in public places by interviewing parents of children/adolescents about their child's bowel habits and psychological profile. Bowel symptoms were investigated using the Rome IV criteria. The Strengths and Difficulties Questionnaire (SDQ) was used to evaluate the emotional and behavioural problems.

RESULTS

Of 799 children/adolescents included, 424 (53.1%) were female. Mean age was 9.1 ± 2.7 years. FC prevalence was 20.4%. The most common symptoms in Rome IV criteria were 'painful or hard bowel movements' (n = 110; 67.5%; 95% confidence interval: 60.0-74.3) and 'retentive posturing or excessive volitional stool retention' (n = 89; 54.6%; 95% confidence interval: 46.9-62.1). Median scores for internalising symptoms (7; interquartile range (IQR): 4-9 vs. 5; IQR: 2-7; P < 0.001) and externalising symptoms (7; IQR 4-11 vs. 6; IQR 3-9; P < 0.001) were higher in constipated children compared to non-constipated participants, respectively. The SDQ domains that were associated with FC were emotional symptoms (median 4, P < 0.001) and conduct problems (median 3, P < 0.001). No association was found between faecal incontinence and median scores for the internalising/externalising symptoms. All Rome IV criteria were associated with abnormal overall SDQ scores.

CONCLUSION

Children and adolescents with FC had more emotional and behavioural problems irrespective of whether faecal incontinence was present or not, with higher scores for internalising and externalising symptoms compared to non-constipated children.

A Randomized, Double-Blind, and Placebo-Controlled Trial of Chinese Herbal Medicine in the Treatment of Childhood Constipation

OBJECTIVES

Management of constipation is still challenging in childhood. The pharmacological effect of XiaojiDaozhi Decoction, a prescription of Chinese Herbal Medicine (CHM), has been well described for the treatment of food and Qi stagnation which account for childhood constipation. However, the efficacy and safety of XiaojiDaozhi Decoction in childhood constipation remains unclear.

METHODS

A randomized, double-blind, and placebo-controlled trial was conducted to evaluate the efficacy and safety of XiaojiDaozhi Decoction in childhood constipation. Two hundred children were recruited and randomly allocated to the CHM or placebo group to receive their respective interventions. The duration of treatment was 8 weeks, with a 12-week follow-up. Main outcome measures were complete spontaneous bowel movements and satisfaction with bowel function. Safety and adverse effects were evaluated by blood laboratory measurements.

RESULTS

At the end of follow-up, the response rates of CHM and placebo were 62% and 31%, respectively (χ2 = 19.315, P < 0.01). At the end of treatment, recurrence was found in 7 cases (10.14%) in CHM and 11 cases (26.19%) in placebo (χ2 = 4.947, P < 0.05). In the main outcome measures, 56 patients (56%) in the CHM group and 25 patients (25%) in the placebo group were satisfied with their bowel movements (χ2 = 19.940, P < 0.05). Increased complete spontaneous bowel movements ≥3 per week from baseline were found in 40 patients (40%) who received CHM and 19 patients (19%) who received placebo (χ2 = 10.602, P < 0.05). No serious adverse effects were found in any of the recruited cases.

DISCUSSION

CHM XiaojiDaozhi Decoction is a safe and effective method for the treatment of childhood constipation.

Efficacy of Non-pharmacologic Auxiliary Treatments in Improving Defecation Function in Children With Chronic Idiopathic Constipation: A Systematic Review and Network Meta-analysis

Background: Non-pharmacologic auxiliary treatments have been considered crucial therapies for treating chronic idiopathic constipation (CIC) during the past decades worldwide. Several treatment patterns are available, but their relative efficacy is obscure because there are no head-to-head randomized controlled trials, especially in children. We conducted this network meta-analysis to evalute the effectiveness of these therapies in improving defecation function based on their direct comparisons with standard medical care. Methods: Medline, Embase, and Cochrane Central were searched for randomized controlled trials (RCTs) published in English from inception to October 2020, assessing the efficacy of auxiliary therapies (behavior therapy, physiotherapy, biofeedback, or anorectal manometry) in children with CIC. We extracted data for endpoints, risk of bias, and evidence quality. Eligible studies in the meta-analysis reported the data of a dichotomous assessment of overall response to treatment (response or not) or defecation frequency per week after treatment. The hierarchical Bayesian network meta-analysis was used in the study. We chose a conservative methodology, random effects model, to pool data which could handle the heterogeneity well. The relative risk (RR) with 95% confidence intervals (CIs) was calculated for dichotomous outcomes. For continuous results, weighted mean difference (WMD) with related CIs was calculated. The included treatments were ranked to define the probability of being the best treatment. Results: Seven RCTs (838 patients) met inclusion and endpoint criteria. Based on an endpoint of the absence of constipation (Rome criteria) with laxatives allowed, physiotherapy plus standard medical care (SMC) had the highest probability (84%) to bethe most effective therapy. When the treatment response was defined as an absence of constipation with not laxatives allowed, biofeedback plus SMC ranked first (probability 52%). Physiotherapy plus SMC ranked first when the endpoint was based on defecation frequency per week with laxatives allowed (probability 86%). Conclusion: Almost all auxiliary therapies are effective complementary therapies for treating CIC, but they needed to be used simultaneously with SMC. Nevertheless, because of the small number of eligible studies and their small sample sizes, the differences in treatment duration and the endpoints, large sample RCTs with long-term follow-up are required for further investigation.

Constipation

Constipation in otherwise healthy infants and children is a common problem despite confusion about how to precisely define constipation and constipation-related disorders. Constipation may, rarely, be a sign or symptom of a more serious disease or a diagnosis defined only by its symptoms and without any structural or biochemical findings. In the latter case it is classified as a functional gastrointestinal disorder (FGID). FGIDs are defined as disorders that cannot be explained by structural or biochemical findings. The Rome Foundation has standardized diagnostic criteria for all FGIDs. The Rome criteria are based on the available research as well as the clinical experience of the Foundation's assembled experts. The most recent report, Rome IV, described clinical criteria and diagnostic tools and encouraged more rigorous research in the area of FGIDs. The true incidence and prevalence of constipation is difficult to know because it may be treated at home using home remedies or diagnosed at a visit to a primary care provider or to a subspecialist pediatric gastroenterologist. The most recent attempts to define the prevalence of all pediatric FGIDs have been made using the Rome IV criteria. The defined FGID entities that may be associated with the complaint of constipation are infant dyschezia, functional constipation, and nonretentive fecal incontinence. The term encopresis, omitted from Rome IV, is defined by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition The 3 Rome-defined (constipation-related) entities and the APA entity of encopresis are the focus of this review.

Management of functional constipation in children and adults

Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.

Long-term results using a transanal irrigation system (Peristeen®) for treatment of stool incontinence in children with myelomeningocele

INTRODUCTION

Faecal incontinence due to constipation associated with myelomeningocele (MMC) is a frustrating problem. It could have a bad impact on patients and their families' quality of life. Conservative measures could be a starting point. In case of failure, Malone antegrade continence enema (MACE) is commonly considered. However, it is associated with higher complications. Peristeen transanal irrigation (TAI) depends on the injection of water into the colon through a rectal catheter with an inflatable balloon to promote a controlled evacuation of large quantities of faecal contents. Transanal irrigation could be an alternative in these patients to avoid surgery.

OBJECTIVE

The objective of this study was to evaluate the long-term effectiveness and satisfaction of TAI management (Peristeen^®, Coloplast, Denmark) in children with MMC who failed to respond to conservative measures for stool incontinence.

STUDY DESIGN

All patients with MMC who did not respond to conservative measures for stool incontinence and were using TAI with the last follow-up 6 months before the end date were included. Data were collected retrospectively from January 2008 till January 2016. The data collected included the age of starting Peristeen, duration of using the Peristeen, acceptance and compliance of the patient's family with the TAI. Success was defined as stool continence.

RESULTS

A total of 109 patients (55 males and 54 females) diagnosed as having MMC were started on TAI Peristeen. With a mean follow-up of 48 months (24-108), 101 patients (90.4%) achieved complete stool continence and 8 patients were considered failures.

DISCUSSION

The study results are comparable with those of previously reported publications. The main limitation of Peristeen TAI is that it cannot be performed by the patient himself/herself. This may present a problem with later independence.

CONCLUSION

Transanal irrigation with Peristeen^® system is a safe and good alternative option for stool incontinence when other conservative measures fail.

A Randomized Controlled Trial Examining the Effects of Reflexology on Children With Functional Constipation

Functional constipation is a common problem in Turkey that affects up to 10% of children. Reflexologists claim that reflexology can be beneficial in the treatment of constipation. The aim of this randomized controlled study was to determine the effectiveness of reflexology in treating functional constipation in children. Thirty-seven children who were referred to a pediatrician with functional constipation as defined by the Rome III criteria were recruited to the study. After the physician's diagnosis, two groups (intervention/control) were created. The intervention and control groups comprised 17 and 20 children, respectively. Each child in the intervention group was given a foot massage for 10 minutes five times a week, and toilet/diet/motivation training was given to their parents. The test period lasted for 4 weeks. Toilet/diet/motivation training was undertaken for 30 minutes once per week (for a total of 4 weeks) in an interactive manner. The parents of children in the control group received equivalent toilet/diet/motivation training only. No significant differences in terms of feces frequency and feces consistency were noted between the intervention and control groups (p > .05). This study sample showed that only toilet/diet/motivation training had potential benefit for treating functional constipation in children. Further larger randomized trials are required to establish whether there are benefits to foot message in the treatment of functional constipation in children.

Effects of Interferential Electrical Stimulation Plus Pelvic Floor Muscles Exercises on Functional Constipation in Children: A Randomized Clinical Trial

OBJECTIVES

Functional constipation is a common condition in children. We assessed the effectiveness of combined interferential (IF) electrical stimulation and pelvic floor muscle (PFM) exercises on functional constipation in children.

METHODS

We conducted a single-center, double-blind randomized clinical trial study during 2014-2017 in Tehran, Iran. Ninety children, aged 5-13 years, who fulfilled Rome III criteria were enrolled and randomly assigned into two treatment groups. Case group (n=45) underwent IF electrical stimulation and PFM exercises, whereas the control group (n=45) received PFM exercises plus sham stimulation. A complete bowel habit diary (with concerning data on the frequency of defecation per week, stool form, and the number of fecal soiling episodes), a constipation score questionnaire, and a visual pain score were recorded before, after the treatment and 6 months later for all participants. In addition, children in both groups were assessed with a constipation-related quality-of-life questionnaire before, after the end of treatment sessions, and 6 months after the treatment.

RESULTS

Treatment success was achieved for 88.4% of children in the case group compared with 43.2% of children in the control group after the treatment (P<0.003). The median constipation score was reduced in both groups, with the cases having significantly lower scores after the treatment (4 vs. 8, P<0.000). Stool form normalized in 75.6% of the cases and 45.5% of the controls after the treatment (P<0.01).

CONCLUSIONS

Our results showed that using IF electrical stimulation as an adjuvant therapy to the medical and rehabilitation programs significantly boosts the effects of treatment among these patients.

Attention Deficit Hyperactivity Disorder and Functional Defecation Disorders in Children

OBJECTIVES

The aim of the study was to assess the prevalence of attention deficit hyperactivity disorder (ADHD) in children presenting with functional defecation disorders (FDDs) and to assess the prevalence of FDDs in children with ADHD.

METHODS

A cross-sectional cohort study was carried out between September 2014 and May 2016. Group 1: Parents of children with FDDs according to the Rome III criteria completed the Child Behavior Checklist and the VvGK (Dutch questionnaire based on the American Disruptive Behavior Disorder rating scale). Patients with ADHD subarea scores ≥70 on the Child Behavior Checklist and/or ≥16 on the VvGK were referred for further psychiatric evaluation. Group 2: Parents of children treated for ADHD at a specialized ADHD outpatient clinic completed a standardized questionnaire regarding their child's defecation pattern.

RESULTS

In group 1 (282 children with FDDs), 10.3% (7.1%-13.5% bias-corrected and accelerate confidence interval) were diagnosed with ADHD. Group 2 consisted of 198 children with ADHD, 22.7% (17.6-28.8 bias-corrected and accelerate confidence interval) fulfilled the Rome III criteria for an FDD. Children with both an FDD and ADHD reported urinary incontinence significantly more often compared to children with an FDD or ADHD alone: 57.1% in FDD + ADHD versus 22.8% in FDD alone (P < 0.001) and 31.1% in ADHD + FDD versus 7.8% in ADHD alone (P < 0.001).

CONCLUSIONS

Approximately 10.3% of children with FDDs had ADHD and 22.7% of children with a known diagnosis of ADHD fulfilled the Rome III criteria for an FDD. This observation suggests that screening for behavioral disorders and FDDs should be incorporated into the diagnostic workup of these groups of children.

Progress in research of functional constipation in children

Constipation is a common symptom in the children population, which can be a manifestation of organic diseases or may be caused by functional factors. More than 90% of cases of constipation in children are functional constipation (FC). As a physical and mental illness in childhood or even a public health problem, FC has multidimensional impacts on children and their families, posing a great healthcare burden on the society. The Rome Ⅳ criteria for diagnosis of functional gastrointestinal disorders were published in 2016, in which a global consensus was formed and modified for the diagnostic criteria of FC in children. However, there are still difficulties in the choice of FC treatments and assessment of its outcome not only because of the distinct understanding and application of the criteria but also because of the incomplete understanding of the pathogenesis of FC. Therefore, the pathophysiological mechanism of FC and its therapeutic efficacy evaluation should be further studied in the future.

Pediatric Integrative Medicine

The practice of pediatrics from an integrative framework is based on physician-patient relationship, informed by evidence, and approaches the health of children and their families from a broad perspective. This article reviews the basic principles of integrative pediatrics and summarizes data and integrative approaches to common pediatric conditions seen in the primary care setting.

Bladder and bowel dysfunctions in 1748 children referred to pelvic physiotherapy: clinical characteristics and locomotor problems in primary, secondary, and tertiary healthcare settings

The aims of this study are to evaluate in a pragmatic cross-sectional study, the clinical characteristics of childhood bladder and/or bowel dysfunctions (CBBD) and locomotor problems in the primary through tertiary health care setting. It was hypothesized that problems would increase, going from primary to tertiary healthcare. Data were retrieved from patient-records of children (1-16 years) presenting with CBBD and visiting pelvic physiotherapists. Prevalence's of dysfunctions were compared between healthcare settings and gender using ANOVA and chi-square test. Agreement between physicians' diagnoses and parent-reported symptoms was evaluated (Cohen's Kappa). One thousand seventy hundred forty-eight children (mean age 7.7 years [SD 2.9], 48.9% boys) were included. Daytime urinary incontinence (P = 0.039) and enuresis (P < 0.001) were more diagnosed in primary healthcare, whereas constipation (P < 0.001) and abdominal pain (P = 0.009) increased from primary to tertiary healthcare. All parent-reported symptoms occurred more frequently than indicated by the physicians. Poor agreement between physicians' diagnoses and parent-reported symptoms was found (k = 0.16). Locomotor problems prevailed in all healthcare settings, motor skills (P = 0.041) and core stability (P = 0.015) significantly more in tertiary healthcare.

CONCLUSIONS

Constipation and abdominal pain (physicians' diagnoses) and the parent-reported symptoms hard stools and bloating increased from primary to tertiary healthcare. Discrepancies exist between the prevalence's of physicians' diagnoses and parent-reported symptoms. Locomotor problems predominate in all healthcare settings. What is Known: • Childhood bladder and/or bowel dysfunctions (CCBD) are common. • Particularly tertiary healthcare characteristics of CBBD are available What is New: • Characteristics of CBBD referred to pelvic physiotherapy are comparable in primary, secondary, and tertiary healthcare settings. • Concomitant CBBD appeared to be more prevalent than earlier reported. • Discrepancies exist between referring physicians' diagnoses and parent-reported symptoms.

Effectiveness of Pelvic Physiotherapy in Children With Functional Constipation Compared With Standard Medical Care

BACKGROUND & AIMS

Functional constipation (FC) is a common childhood problem often related to pelvic floor muscle dysfunction. We compared the effectiveness of pelvic physiotherapy (PPT) vs standard medical care (SMC) in children with FC.

METHODS

We performed a multicenter randomized controlled trial of 53 children (age, 5-16 y) with FC according to the Rome III criteria, at hospitals in The Netherlands from December 2009 to May 2014. Group allocation was concealed using a central computer system. SMC consisted of education, toilet training, and laxatives (n = 26), whereas PPT included SMC plus specific physiotherapeutic interventions (n = 27). Results were obtained from written reports from the subjects' pediatricians and parents. The primary outcome was absence of FC, according to Rome III criteria, after a 6-month follow-up period. Secondary outcomes were global perceived effect (range, 1-9; success was defined as a score ≥ 8), numeric rating scales assessing quality of life (parent and child; scale, 1-10), and the strengths and difficulties questionnaire (SDQ).

RESULTS

Treatment was effective for 92.3% of the children receiving PPT and for 63.0% of the children receiving SMC (adjusted odds ratio for success of PPT, 11.7; 95% confidence interval, 1.8-78.3) (P = .011). Significantly more children undergoing PPT stopped using laxatives (adjusted odds ratio, 6.5; 95% confidence interval, 1.6-26.4) (P = .009). Treatment success (based on global perceived effect) was achieved for 88.5% of subjects receiving PPT vs 33.3% of subjects receiving SMC) (P < .001). PPT also produced larger adjusted mean differences, before vs after treatment, in numeric rating scales to assess quality of life: an increase of 1.8 points for parents (P = .047) and 2.0 points for children (P = .028). Results from the SDQ did not differ significantly between groups (P = .78).

CONCLUSIONS

In a randomized controlled trial of children with FC, PPT was more effective than SMC on all outcomes measured, with the exception of findings from the SDQ. PPT should be considered as a treatment option for FC in children 5-16 years old. Dutch Clinical Trial Registration no: NL30551.068.09.

Defecation-Specific Behavior in Children with Functional Defecation Issues: A Systematic Review

CONTEXT

Atypical defecation habits are common and distressing for children and families and can have a major impact on quality of life. Often, no underlying factor can be identified, and the defecation disorder is considered functional. Current interventions are not successful for up to 50% of children. We suggest this high failure rate may be caused by lack of consistency in descriptors of behavioral indicators for functional defecation problems. Most investigations and descriptors focus on general behavior. There are fewer reports concerning defecation-specific behaviors.

OBJECTIVE

To develop a thorough inventory of defecation-specific behaviors, providing a more informed foundation for assessment and intervention.

DESIGN

A systematic review of six common databases was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Reference lists of retained articles were screened for additional studies.

MAIN OUTCOME MEASURES

Content analysis was used to classify defecation-specific behaviors into 17 categories.

RESULTS

Our search yielded 2677 articles; 98 peer-reviewed publications were retained for full-text review, and 67 articles were included in the final qualitative synthesis. Although there is inconsistency in reported diagnostic criteria, stool withholding and manifesting pain on defecation are the most commonly reported defecation-specific behaviors. In the studies that included children with autism or attention-deficit/hyperactivity disorder, the defecation-specific behaviors were not unique to the diagnostic group.

CONCLUSION

Consistent use of established diagnostic criteria, along with use of behaviors identified through this review, lay a foundation for more effective interventions.

Need for Rectal Biopsy for Childhood Constipation Predicts Severity of Illness and Need for Laxatives

OBJECTIVES

This study aimed to examine the long-term clinical outcomes of children with severe constipation, as defined by need for rectal biopsy (RB), and to determine which baseline characteristics were predictors of successful outcome.

METHODS

Children with severe constipation who underwent RB for evaluation of Hirschsprung disease at a tertiary medical center were eligible. A cohort of children with constipation without a history of RB served as controls (matched 2:1 by sex and age). Retrospective chart review of clinic visits was performed at baseline, 3, 6, 12, 18, and 24 months. Successful clinical outcomes were defined as ≥3 bowel movements weekly for ≥4 weeks, with ≤2 fecal incontinence episodes monthly, irrespective of laxative use.

RESULTS

A total of 175 RB children (90 boys, mean age: 6.7 years) were matched to 350 controls. Mean duration of constipation symptoms before intake in the RB group was significantly longer compared with controls (3.7 vs 0.4 years, P < 0.001). By 24 months, the cumulative percentage of children achieving at least 1 period of successful outcome was significantly higher in the control group compared with RB population (73% vs 24%, P < 0.001). Multivariate analysis revealed that younger age (P = 0.001, odds ratio 0.87) and shorter duration of constipation before RB (P = 0.03, odds ratio 0.45) were significant predictors of successful outcome.

CONCLUSIONS

Only one-quarter of patients with severe constipation achieved successful outcome during 2-year follow-up. Younger age and shorter duration of constipation at time of biopsy were predictors of successful outcomes, emphasizing the importance of early diagnosis and initiation of treatment in this population.

Conventional treatment of functional constipation has a positive impact on the behavioural difficulties in children with and without faecal incontinence

AIM

Constipation studies have only evaluated behavioural difficulties in children with faecal incontinence. This study evaluated changes in behavioural difficulties in childhood with functional constipation (FC) with and without faecal incontinence, based on treatment outcomes.

METHODS

Children aged five to 16 years who fulfilled the Rome III criteria for FC received conventional treatment. The Strength and Difficulties Questionnaire was completed at inclusion and at the 12-month follow-up.

RESULTS

We included 116 children. The behaviour scores decreased in successfully treated boys (10.3 versus 7.9; p < 0.001) and girls (10.0 versus 7.4; p = 0.0001) with and without faecal incontinence. There was no decrease in the behaviour scores in children with unsuccessful outcomes. Unsuccessfully treated boys had significantly higher behaviour scores than successfully treated boys at inclusion (13.2 versus 10.3; p = 0.006) and after 12 months (11.4 versus 7.9; p = 0.02). No difference was found between unsuccessfully treated and successfully treated girls at inclusion (10.5 versus 10.0; p = 0.77) or after 12 months (10.3 versus 7.4; p = 0.18).

CONCLUSION

Our findings indicate that conventional treatment of FC had a positive impact on behavioural difficulties in constipated children with and without faecal incontinence. This study highlights the importance of proactive detection and treatment of FC in paediatric patients.

Screening for autism identifies behavioral disorders in children functional defecation disorders

This study prospectively assessed whether positive screening surveys for autism spectrum disorders (ASDs) in children with functional defecation disorders (FDDs) accurately identify ASD. Parents of children (4-12 years) who met Rome III criteria for functional constipation (FC), FC with fecal incontinence (FI) and functional nonretentive FI (FNRFI) completed two ASD screening surveys. Children with positive screens were referred for psychological evaluation, and a year later, follow-up surveys were conducted. Of the 97 study participants, 30.9 % were diagnosed with FC, 62.9 % with FC with FI, and 6.2 % with FNRFI. ASD surveys were positive for 27 children (27.8 %). New DSM diagnoses were made in 10 out of the 15 children that completed further evaluation. Two (2.1 %) met criteria for ASD, and 12 (12.4 %) met criteria for other behavioral disorders. Average SRS and SCQ-L scores were higher in subjects with FC with FI as compared to FC alone and in those who reported no improvement versus those who reported improvement 1 year later.

CONCLUSION

While positive ASD screening surveys did not correctly identify ASD in the majority, it did help to identify other unrecognized behavioral disorders in children with FDD. High screening scores were more common in children with FC with FI and in children with poorer responses to current medical treatments.

WHAT IS KNOWN

•A prior study found that 29 % of children with FDD scored positive on ASD screening questionnaires. •Whether positive screens correctly identify ASD in children with FDD is unknown. What is New: •This study shows that positive ASD screens do not correctly identify ASD in children with FDD. However, the use of ASD screening questionnaires can identify previously unrecognized and untreated behavioral/developmental disorders in children with FDD. •High screening scores are more common in children with FC with FI and in children with poorer responses to current medical treatments.

Self-administered acupressure for treating adult psychiatric patients with constipation: a randomized controlled trial

BACKGROUND

Constipation has a high prevalence rate (>30 %) in psychiatric patients with psychotropic drugs. Common pharmacological and non-pharmacological interventions for constipation might have longer-term negative and adverse effects that would outweigh their short-term efficacy in symptom reduction. This randomized controlled trial aims to investigate the effect of self-administered acupressure for the management of constipation, in hospitalized psychiatric patients.

METHODS

Seventy-eight patients were recruited in matched pairs in terms of gender, age and laxative use from five acute psychiatric wards in Hong Kong. Each of these matched pairs of patients was randomly assigned to either a self-administered acupressure (n = 39) or a sham group (n = 39), using computer-generated random numbers. After baseline measurement, the intervention and sham group received the same training in self-administered acupressure and supervised practice once per day for 10 days, except light pressure on non-acupoints was taught to the sham group. The acupoints chosen for acupressure included Zhongwan (RN12), right and left Tianshu (ST25), right and left Quchi (LI11). Participants' symptoms and quality of life regarding constipation were measured at baseline and immediately and 2 weeks after completion of the interventions with constipation assessment scale and patient assessment of constipation quality of life questionnaire, respectively.

RESULTS

After 2 weeks follow-up, participants who had received self-administered acupressure indicated significantly greater improvements in both symptom severity (P = 0.0003) and quality of life (P = 0.0004) when compared with the sham group.

CONCLUSION

The psychiatric patients with constipation who practiced self-administered acupressure for 10 days improved their symptom severity and perceived quality of life immediately and 2 weeks after completion of the intervention in comparison with the sham group.

TRIAL REGISTRATION

The trial was registered with the ClinicalTrials.gov (Reg. No: NCT02187640).

Management of Functional Constipation in Children: Therapy in Practice

Functional constipation is a common healthcare problem among children worldwide and accounts for high healthcare usage and costs. Functional constipation is a clinical diagnosis; the evaluation primarily consists of a thorough medical history and a complete physical examination. Additional investigations are not necessary in most cases. Treatment consists of non-pharmacological and pharmacological interventions. Non-pharmacological interventions involve education and demystification, toilet training (with a reward system), and a defecation diary. Pharmacological treatment comprises three steps: disimpaction, maintenance treatment, and weaning. The treatment of first choice is oral laxatives, preferably polyethylene glycol. When this is insufficient, other therapeutic agents are available. This review discusses the evaluation and management of functional constipation in the pediatric population and provides a summary of drug treatment options.

Parental child-rearing attitudes are associated with functional constipation in childhood

OBJECTIVE

Parenting factors are assumed to play a role in the development and maintenance of childhood constipation. However, knowledge about the association between parenting factors and childhood constipation is limited. This study investigates the association between parental child-rearing attitudes and prominent symptoms of functional constipation and assesses the strength of this association.

DESIGN

Cross-sectional data of 133 constipated children and their parents were collected.

SETTING

The gastrointestinal outpatient clinic at the Emma Children's Hospital in the Netherlands.

PATIENTS

Children with functional constipation aged 4-18 years referred by general practitioners, school doctors and paediatricians.

MAIN OUTCOME MEASURES

Parental child-rearing attitudes were assessed by the Amsterdam version of the Parental Attitude Research Instrument (A-PARI). Symptoms of constipation in the child were assessed by a standardised interview. Negative binomial and logistic regression models were used to test the association between child-rearing attitudes and constipation symptoms.

RESULTS

Parental child-rearing attitudes are associated with defecation and faecal incontinence frequency. Higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence. More and stronger associations were found for children aged ≥6 years than for younger children.

CONCLUSIONS

Parental child-rearing attitudes are associated with functional constipation in children. Any parenting issues should be addressed during treatment of children with constipation. Referral to mental health services is needed when parenting difficulties hinder treatment or when the parent-child relationship is at risk.

TRIAL REGISTRATION NUMBER

ISRCTN2518556.

Clinical, psychological and maternal characteristics in early functional constipation

BACKGROUND

This cross-sectional study investigated the clinical features of functional constipation (FC) at preschool age, as well as emotional and behavioral characteristics of the children, psychological symptom level and parental attitudes of the mothers, and compared these with that of non-referred typically developing controls with normal intestinal habits.

METHODS

Participants included 65 children with FC (mean age, 43.6 ± 15.4 months; range, 25-72 months), 59 healthy controls (mean age, 46.9 ± 14.5 months; range, 25-72 months) and the mothers of the children. The Childhood Behavior Checklist, Symptom Checklist 90 and Parental Attitude Research Instrument were filled in by the mothers.

RESULTS

Participants with FC had higher problem scores than the comparison children in a variety of emotional and behavioral parameters. Approximately half exhibited internalizing and one-third had externalizing problems in the clinical range. The mothers of the patient group had higher levels of psychological distress, overprotective parenting and strict discipline. On multiple logistic regression analysis child psychopathology, maternal education level and maternal distress were independently associated with FC.

CONCLUSION

Behavior problems are common in children with FC from an early age. Low level of education and high psychological distress of the mothers seem to be important risk factors for constipation and should be assessed carefully in the management of these cases.

Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN

BACKGROUND

Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines.

METHODS

Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to the classification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.

RESULTS

This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants <6 months of age and the other for older infants and children.

CONCLUSIONS

This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.

Development of an early nurse led intervention to treat children referred to secondary paediatric care with constipation with or without soiling

Background

Constipation is a common chronic childhood condition referred to secondary care. Effective treatment requires early intervention, prolonged medication to soften stools and behavioural support to achieve a regular habit of sitting on the toilet to pass a stool. The purpose of this audit and service development was to assess routine consultant paediatrician-led care against minimum standards and if appropriate to develop a nurse-led intervention. The new care package could then be tried out within general paediatric clinics in Glasgow as a service evaluation. NICE guideline (CG99) has a research recommendation to compare nurse-led care with routine consultant-led care.

Methods

Design was an audit then development of a nurse-led intervention followed by a service evaluation. Participants were children (age 0–13 years), referred by their General Practitioner (GP) to the Royal Hospital for Sick Children Glasgow, with constipation the main problem in the GP letter. The audit covered appointment waiting times, intervention provided, initial follow-up and parental satisfaction with routine consultant-led practice. The nurse-led intervention focused on self-help psychology practice with NICE guideline medical support. This was compared with routine consultant paediatrician care in a service evaluation.

Results

The audit found consultant-led care had long waiting times, delayed initial follow-up and variable intervention. The new nurse-led intervention is described in detail. The nurse-led intervention performed well compared with consultant-led care. Less ‘nurse-led’ children, 3/45 (7%), were still constipated passing less than 3 stools per week compared with 8/58 (14%) receiving consultant-led care. Less ‘nurse-led’ parents, 10/45 (22%), reported their child having pain passing stools in the previous week compared with consultant-led care, 26/58 (45%). The proportion of children, over 4 years, free from soiling accidents was similar, 15/23 (65%) in the nurse-led group and 18/29 (62%) with consultant-led care. Parental satisfaction was slightly better in the nurse-led group.

Conclusion

It is difficult to achieve minimum standards using routine consultant-led care for children referred by their GP with constipation. Nurse-led early intervention is feasible and has produced promising results in a service evaluation. An exploratory trial is planned to develop a teaching module, robust outcomes including costs and benefits, and methodology for a definitive trial recommended by NICE.

Occupational Therapy Based on Ayres Sensory Integration in the Treatment of Retentive Fecal Incontinence in a 3-Year-Old Boy

OBJECTIVE. We present the case report of a 3-yr-old boy with retentive fecal incontinence and sensory overresponsivity. Sensory integration theory was used to address the overresponsivity affecting the child’s ability to acquire age-appropriate toileting habits. We describe the 7 mo of treatment and 3 mo of follow-up in occupational therapy.

METHOD. We analyzed a retrospective chart review of daily defecation log outcome data and parent interview.

RESULTS. Notable improvements in acquiring age-appropriate toileting habits were documented and measured using daily defecation logs. Improvements in sensory processing were documented using the Sensory Profile and corroborated improvements in the child’s ability to participate in toileting routines and parent report of improved quality of life.

CONCLUSION. Occupational therapy using Ayres Sensory Integration® was a useful framework for addressing this child’s toileting habits. This case explicates occupational therapy using data-driven intervention principles to address the relationship among sensory processing, behavior, and occupational performance.

The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial

Background

Functional constipation is a common disorder worldwide and is found in all paediatric age groups. Functional constipation can be caused by delayed colonic transit or dysfunction of the pelvic floor muscles. Standard medical care in paediatric practice is often based on clinical experience and mainly consists of a behavioural approach and toilet training, along with the prescription of laxatives. Evidence to evaluate the effectiveness of pelvic physiotherapy for this complaint is lacking.

Methods/design

A two-armed multicentre randomised controlled trial has been designed. We hypothesise that the combination of pelvic physiotherapy and standard medical care will be more effective than standard medical care alone for constipated children, aged 5 to 17 years. Children with functional constipation according to the Rome III will be included. Web-based baseline and follow-up measurements, scheduled at 3 and 6 months after inclusion, consist of the numeric rating scale in relation to the perceived severity of the problem, the Strength and Difficulties Questionnaire and subjective improvement post-intervention (global perceived effect). Examination of the pelvic floor muscle functions, including digital testing and biofeedback, will take place during baseline and follow-up measurements at the physiotherapist. The control group will only receive standard medical care, involving at least three contacts during five months, whereas the experimental group will receive standard medical care plus pelvic physiotherapy, with a maximum of six contacts. The physiotherapy intervention will include standard medical care, pelvic floor muscle training, attention to breathing, relaxation and awareness of body and posture. The study duration will be six months from randomisation, with a three-year recruitment period. The primary outcome is the absence of functional constipation according to the Rome III criteria.

Discussion

This section discusses the relevance of publishing the study design and the development of the presented physiotherapy protocol. It also addresses difficulties when interpreting the literature with regard to the effectiveness of biofeedback, potential confounding, and future research indications. To our knowledge, this article is the first to describe the design of a randomised controlled trial among children with constipation to assess the effect of pelvic physiotherapy as an add-on to standard medical care.

Trial registration

Current Controlled Trials NL30551.068.09

Bladder and bowel dysfunction: evidence for multidisciplinary care

PURPOSE

We examined the symptoms of bladder-bowel dysfunction (ie severity of voiding dysfunction and stool consistency) and psychosocial difficulties in children presenting to the pediatric urology clinic for voiding dysfunction and to the pediatric gastroenterology clinic for functional constipation.

MATERIALS AND METHODS

Parents of children seen at the gastroenterology clinic were recruited during the outpatient clinic appointment, and parents of children seen at the urology clinic were randomly selected from the research database and matched to the gastroenterology sample based on age and gender of the child. All parents completed the Dysfunctional Voiding Scoring System, Bristol Stool Form Scale, Pediatric Symptom Checklist and Parenting Stress Index™-Short Form, which assessed severity of voiding dysfunction, stool consistency, level of psychosocial difficulties and level of parenting stress, respectively.

RESULTS

Children seen at the urology and gastroenterology clinics did not differ significantly on any of the measures, indicating that the severity of their bladder-bowel dysfunction is similar. However, they had significantly more severe voiding dysfunction, more constipated stool and more psychosocial difficulties than historical healthy controls. Additionally, level of parenting stress was significantly correlated with patient level of psychosocial difficulties and severity of voiding dysfunction.

CONCLUSIONS

Patients with bladder and bowel dysfunction represent a homogeneous group that would potentially benefit from a multidisciplinary treatment approach involving urology, gastroenterology and psychology professionals.

The use of abdominal muscle training, breathing exercises and abdominal massage to treat paediatric chronic functional constipation

AIM

The effect of muscular training, abdominal massage and diaphragmatic breathing was compared with medical treatment in a prospective randomized trial of patients with chronic functional constipation.

METHOD

Patients aged 4-18 years old with functional constipation according to the Rome III criteria were randomized to physiotherapy or medical treatment. In the physiotherapy group, exercises (isometric training of the abdominal muscles, diaphragmatic breathing exercises and abdominal massage) were employed during 12 40-min sessions twice a week by a trained physiotherapist, with laxatives. Patients in the medication group were only given laxatives. Primary outcome measures were frequency of defaecation and faecal incontinence. The analysis was performed by intention-to-treat.

RESULTS

After 6 weeks of treatment, the frequency of bowel movements was higher in the physiotherapy group [5.1 (2.1) days/week] than in the medication group [3.9 (2.0) days/week] (P = 0.01). The frequency of faecal incontinence was no different between the groups [3.6 (1.9) days/week vs 3.0 (2.1) days/week] (P = 0.31).

CONCLUSION

The combined use of isometric training of abdominal muscles, breathing exercises and abdominal massage increased defaecation frequency after 6 weeks but faecal incontinence remained unchanged. Physiotherapy may be a useful treatment for constipation.

Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Tool

Chronic constipation (CC) may impact on quality of life. There is substantial patient dissatisfaction; possible reasons are failure to recognize underlying constipation, inappropriate dietary advice and inadequate treatment. The aim of these practical guidelines intended for primary care physicians, and which are based on Asian perspectives, is to provide an approach to CC that is relevant to the existing health-care infrastructure. Physicians should not rely on infrequent bowel movements to diagnose CC as many patients have one or more bowel movement a day. More commonly, patients present with hard stool, straining, incomplete feeling, bloating and other dyspeptic symptoms. Physicians should consider CC in these situations and when patients are found to use laxative containing supplements. In the absence of alarm features physicians may start with a 2-4 week therapeutic trial of available pharmacological agents including osmotic, stimulant and enterokinetic agents. Where safe to do so, physicians should consider regular (as opposed to on demand dosing), combination treatment and continuous treatment for at least 4 weeks. If patients do not achieve satisfactory response, they should be referred to tertiary centers for physiological evaluation of colonic transit and pelvic floor function. Surgical referral is a last resort, which should be considered only after a thorough physiological and psychological evaluation.

Management of functional constipation in children with lower urinary tract symptoms: report from the Standardization Committee of the International Children's Continence Society

PURPOSE

We present a consensus view of members of the International Children's Continence Society (ICCS) together with pediatric gastroenterologists, experts in the field of functional gastrointestinal disorders, on the management of functional constipation in children with lower urinary tract symptoms.

MATERIALS AND METHODS

Discussions were held by the board of the ICCS and a multidisciplinary core group of authors was appointed. The draft document review process was open to all ICCS members via the website. Feedback was considered by the core authors and, by agreement, amendments were made as necessary.

RESULTS

Guidelines on the assessment, and pharmacological and nonpharmacological management of functional constipation in children with lower urinary tract symptoms are outlined.

CONCLUSIONS

The final document is not a systematic literature review. It includes relevant research when available, as well as expert opinion on the current understanding of functional constipation in children with lower urinary tract symptoms. The document is intended to be clinically useful in primary, secondary and tertiary care settings.

The effect of cassia fistula emulsion on pediatric functional constipation in comparison with mineral oil: a randomized, clinical trial

Background

The prevalence of Pediatric Functional Constipation (FC) has been reported between 0.7% to 29.6%. This study was conducted to compare the laxative effect of cassia fistula emulsion (CFE) with mineral oil (MO) on FC. Cassia fistula is named in Traditional Iranian Medicine (TIM) as “Folus”.

Materials and methods

A randomized clinical trial was carried on 81 children (age range: 4–13 years) with FC, according to Rome III criteria in Amirkola Children’s Hospital, Babol, Iran. They received CFE or MO randomly for three weeks. CFE was produced according to the order of TIM references. Children were counted as improved when they exited from Rome III criteria of FC. Frequency of defecation, fecal incontinence, retentive posturing, severity of pain, consistency of stool and anal leakage of oily material were compared between the two groups and with baselines. An intent-to-treat analysis was used. Safety of drugs was assessed with the evaluation of clinical adverse effects.

Results

41 children were assigned randomly to receive CFE and 40 children received MO. After three weeks of medication, 84% of children in CFE group and 50% in MO group (p = 0.002) exited from the criteria of FC, so called improved. All measurable criteria improved in both groups. The frequency of defecation in CFE group improved from 1.7 per week (before the study) to 10.6 per week (at the third week) while this parameter differed in MO group from 2 to 6.1 (p < 0.001). The severity of pain during defecation and consistency of stool improved significantly better in CFE group than MO group (p < 0.05), but there were not any significant differences between the two groups in fecal incontinence and retentive posturing. Anal leakage of oily material occurred as an important complication in MO group while the children in CFE group did not complaint it. Drug’s compliances were not significantly different in the two groups. CFE and MO did not cause clinically significant side effects.

Conclusions

CFE was most effective than MO in the 3-week treatment of children with FC.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

BACKGROUND

Faecal incontinence is a common and potentially distressing disorder of childhood.

OBJECTIVES

To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted authors in the field to identify any additional or unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.

DATA COLLECTION AND ANALYSIS

Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Twenty one randomised trials with a total of 1371 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).

AUTHORS' CONCLUSIONS

There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

Nonpharmacologic treatments for childhood constipation: systematic review

OBJECTIVE

To summarize the evidence and assess the reported quality of studies concerning nonpharmacologic treatments for childhood constipation, including fiber, fluid, physical movement, prebiotics, probiotics, behavioral therapy, multidisciplinary treatment, and forms of alternative medicine.

METHODS

We systematically searched 3 major electronic databases and reference lists of existing reviews. We included systematic reviews and randomized controlled trials (RCTs) that reported on nonpharmacologic treatments. Two reviewers rated the methodologic quality independently.

RESULTS

We included 9 studies with 640 children. Considerable heterogeneity across studies precluded meta-analysis. We found no RCTs for physical movement, multidisciplinary treatment, or alternative medicine. Some evidence shows that fiber may be more effective than placebo in improving both the frequency and consistency of stools and in reducing abdominal pain. Compared with normal fluid intake, we found no evidence that water intake increases or that hyperosmolar fluid treatment is more effective in increasing stool frequency or decreasing difficulty in passing stools. We found no evidence to recommend the use of prebiotics or probiotics. Behavioral therapy with laxatives is not more effective than laxatives alone.

CONCLUSIONS

There is some evidence that fiber supplements are more effective than placebo. No evidence for any effect was found for fluid supplements, prebiotics, probiotics, or behavioral intervention. There is a lack of well-designed RCTs of high quality concerning nonpharmacologic treatments for children with functional constipation.

Impact of a nurse-led clinic for chronic constipation in children

The impact of a nurse-led constipation clinic was assessed by evaluating the first 50 patients, aged 1.5 to 10 years, using a questionnaire before initial clinic visit and at the third clinic visit, three to four months later. Patients had been constipated for at least six months. The nurses explained the physiology of constipation, the rationale for laxative treatment and the need to comply with treatment. Good toileting behaviour was encouraged. This resulted in an increase in defaecation frequency and stool softness, whereas soiling and pain on defaecation decreased. There was no significant change in the amount of laxatives taken, although it was suspected that compliance improved. Parental understanding of constipation and its management increased. Overall, the control of constipation in children improved markedly through attendance at a nurse-led clinic.

Constipation in childhood

Constipation in children is an often long-lasting pediatric functional gastrointestinal disorder with a worldwide prevalence varying between 0.7% and 29.6%, and estimated health-care costs of US$3.9 billion per year in the USA alone. The pathophysiology of childhood constipation is multifactorial and remains incompletely understood; however, withholding of stools, starting after an experience of a hard, painful, or frightening bowel movement is the most common cause found in children. A thorough medical history and physical examination, including a rectal examination in combination with a bowel diary, is sufficient in the majority of cases to diagnose constipation. The current standard treatment consists of education, toilet training, disimpaction, maintenance therapy and long-term follow-up. In the past decade, well-designed treatment trials in the pediatric population have emerged and long-term outcome studies have been completed. This Review summarizes the current knowledge of the clinical aspects of childhood constipation, including pathogenesis, diagnosis and treatment, with particular emphasis on the latest available data.

Clinical practice : diagnosis and treatment of functional constipation

Childhood functional constipation has an estimated prevalence of 3% in the Western world and is probably the most common gastrointestinal complaint in children. It is characterized by infrequent painful defecation, faecal incontinence and abdominal pain. Only less than 5% of children with constipation have an underlying disease. Only recently two evidence-based guidelines (the Netherlands and Great Britain) have been developed concerning the diagnostic and therapeutic approach for childhood constipation which we both discuss in this article. At present, a thorough medical history and complete physical exam are usually sufficient to confirm the diagnosis of functional constipation. Further laboratory or radiological investigations should only be performed in case of doubt, to exclude an underlying disease. Treatment of childhood constipation consists of four steps: (1) education, (2) disimpaction, (3) prevention of re-accumulation of faeces and (4) follow-up. Surprisingly, there is only limited evidence that laxative treatment is better than placebo in children with constipation. However, according to the available evidence, the Dutch guideline recommends lactulose for children <1 year as first-choice treatment. For children below the age of older than 1 year, both lactulose and polyethylene glycol (PEG) with or without electrolytes can be used as first-choice treatment. According to the National Institute for Health and Clinical Excellence guideline, PEG plus electrolytes is the first-choice treatment for all ages.

CONCLUSION

Children with functional constipation should be diagnosed and treated according to recently developed evidence-based guidelines.

Coexistence of constipation and incontinence in children and adults

The coexistence of constipation and fecal incontinence has long been recognised in paediatric and geriatric populations, but is grossly underappreciated in the rest of the adult population. In children, functional fecal incontinence is usually associated with constipation, stool retention and incomplete evacuation, and is frequently allied to urinary incontinence. Pathophysiology of the incontinence is incompletely understood, although both in children and adults, it is thought to be secondary to overflow, while in adults it may also be related to pelvic floor dysfunction and denervation. Incontinence has an important impact on quality of life and daily functioning, and in children may be associated with behaviour problems. The treatment of underlying constipation usually results in improvement in incontinence. This review broadly addresses the epidemiology and pathophysiology of coexistent constipation and incontinence in both children and adults, and also reviews clinical presentation and treatment response in pediatrics.

Constipation in children: novel insight into epidemiology, pathophysiology and management

Constipation in children is a common health problem affecting 0.7% to 29.6% children across the world. Exact etiology for developing symptoms is not clear in children and the majority is considered to have functional constipation. Alteration of rectal and pelvic floor function through the brain-gut axis seems to play a crucial role in the etiology. The diagnosis is often a symptom-based clinical process. Recently developed Rome III diagnostic criteria looks promising, both in clinical and research fields. Laboratory investigations such as barium enema, colonoscopy, anorectal manometry and colonic transit studies are rarely indicated except in those who do not respond to standard management. Treatment of childhood constipation involves several facets including education and demystification, toilet training, rational use of laxatives for disimpaction and maintenance and regular follow-up. Surgical options should be considered only when medical therapy fails in long standing constipation. Since most of the management strategies of childhood constipation are not evidence-based, high-quality randomized controlled trials are required to assess the efficacy of currently available or newly emerging therapeutic options. Contrary to the common belief that children outgrow constipation as they grow up, a sizable percentage continue to have symptoms beyond puberty.

Bowel habit, diet and body weight in preadolescent children

BACKGROUND

The possible influence of diet and body weight on bowel habit in children is unknown. The present study aimed to investigate the inter-relationships between bowel function, excess body weight and dietary intake in a group of preadolescent children.

METHODS

Eighty-four preadolescent children aged 7-10 years were recruited [mean (SD) age 9.7 (1.0) years]. All children completed a bowel habit diary, examining specific parameters of bowel function and a weighed food inventory concurrently for seven consecutive days. Height and weight measurements were also taken. Children were grouped according to whether they met dietary recommendations and by overweight status; differences in bowel function between the groups were then analysed.

RESULTS

Children who exceeded reference values for fat were more likely to report an incidence of straining to start (P = 0.005) and pain during defaecation (P = 0.021). Subjects who met protein recommendations were less likely to report incomplete evacuation (P = 0.000) and those who met zinc recommendations were less likely to report pain during defaecation (P = 0.044). Excess body weight (according to International Obesity Task Force cut-offs) was also associated with poor bowel habit, with overweight and obese children reporting lower defaecation frequency and a higher incidence of straining and feelings of incomplete evacuation, although these findings were not statistically significant. Defaecation frequency in healthy children was 1.4 defaecations per day compared to 1.2 defaecations for overweight and obese children.

CONCLUSION

A poor diet that fails to meet dietary recommendations as well as being overweight and obese appears to be associated with increased defaecation problems in preadolescent children.

Prevalence and associated clinical characteristics of behavior problems in constipated children

OBJECTIVE

Behavior problems are common in children with functional constipation. This study assessed the prevalence of overall, internalizing, and externalizing behavior problems in children with functional constipation and explored which clinical characteristics of constipation are associated with these behavior problems.

METHODS

Children who had functional constipation, were aged 4 to 18 years, and were referred to the gastrointestinal outpatient clinic at the Emma Children's Hospital were eligible for enrollment. This study made use of baseline data of 133 children who participated in a randomized, controlled trial that evaluated the clinical effectiveness of behavioral therapy compared with conventional treatment. Prevalence of behavior problems was assessed by the Child Behavior Checklist. Univariate and multivariate logistic regression models were used to test the association between clinical characteristics and behavior problems.

RESULTS

The prevalence rate of overall, internalizing, and externalizing behavior problems was considerable: respectively 36.8%, 36.1%, and 27.1% compared with 9% in the Dutch norm population. A long duration of treatment was found to have the strongest association with overall and externalizing behavior problems in children with constipation. Children with constipation and nighttime urinary incontinence have an increased risk for having overall behavior problems. Fecal incontinence and the production of large stools seemed to be exclusively related to externalizing behavior problems.

CONCLUSIONS

Behavior problems are common in children who have constipation and are referred to gastrointestinal outpatient clinics, suggesting that a behavioral screening should be incorporated into the diagnostic workup of children with constipation.

Conservative and behavioural management of constipation

This article deals with psychological contributions, such as stool withholding or responses to abuse experiences, to the aetiology of evacuation disorders (with a focus on dyssynergic defecation), and with education and behavioural approaches to treatment.