The Feasibility of Screening for Sleep Problems in Early Childhood Education Programs

OBJECTIVES

Assess the feasibility and staff experience of screening for behavioral sleep problems (BSP) and sleep disordered breathing (SDB) in early childhood education (ECE) settings; examine BSP/SDB prevalence and caregivers' knowledge/attitudes, perception of child sleep problems, and sleep health engagement in this sample.

METHOD

Eight staff representatives from four ECE sites involved with sleep problem screening procedures within a larger RCT on ECE sleep health, discussed their experiences in a focus group; transcript content reviewed. A random subset of caregiver-child dyads (n = 59) from the four ECE sites completed sleep problem measures (BSP: Children's Sleep Habits Questionnaire, Short form [SF-CSHQ], Tayside Children's Sleep Questionnaire [TCSQ-sleep disturbance and difficulty] and SDB: Pediatric Sleep Questionnaire [PSQ], in addition to RCT measures (Parent Knowledge/Attitude/Self-efficacy/Beliefs survey and sleep health goals). Caregiver sleep health engagement was measured by the sleep health goals set.

RESULTS

ECE staff reported sleep problem screening as self-explanatory and doable but sometimes administratively burdensome. BSPs were identified in 44% (SF-CSHQ) to 63% (TCSQ-sleep disturbance) of children; SDBs in 13%. Only 11% of caregivers endorsed their child having a sleep "difficulty" (TCSQ). Sleep health goals were set by 85% of caregivers; 63% employed educational materials' language.

CONCLUSION

Sleep problem screening in ECE is feasible, and problems are elicited. While caregivers readily engage in setting healthy sleep goals, few endorse sleep as difficult. ECE education could improve caregiver understanding/recognition of sleep problems.

Emotion regulation as a complex system: A multi-contextual and multi- level approach to understanding emotion expression and cortisol reactivity among Chinese and US preschoolers

Are children from "Eastern" cultures less emotionally expressive and reactive than children from "Western" cultures? To answer this, we used a multi-level and multi-contextual approach to understand variations in emotion displays and cortisol reactivity among preschoolers living in China and the United States. One hundred two preschoolers from China (N = 58; 55% males) and the United States (N = 44, 48% males) completed three (i.e., control, interpersonal-related, and achievement-related) emotion-challenging paradigms over 3 days. Behavioral emotion expressions were coded, and salivary cortisol was sampled 30 minutes before and across 90 minutes post-task. Without considering context, Chinese preschoolers displayed fewer levels of positive and negative emotion expressions relative to their United States counterparts. However, Chinese preschoolers displayed similar levels of expressions as their United States counterparts during an achievement-related challenge that is more salient to their sociocultural emphases and showed higher negative emotion expressions in this challenge, relative to other contexts. Moreover, only the achievement-related challenge elicited increased cortisol levels among Chinese preschoolers, and this was correlated with higher levels of negative expressions. For US preschoolers, no cortisol increase was observed in any challenging paradigms, nor was cortisol associated with emotional expressions. Findings counter prior notions that East Asian children are generally less emotionally expressive. Instead, an achievement-related challenge elicited higher emotion expression and cortisol reactivity among Chinese preschoolers, suggesting that children's emotion expression and biological reactivity may be most responsive to contexts salient to their socio-cultural environments. We discuss the importance of considering cultural contexts when studying emotion regulation. RESEARCH HIGHLIGHTS: Chinese preschoolers displayed lower overall positive and negative expressions relative to their US counterparts without considering situational contexts. Chinese preschoolers displayed similar levels of emotion expressions as their US counterparts during an achievement-related challenge salient to their social-cultural environment. Chinese preschoolers are particularly responsive to achievement-related challenges, relative to other emotion-challenging situations that are less culturally salient. No cortisol increase was observed in any of the emotion-challenging paradigms among US preschoolers. Children's emotion expression and biological reactivity may be most responsive to challenges relevant to their socio-cultural environments.

Are Preschoolers' Neurobiological Stress Systems Responsive to Culturally Relevant Contexts?

Adults are biologically responsive to context, and their responses to particular situations may differ across cultures. However, are preschoolers' biological systems also responsive to situational contexts and cultures? Here, we show that children's neurobiological stress responses, as indexed by salivary cortisol, are activated and responsive to psychosocial stressors relevant to their sociocultural emphases. By examining cortisol changes across different contexts among 138 preschoolers living in the United States, China, and Japan, we found that an achievement-related stressor elicited an increased cortisol response among Chinese preschoolers, whereas interpersonal-related stressors elicited an increased cortisol response among Japanese preschoolers. By contrast, U.S. preschoolers showed decreased cortisol responses after these stressors but consistently higher levels of anticipatory responses to separation at the beginning of each session. Our findings suggest that children's neurobiological stress systems may be a critical biological mechanism allowing societal-level cultural phenomena to be embodied in individual-level responses, even among preschoolers.

0911 Association Between Chromosomal Abnormality And Sleep Disordered Breathing Characteristics In Children With Prader Willi Syndrome

Introduction

Prader-Willi Syndrome (PWS) is a genetic disorder caused by lack of expression of paternal genes from the chromosomal region 15 q11.2-q13. PWS is associated with excessive daytime sleepiness, sleep-disordered breathing (SDB), hypoventilation and circadian rhythm disturbance. Chromosomal deletion and uniparental disomy (UPD) are the two most common genetic etiologies of PWS. Differences in clinical features between these groups are recognized; however, limited literature exists regarding sleep characteristics.

Methods

The objective was to evaluate sleep characteristics of children with PWS between those with 15q11.2-q13 chromosomal deletion and those with other genetic etiologies. A retrospective chart review of in-laboratory polysomnograms (PSG) in children with PWS prior to growth hormone treatment was performed. The apnea hypopnea index (AHI), REM AHI, NREM AHI, Obstructive Apnea Index (OAI), Central Apnea Index (CAI), hypopnea index, arousal index, presence of hypoventilation, and positional AHI were assessed.

Results

Overall 33 PWS children were identified. Mean age was 5.9 ± 5.19 (range 1-16 years), 57% were male and 85% had SDB. Almost half (42%) had a 15q11.2-q13 chromosomal deletion. Of those without deletion, 30% had UPD. Sleep variables were similar in PWS with and without deletion: AHI (5.9±5.7 vs. 8.54±7.1; p=0.27), NREM AHI (3.3±4.6 vs. 6.2±6.3; p=0.16), CAI (1.1±1.5 vs. 1.9±3.8; p=0.43) SpO2 nadir 82.7±9.9% vs. 85.3±5.7%; p=0.36) and arousal index (10.3±7.8 vs. 15.4±7.8; p=0.09).

Conclusion

Sleep characteristics do not appear to clearly differ between genetic etiologies of PWS. Larger sample sizes are needed to support these findings.

Support

 

Early-Life Iron Deficiency Alters Glucose Transporter-1 Expression in the Adult Rodent Hippocampus

BACKGROUND

Early-life iron deficiency (ID) impairs hippocampal energy production. Whether there are changes in glucose transporter (GLUT) expression is not known.

OBJECTIVE

The aim of this study was to investigate whether early-life ID and the treatment iron dose alter brain regional GLUT expression in adult rats and mice.

METHODS

In Study 1, ID was induced in male and female Sprague Dawley rat pups by feeding dams a 3-mg/kg iron diet during gestation and the first postnatal week, followed by treatment using low-iron [3-10 mg/kg; formerly iron-deficient (FID)-10 group], standard-iron (40-mg/kg; FID-40 group), or high-iron (400-mg/kg; FID-400 group) diets until weaning. The control group received the 40 mg/kg iron diet. GLUT1, GLUT3, hypoxia-inducible factor (HIF)-1α, and prolyl-hydroxylase-2 (PHD2) mRNA and protein expression in the cerebral cortex, hippocampus, striatum, cerebellum, and hypothalamus were determined at adulthood. In Study 2, the role of hippocampal ID in GLUT expression was examined by comparing the Glut1, Glut3, Hif1α, and Phd2 mRNA expression in adult male and female wild-type (WT) and nonanemic hippocampal iron-deficient and iron-replete dominant negative transferrin receptor 1 (DNTfR1-/-) transgenic mice.

RESULTS

In Study 1, Glut1, Glut3, and Hif1α mRNA, and GLUT1 55-kDa protein expression was upregulated 20-33% in the hippocampus of the FID-10 group but not the FID-40 group, relative to the control group. Hippocampal Glut1 mRNA (-39%) and GLUT1 protein (-30%) expression was suppressed in the FID-400 group, relative to the control group. Glut1 and Glut3 mRNA expression was not altered in the other brain regions in the 3 FID groups. In Study 2, hippocampal Glut1 (+14%) and Hif1α (+147%) expression was upregulated in the iron-deficient DNTfR1-/- mice, but not in the iron-replete DNTfR1-/- mice, relative to the WT mice (P < 0.05, all).

CONCLUSIONS

Early-life ID is associated with altered hippocampal GLUT1 expression in adult rodents. The mouse study suggests that tissue ID is potentially responsible.

The Role of Iron in Pediatric Restless Legs Syndrome and Periodic Limb Movements in Sleep

Restless legs syndrome (RLS) is a common and treatable neurologic condition in pediatric patients, with a prevalence as high as 2 to 3%. The diagnosis of RLS is made clinically based on an urge to move the legs accompanied by lower extremity discomfort that occurs during rest usually later in the day and is relieved by movement. Periodic limb movements in sleep (PLMS) can overlap with RLS, although PLMS also exists as a separate entity characterized by stereotyped movements of lower extremities in sleep. Both conditions may be highly debilitating and interfere with daily function notably in the areas of educational attainment and behavioral regulation. Iron deficiency has been implicated in the pathophysiology of both RLS and PLMS. Current evidence suggests that treatment of ferritin levels < 50 µg/L may be beneficial in improving pediatric RLS symptoms and comorbid conditions or daytime dysfunction associated with RLS. Areas for future research include (1) clarifying the ferritin or other iron status measure level which predicts iron treatment will provide symptom improvement in pediatric patients, and (2) randomized clinical trials using iron therapy to determine the degree and duration of treatment.

Consequences of 'tiger' parenting: a cross-cultural study of maternal psychological control and children's cortisol stress response

Parenting strategies involving psychological control are associated with increased adjustment problems in children. However, no research has examined the extent to which culture and psychological control predict children's stress physiology. We examine cultural differences in maternal psychological control and its associations with children's cortisol. Chinese (N = 59) and American (N = 45) mother-child dyads participated in the study. Mothers reported on psychological control. Children's cortisol was collected during a stressor and two indices of Area Under the Curve (AUC) were computed: AUCg which accounts for total output, and AUCi, which captures reactivity. Results indicate that Chinese mothers reported higher levels of psychological control and Chinese children had higher levels of AUCg than their American counterparts. Across both cultures, psychological control was significantly associated with increased cortisol levels as indexed by AUCg. There were no associations for AUCi. Finally, mediation analyses demonstrated that psychological control fully explained cultural differences in children's cortisol stress response as indexed by AUCg.

Rectal prolapse in older children associated with behavioral and psychiatric disorders

PURPOSE

Rectal prolapse (RP) beyond infancy is challenging, and despite surgical correction, recurrences are not uncommon, suggesting that underlying contributing processes may have a role. This study highlights a previously poorly recognized relationship between RP in older children and behavioral/psychiatric disorders (BPD). We describe the incidence of recurrence and use of behavioral, psychological and physical therapeutic tactics in a multidisciplinary approach to pediatric RP.

METHODS

A retrospective 20-year review of RP in children >3 years of age was adopted. Charts were reviewed for gastrointestinal, connective tissue, and BPD conditions, incidence of recurrence, and therapies employed including surgery, behavioral, and physical therapy.

RESULTS

45 patients were included, ranging from 3 to 18 years of age; 29 males. Thirty-seven underwent surgery. Six of the 45 were excluded as they had gastrointestinal or connective tissue conditions placing them at risk for prolapse. Over half (21/39, 53%) had BPD. Slightly more than half of patients had a recurrence, but there was no increased risk in those with associated BPD. While all 21 underwent some therapy for their BPD, over the past 5 years we have enrolled eight of these patients into a program of behavioral and/or physical therapy with all reporting reductions in frequency and severity of prolapse after initiating pelvic floor strengthening, behavior modification, and biofeedback, and avoidance of surgery in three.

CONCLUSIONS

This study highlights an important group of pediatric patients with RP that may well benefit from a combination of behavioral therapy, physical therapy as well as surgical intervention to obtain the most optimal outcome.

Iron supplementation dose for perinatal iron deficiency differentially alters the neurochemistry of the frontal cortex and hippocampus in adult rats

BACKGROUND

Long-term prefrontal cortex (PFC)- and hippocampus-based cognitive deficits are the sequelae of perinatal iron deficiency, despite iron supplementation starting in the newborn period. Whether high-dose iron supplementation prevents these deficits is yet to be determined.

METHODS

Perinatal iron deficiency was induced in rat pups using a low-iron (3 mg/kg diet) diet during gestation until postnatal day (P)8. Iron was supplemented using a standard (40 mg/kg diet) or a 10-fold higher (400 mg/kg diet) iron-containing diet until P21. PFC and hippocampal neurochemistry was determined using in vivo (1)H nuclear magnetic resonance (NMR) spectroscopy at 9.4 Tesla on P90.

RESULTS

Both standard and 10-fold higher iron supplementation doses corrected anemia and brain iron deficiency by P21. The neurochemical profile of the PFC in both supplementation groups was comparable with the control group. In the hippocampus, standard-dose iron supplementation resulted in lower concentrations of N-acetylaspartate (NAA) and phosphoethanolamine (PE) and higher concentrations of N-acetylaspartylglutamate (NAAG) and glycerophosphocholine + phosphocholine (GPC + PC). High-dose iron supplementation resulted in lower PE and higher GPC + PC concentrations.

CONCLUSION

The iron supplementation dose for perinatal iron deficiency differentially alters the neurochemical profile of the PFC and hippocampus in adults. The neurochemical changes suggest altered glutamatergic neurotransmission, hypomyelination, and abnormal phospholipid metabolism in the formerly iron-deficient (FID) hippocampus.

Behavior and monoamine deficits in prenatal and perinatal iron deficiency are not corrected by early postnatal moderate-iron or high-iron diets in rats

Developmental iron deficiency anemia (IDA) causes brain and behavioral deficits in rodent models, which cannot be reversed when treated at periods equivalent to later infancy in humans. This study sought to determine whether earlier iron treatment can normalize deficits of IDA in rats and what iron dose is optimal. The offspring of dams with IDA during gestation were cross-fostered at postnatal d (P) 8 to dams receiving diets with 1 of 3 iron concentrations until weaning (P21): 0.003-0.01 g/kg [totally iron deficient (TID)]; 0.04 g/kg [formerly iron deficient (FID-40)]; or 0.4 g/kg (FID-400). Always iron-sufficient control dams (CN-40) received a 0.04-g/kg iron diet. At P21, TID pups received a 0.01 g iron/kg diet; all others received a 0.04 g iron/kg diet. Hematocrit and brain iron and monoamine concentrations were assessed at P21 and P100. Pup growth, development, activity, object recognition, hesitancy, and watermaze performance were evaluated. Regional brain iron was restored by iron treatment. Regional monoamine and metabolite concentrations were elevated in FID-40 rats and reduced in FID-400 and TID rats compared with CN-40 rats. FID-40 offspring had motor delays similar to TID during lactation and FID-400 rats had elevated thigmotaxis similar to TID rats at P25 and P100 in the spatial watermaze. In conclusion, iron treatment at P8 in rats did not normalize all monoamine or behavioral measures after early IDA. Moderate iron treatment improved adult behavior, but higher iron treatment caused brain and behavioral patterns similar to TID in the short and long term.

Gestational and lactational iron deficiency alters the developing striatal metabolome and associated behaviors in young rats

Gestational and early postnatal iron deficiency occurs commonly in humans and results in altered behaviors suggestive of striatal dysfunction. We hypothesized that early iron deficiency alters the metabolome of the developing striatum and accounts for abnormalities in striatum-dependent behavior in rats. Sixteen metabolite concentrations from a 9-11 microL volume within the striatum were serially assessed in 10 iron-deficient and 10 iron-sufficient rats on postnatal days 8, 22 (peak anemia), and 37 (following recovery from anemia) using (1)H NMR spectroscopy at 9.4 tesla. Chin-elicited bilateral forelimb placing and vibrissae-elicited unilateral forelimb placing were also assessed on these days. Iron deficiency altered metabolites indexing energy metabolism, neurotransmission, glial integrity, and myelination over time (P < 0.05). Successful development of behaviors was delayed in the iron-deficient group (P < or = 0.01). Alterations in creatine, glucose, glutamine, glutamate, N-acetylaspartate, myo-inositol, and glycerophosphorylcholine + phosphorylcholine concentrations accounted for 77-83% of the behavioral variability during peak anemia on postnatal day 22 in the iron-deficient group. Correction of anemia normalized the striatal metabolome but not the behaviors on postnatal day 37. These novel data imply that alterations in the metabolite profile of the striatum likely influence later neural functioning in early iron deficiency.

Early iron deficiency alters sensorimotor development and brain monoamines in rats

Iron deficiency in human infancy reportedly leads to developmental delays and changes in neurobiology that may be irreversible. Using a rodent model, the present study examined whether dietary iron deficiency late in pregnancy and during lactation alters sensorimotor development and brain monoaminergic systems. Rats were assigned to 1 of 4 dietary treatments during gestation and lactation: 1) iron sufficient control; 2) prenatal iron deficiency beginning on gestational d 15 (G15); 3) postnatal iron deficiency beginning on postnatal d 4 (P4); 4) iron deficiency beginning on G15 followed by an iron sufficient diet on P4. Developmental milestones, open field behavior, brain iron and proteins, monoamines, and their transporters were evaluated between P6 and P21. Only G15 iron deficient rats had greater dopaminergic activity than controls as indicated by increased tyrosine hydroxylase levels, phosphorylated tyrosine hydroxylase levels, and cellular dopamine in prefrontal cortex and striatum at P15. These rats also showed delayed eye opening, ear development, and reduced locomotor activity. Iron repletion at P4 returned most measures to control levels by the time of weaning. Postnatal iron deficiency reduced striatal and ventral midbrain iron as well as cellular dopamine levels in prefrontal cortex and striatum at P21. Developmental delays in ear development and achievement in bar holding and surface righting also resulted from postnatal iron deficiency. These results indicate that iron deficiency begun at G15 affects early dopamine neurobiology, the development of specific developmental milestones, and behavior in preweaned rats.

Iron deficiency in infancy predicts altered serum prolactin response 10 years later

Serum prolactin may reflect CNS dopaminergic function. Because iron deficiency (ID) alters brain dopamine in rats, serum prolactin levels were previously investigated in infants with varied iron status. High serum prolactin levels correlated with behaviors typical of chronic ID. The objective of this study was to determine the effect of infant iron status on serum prolactin levels after a stressor in early adolescence. One hundred fifty-nine of 191 children enrolled in infancy (chronic ID, n = 46; good iron comparison group, n = 113) had serum prolactin measurements after catheter placement at 11-14 y of age. Serum prolactin levels were compared by sex, pubertal status and infant iron status and the pattern of change over time was compared by infant iron status controlling for pubertal stage and background factors. Males and less mature adolescents had lower serum prolactin concentrations than females and more mature adolescents. Controlling for these factors, the serum prolactin response pattern differed significantly by infant iron status. Serum prolactin declined earlier for the chronic ID group. In conclusion, an altered serum prolactin response pattern was observed 10 y after chronic ID in infancy and may suggest a long-lasting effect of ID on the regulation of prolactin.

Moderate iron deficiency in infancy: Biology and behavior in young rats

Iron deficiency anemia in early childhood is associated with developmental delays and perhaps, irreversible alterations in neurological functioning. The goals were to determine if dietary induced gestational and lactational iron deficiency alters brain monoamine metabolism and behaviors dependent on that neurotransmitter system. Young pregnant rats were provided iron deficient or control diets from early in gestation through to weaning of pups and brain iron concentration, regional monoamine variables and achievement of specific developmental milestones were determined throughout lactation. Despite anemia during lactation, most brain iron concentrations did not fall significantly until P25, and well after significant changes in monoamine levels, transporter levels, and D2R density changed in terminal fields. The changes in D2R density were far smaller than previously observed models that utilized severe dietary restriction during lactation or after weaning. Iron deficient pups had normal birth weight, but were delayed in the attainment of a number of milestones (bar holding, vibrissae-evoked forelimb placing). This approach of iron deficiency in utero and during lactation sufficient to cause moderate anemia but not stunt growth demonstrates that monaminergic metabolism changes occur prior to profound declines in brain iron concentration and is associated with developmental delays. Similar developmental delays in iron deficient human infants suggest to us that alterations in iron status during this developmental period likely affects developing brain monaminergic systems in these infants.

Intracerebral hemorrhage in the iron-deficient rat

BACKGROUND AND PURPOSE

Iron contributes to brain injury after intracerebral hemorrhage (ICH). Because ICH may occur in the context of iron deficiency anemia (IDA), a common nutritional disorder, the purpose of this study was to determine whether IDA in rats affects brain edema, functional behavior, and changes in brain iron-handling proteins after ICH.

METHODS

Six-week-old male rats (n=75) were randomized to non-IDA or IDA groups and provided iron-sufficient or -deficient diets, respectively. After 1 month, 100 microL autologous blood was infused into the right basal ganglia (BG). Brains removed at days 1, 3, 7, and 28 after ICH were assessed for regional brain water content and BG transferrin and transferrin receptor concentrations (Western blotting). Sensorimotor measures of functional recovery were assessed.

RESULTS

Brain water content was increased for IDA versus non-IDA in injured cortex and BG at day 3 (P<0.05). IDA rats had impaired left forepaw placing and more asymmetric forelimb use versus non-IDA after ICH (P<0.05). Transferrin and transferrin receptor concentrations in the BG were increased for IDA versus non-IDA within the first week (P<0.05).

CONCLUSIONS

Rats with IDA have greater brain edema, poorer sensorimotor outcome, and a greater expression of iron regulatory proteins than non-IDA rats after ICH, suggesting brain iron status is a determinant of injury severity and recovery.

Effect of manipulation of iron storage, transport, or availability on myelin composition and brain iron content in three different animal models

Several observations suggest that iron is an essential factor in myelination and oligodendrocyte biology. However, the specific role of iron in these processes remains to be elucidated. This role could be as an essential cofactor in metabolic processes or as a transcriptional or translational regulator. In this study, we used animals models each with a unique defect in iron availability, storage, or transfer to test the hypothesis that disruptions in these mechanisms affect myelinogenesis and myelin composition. Disruption of iron availability either by limiting dietary iron or by altering iron storage capacity resulted in a decrease in myelin proteins and lipids but not the iron content of myelin. Among the integral myelin proteins, proteolipid protein was most consistently affected, suggesting that limiting iron to oligodendrocytes results not only in hypomyelination but also in a decrease in myelin compaction. Mice deficient in transferrin must receive transferrin injections beginning at birth to remain viable, and these mice had increases in all of the myelin components and in the iron content of the myelin. This finding indicates that the loss of endogenous iron mobility in oligodendrocytes could be overcome by application of exogenous transferrin. Overall, the results of this study demonstrate how myelin composition can be affected by loss of iron homeostasis and reveal specific chronic changes in myelin composition that may affect behavior and attempts to rescue myelin deficits.

Thy1 expression in the brain is affected by iron and is decreased in Restless Legs Syndrome

Thy-1 is a cell adhesion molecule that plays a regulatory role in the vesicular release of neurotransmitters. The objective of this study is to examine the relationship between iron status and Thy1 expression in neuronal systems of varying complexity. Pheochromocytoma cell (PC12) cells were used to explore whether there was a direct relation between cellular iron status and Thy1 expression. Iron chelation significantly decreased expression of Thy1 in PC12 cells in a dose and time dependent manner. Transferrin receptor expression was increased with iron chelation demonstrating that a global decrease in protein synthesis could not account for the Thy1 changes. We also examined brain homogenates from adult rats that were nursed by dams on an iron deficient (ID) diet and found a significant decrease in Thy1 compared to control rats. Finally, the substantia nigra from individuals with Restless Legs Syndrome reportedly has lower than normal amounts of iron. Therefore, we examined this brain region from individuals with the clinical diagnosis of primary Restless Legs syndrome (RLS) and found the concentration of Thy1 was less than half that of controls. The results of these studies support the novel concept that there is a relationship between Thy1 and iron and point to a novel mechanism by which iron deficiency can affect brain function. They also indicate a possible mechanism by which iron deficiency compromises dopaminergic transmission in RLS, providing a potentially important link between decreased brain iron and the responsiveness to levodopa and iron supplementation treatment in RLS.

Guideline for the management of pediatric idiopathic constipation and soiling. Multidisciplinary team from the University of Michigan Medical Center in Ann Arbor

OBJECTIVE

To develop an evidence-based guideline for the primary pediatric care of children (birth to 18 years old) with idiopathic constipation and soiling.

DATA SOURCES

References were identified through a MEDLINE search from January 1975 through January 1998 to address 3 focus questions: (1) the best path to early, accurate diagnosis; (2) best methods for adequate clean-out; and (3) best approaches to promote patient and family compliance with management.

DATA SELECTION

Twenty-five references were identified.

DATA EXTRACTION

References were reviewed by a multidisciplinary team and graded according to the following criteria: randomized controlled trial; controlled trial, no randomization; observational study; and expert opinion. Evidence tables were developed for each focus question.

DATA SYNTHESIS

An algorithm and clinical care guideline were developed by consultation and consensus among team members. Emphasis was placed on methods to promote early identification of pediatric idiopathic constipation and soiling, to recognize points of referral, and to increase patient and family compliance with treatment through use of education, developmentally based interventions, and variables for tracking success of management.

CONCLUSION

An algorithm and guideline for pediatric idiopathic constipation and soiling are presented for use by primary care physicians.