Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for Pediatric Gastroenterology and Nutrition

Diagnostic accuracy of the Barr and Blethyn radiological scoring systems for childhood constipation assessed using colonic transit time as the gold standard

BACKGROUND

Constipation is a common childhood symptom and abdominal radiography is advocated in diagnosis and management.

OBJECTIVE

To assess the reproducibility and diagnostic accuracy of the Barr and Blethyn systems for quantifying constipation on abdominal radiographs in children.

MATERIALS AND METHODS

Radiographs were scored by three observers of increasing radiological experience (student, junior doctor, consultant). Abdominal radiographs produced during measurement of colonic transit time (CTT) were classified as constipated or normal based on the value of the transit time, and were scored using both systems by observers blinded to the CTT. Abdominal radiographs obtained in children for reasons other than constipation were classed as normal and similarly scored. Reproducibility was measured using the kappa statistic. Diagnostic accuracy was measured using the area under the curve (AUC) for the receiver operator characteristic (ROC) curve.

RESULTS

Using either system, scores were higher for constipated children (P<0.01). The consultant produced higher scores than the other observers (P<0.01). Interobserver reproducibility was moderate with the best kappa value only 0.48. The best correlation between score and CTT was 0.51 (junior doctor scores). Diagnostic accuracy of the scores was only moderate, with the largest AUC for a ROC curve of 0.84 for the consultant using the Barr score.

CONCLUSIONS

Scoring of abdominal radiographs in the assessment of childhood constipation should be abandoned because it is dependent on the experience of the observer, is poorly reproducible, and does not accurately discriminate between constipated children and children without constipation.

A novel stable isotope approach for determining the impact of thickening agents on water absorption

Research on the bioavailability of water from thickened fluids has recently been published and it concluded that the addition of certain thickening agents (namely, modified maize starch, guar gum, and xanthan gum) does not significantly alter the absorption of water from the healthy, mature human gut. Using xanthan gum as an example, our "proof of concept" study describes a simple, accurate, and noninvasive alternative to the methodology used in that first study, and involves the measurement and comparison of the dilution space ratios of the isotopes (2)H and (18)O and subsequent calculation of total body water. Our method involves the ingestion of a thickening agent labeled with (2)H 1 day after ingestion of (18)O. Analyses are based on the isotopic enrichment of urine samples collected prior to the administration of each isotope, and daily urine samples collected for 15 days postdosing. We urge that further research is needed to evaluate the impact of various thickening agents on the bioavailability of water from the developing gut and in cases of gut pathology and recommend our methodology.

The crying infant: diagnostic testing and frequency of serious underlying disease

OBJECTIVE

To determine the proportion of children evaluated in an emergency department because of crying who have a serious underlying etiology. Secondary outcomes included the individual contributions of history, physical examination, and laboratory investigations in determining a diagnosis.

PATIENTS AND METHODS

We performed a retrospective review of all afebrile patients <1 year of age who presented with a chief complaint of crying, irritability, screaming, colic, or fussiness. All children with a serious underlying illness were identified by using a priori defined criteria. Chart review was conducted to determine if history, physical examination, or investigation data contributed to establishing the child's diagnosis.

RESULTS

Enrollment criteria were met by 237 patients, representing 0.6% of all visits. A total of 12 (5.1%) children had serious underlying etiologies with urinary tract infections being most prevalent (n = 3). Two (16.7%) of the serious diagnoses were only made on revisit. Of the 574 tests performed, 81 (14.1%) were positive. However, only 8 (1.4%) diagnoses were assigned on the basis of a positive investigation. History and/or examination suggested an etiology in 66.3% of cases. Unwell appearance was associated with serious etiologies. In only 2 (0.8%) children did investigations in the absence of a suggestive clinical picture contribute to the diagnosis. Both of these children were <4 months of age and had urinary tract infections. Among children <1 month of age, the positive rate of urine cultures performed was 10%. Ocular fluorescein staining and rectal examination with occult blood testing were performed infrequently, and results were negative in all cases. Successful follow-up was completed with 60% of caregivers, and no missed diagnoses were found.

CONCLUSIONS

History and physical examination remains the cornerstone of the evaluation of the crying infant and should drive investigation selection. Afebrile infants in the first few months of life should undergo urine evaluation. Other investigations should be performed on the basis of clinical findings.

Neuroimmune interaction and anorectal motility in children with food allergy-related chronic constipation

OBJECTIVES

Food allergy is thought to trigger functional constipation in children but the underlying mechanisms are still unknown. Mast cells (MCs) and their relationship with nerve fibers (NFs) in the rectal mucosa, as well as anorectal motility, were studied in children with refractory chronic constipation before and after an elimination diet for cow's milk, egg, and soy proteins.

METHODS

Thirty-three children (range: 1-10.8 years) underwent anorectal manometry and suction rectal biopsy before and after 8 weeks of oligoantigenic diet. MCs and NFs were identified immunohistochemically. Quantification of MCs (%MC/area) and MCs within 10 microm of NFs (%MC-NF/area) was performed by computer-assisted analysis.

RESULTS

Eighteen children responded to the diet (R-group) and fifteen did not (the NR-group). At baseline there was a significant difference in anal resting pressure (ARP; mm Hg), percentage of relaxation (%R), and residual pressure (RP; mm Hg) of anal canal during rectal distension between the R-group (66+/-4.1, 84.3+/-2.8, 10.4+/-2.3, respectively) and the NR-group (49+/-5, 92.2+/-1.7, 4.8+/-1.7, respectively; P<0.05). After the diet, significant changes in ARP, RP, and %R were observed only in the R-group (44+/-3.7, 93.7+/-1.5, 3.8+/-1.2, respectively; P<0.05). At baseline, the R-group showed an increase in %MC/area (8.3+/-0.7) and %MC-NF/area (5.2+/-2.6) with respect to the NR-group (5.1+/-0.5 and 2.3+/-0.4, respectively; P<0.05). After the diet, only the R-group showed a significant reduction of %MC/area and %MC-NF/area (4.4+/-0.5 and 2.2+/-0.4, respectively; P<0.001). Both ARP and RP significantly correlated with %MC/area and %MC-NF/area; %R showed a significant inverse correlation with both %MC/area and %MC-NF/area.

CONCLUSIONS

In children with food allergy-related chronic constipation, an increase in both rectal MC density and spatial interactions between MCs and NFs correlates with anal motor abnormalities. These variables are significantly affected by the diet.

Macrogol (polyethylene glycol) laxatives in children with functional constipation and faecal impaction: a systematic review

As the evidence base supporting the use of laxatives in children is very limited, we undertook an updated systematic review to clarify the issue. A comprehensive literature search was carried out to identify randomised controlled trials of polyethylene glycol (PEG) versus either placebo or active comparator, in patients aged <18 years with primary chronic constipation. Outcomes were assessed as either global assessments of effectiveness or differences in defaecation rates. Seven qualifying studies involving 594 children were identified. Five were comparisons of PEG with lactulose, one with milk of magnesia and one with placebo. Study duration ranged from 2 weeks to 12 months. PEG was significantly more effective than placebo and either equivalent to (two studies) or superior to (four studies) active comparator. Differences in study design precluded meaningful meta-analysis. Lack of high quality studies has meant that the management of childhood constipation has tended to rely on anecdote and empirical treatment choice. Recent publication of well designed randomised trials now permits a more evidence-based approach, with PEG-based treatments having been proven to be effective and well-tolerated first-line treatment.

Morphological changes of the enteric nervous system, interstitial cells of cajal, and smooth muscle in children with colonic motility disorders

OBJECTIVES

To evaluate the relation between colonic manometry findings and the colonic enteric nervous system, interstitial cells of Cajal, and smooth muscle morphology.

PATIENTS AND METHODS

Colonic specimens from surgical resections or full-thickness biopsy specimens were assessed from a cohort of children who underwent colonic manometry before surgery. Colonic manometric patterns were subdivided into high-amplitude propagating contractions, low-amplitude propagating contractions, absence of contractions, and low-amplitude simultaneous contractions. Immunohistochemistry was performed to identify abnormalities in the enteric nervous system, interstitial cells of Cajal, and smooth muscle layers.

RESULTS

Study participants included patients with Hirschsprung disease (n = 4), chronic intestinal pseudo-obstruction (n = 1), and idiopathic intractable constipation (n = 8). Thirty-seven ganglionic segments were studied. Abnormalities in myenteric plexus were recognized in segments of all manometry groups, and no differences could be identified when they were compared with segments with high-amplitude propagating contractions. All of the segments showed an abnormal interstitial cells of Cajal plexus, and no statistical difference could be identified between the 4 groups (n = 0.08). Homogeneous expression of smooth muscle actin was observed in all of the segments.

CONCLUSIONS

In this cohort we were unable to classify specific manometric findings as reflective of myopathic or neuropathic abnormalities in patients with motility disorders. Caution should be used when predicting the type of neuromuscular disorder based on colonic manometry.

Aggressiveness and hostility in the family environment and chronic constipation in children

OBJECTIVE

To compare the emotional aspects of children with and without constipation.

METHODOLOGY

Some emotional aspects were studied in children with and without constipation. A nonstructured interview was performed with the mothers regarding the emotional aspects of their children. The children were asked to tell a story based on the observation of a board from the thematic children apperception test. This is a qualitative study using the technique of constant comparison.

RESULTS

In the interview with the mothers of constipated children.

CONCLUSION

In the children with constipation a higher prevalence of some emotional aspects was observed.

Pediatric anorectal disorders

This article reports the clinical, physiopathologic, diagnostic, and therapeutic aspects of the most common anorectal disorders in children. In particular, it focuses on the differential diagnosis between organic and functional constipation. In addition, the authors separately examine some of the clinical conditions such as atopy, neurologic diseases, and anorectal malformations, in which chronic constipation may be an important clinical manifestation.

The impact of constipation on growth in children

The observation on the impact of constipation on nutritional and growth status in healthy children was never reported. During a 4-y period, we evaluated the consequence of constipation on growth in children. The enrolled children were aged between 1 and 15 y with constipation. Medical response of constipation to treatment was evaluated by the scoring of constipation symptoms. The correlation of therapeutic effect of constipation with growth status at 12 wk and 24 wk was statistically evaluated. About 2426 children (1284 boys, 1142 girls) with a mean age of 7.31 +/- 3.65 (range 1.1-14.9) y were enrolled. After 12-wk treatment, significant increase of z-scores of height-for-age, weight-for-age, and body mass index-for-age were all found in patients with good medical responses (1377 cases) than in those with poor medical responses (1049 cases). The 1049 patients with poor medical response received advanced medications; significant increase of z-scores of height-for-age, weight-for-age, and body mass index were also found in these patients. A marked increase of appetite was significantly correlated with better gain on height and weight after treatment. We conclude that chronic constipation may retard growth status in children, and a long-term medication for constipation in children appears beneficial to their growth status.

Allergic gastrointestinal motility disorders in infancy and early childhood

Gastro-oesophageal reflux disease, constipation and colic are among the most common disorders in infancy and early childhood. In at least a subset of infants with these functional disorders, improvement after dietary elimination of specific food proteins has been demonstrated. Gastrointestinal food allergy should therefore be considered in the differential diagnosis of infants presenting with persistent regurgitation, constipation or irritable behaviour, particularly if conventional treatment has not been beneficial. The diagnosis of food protein-induced gastrointestinal motility disorders is hampered by the absence of specific clinical features or useful laboratory markers. Gastrointestinal biopsies before commencing a hypoallergenic diet may provide the most important diagnostic clues. Early recognition is essential for the optimal management of these patients to prevent nutritional sequelae or aversive feeding behaviours. Treatment relies on hypoallergenic formulae, as well as maternal elimination diets in breast-fed infants. Further research is required to better define the pathological mechanisms and diagnostic markers of paediatric allergic gastrointestinal motility disorders. The following article will present three instructive cases followed by discussion of the clinical presentation, diagnosis, treatment and natural history of food allergic motility disorders in infancy and early childhood.

Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant foods: A community-based study

AIM

To evaluate consumption of foods rich in dietary fibre and its relation to the prevalence of constipation in pre-school children.

METHODS

In total, 368 children aged 3-5 years were randomly selected from kindergartens in Hong Kong. Constipation was confirmed by Rome-criteria. Children with normal bowel habits served as non-constipated controls. Consumption of vegetables, fruits, whole-grain cereals and fluid were determined using a 3-day food record.

RESULTS

A total of 28.8% children were reported to have constipation. Median dietary fibre intake of constipated children was significantly lower than non-constipated children (3.4 g/d (inter-quartile range (IQR): 2.3-4.6 g/d) vs. 3.8 g/d (IQR: 2.7-4.9 g/d); P = 0.044) corresponding to 40% reference dietary fibre intake. Constipated children also had significantly lower intakes of vitamin C (P = 0.041), folate (P = 0.043) and magnesium (P = 0.002). Fruit intake and total plant foods intake were significantly lower in the constipated than non-constipated children: (61 g/d (IQR: 23.8-115 g/d) vs. 78 g/d (IQR: 41.7-144.6 g/d); P = 0.047) and (142.5 g/d (IQR: 73.7-214.7 g/d) vs. 161.1 g/d (IQR: 98.3-233.3 g/d); P = 0.034), respectively. Total fluid intake did not differ between groups but milk intake among the constipated children was marginally higher than the non-constipated children (P = 0.055)

CONCLUSION

Insufficient dietary fibre intake is common in Hong Kong pre-school children. Constipated children had significantly lower intakes of dietary fibre and micronutrients including vitamin C, folate and magnesium than non-constipated counterparts which was attributable to under-consumption of plant foods. However, milk intake was marginally higher in the constipated children. More public education is necessary for parents to help develop healthy dietary habit and bowel habit in early life in order to prevent childhood constipation.

Tegaserod use in children: a single-center experience

BACKGROUND

Tegaserod is increasingly prescribed by pediatric gastroenterologists even though there are few published data concerning its use in children. The aim of this study was to describe the authors' experience with tegaserod in children.

PATIENTS AND METHODS

Patients treated with tegaserod from 2004 through 2006 were included in this study. Defecation and fecal incontinence frequency and global assessment of relief of symptoms were assessed.

RESULTS

Seventy-two patients (44 girls) ranging in age from 1.1 to 18.3 years constitute the patient sample of this report. The median age was 10 years and the median follow-up after initiation of tegaserod treatment was 11.3 months (range 2.3-45.2 months). Indications to prescribe tegaserod were constipation (58%) and a variety of other conditions including functional dyspepsia or inflammatory bowel disease (42%). Defecation frequency increased after tegaserod use (1 vs 7/week, P < 0.001) and presence of fecal incontinence decreased (47% vs 23%, P < 0.001) in the constipation group. Parents rated relief of constipation as moderate or significant in 71% of cases in the constipation group. In the group with other indications to start tegaserod therapy, moderate or significant relief of abdominal pain and bloating was noted in 64% and 68% of patients, respectively. The median dose of tegaserod prescribed was 0.22 mg x kg x day (range 0.05-0.87 mg x kg(-1) x day(-1)). Adverse events were observed in 32% of the patients. The most common side effects were self-limiting diarrhea (20%) and abdominal pain (8%). Only one patient discontinued tegaserod because of side effects; this patient experienced pain at his cecostomy site.

CONCLUSIONS

Tegaserod seems to relieve a variety of functional gastrointestinal symptoms in children. Further randomized controlled studies are needed to support the specific pediatric target of prescribing tegaserod.

Health potential of polyols as sugar replacers, with emphasis on low glycaemic properties

Abstract Polyols are hydrogenated carbohydrates used as sugar replacers. Interest now arises because of their multiple potential health benefits. They are non-cariogenic (sugar-free tooth-friendly), low-glycaemic (potentially helpful in diabetes and cardiovascular disease), low-energy and low-insulinaemic (potentially helpful in obesity), low-digestible (potentially helpful in the colon), osmotic (colon-hydrating, laxative and purifying) carbohydrates. Such potential health benefits are reviewed. A major focus here is the glycaemic index (GI) of polyols as regards the health implications of low-GI foods. The literature on glycaemia and insulinaemia after polyol ingestion was analysed and expressed in the GI and insulinaemic index (II) modes, which yielded the values: erythritol 0, 2; xylitol 13, 11; sorbitol 9, 11; mannitol 0, 0; maltitol 35, 27; isomalt 9, 6; lactitol 6, 4; polyglycitol 39, 23. These values are all much lower than sucrose 65, 43 or glucose 100, 100. GI values on replacing sucrose were independent of both intake (up to 50 g) and the state of carbohydrate metabolism (normal, type 1 with artificial pancreas and type 2 diabetes mellitus). The assignment of foods and polyols to GI bands is considered, these being: high (> 70), intermediate (> 55–70), low (> 40–55), and very low (< 40) including non-glycaemic; the last aims to target particularly low-GI-carbohydrate-based foods. Polyols ranged from low to very low GI. An examination was made of the dietary factors affecting the GI of polyols and foods. Polyol and other food GI values could be used to estimate the GI of food mixtures containing polyols without underestimation. Among foods and polyols a departure of II from GI was observed due to fat elevating II and reducing GI. Fat exerted an additional negative influence on GI, presumed due to reduced rates of gastric emptying. Among the foods examined, the interaction was prominent with snack foods; this potentially damaging insulinaemia could be reduced using polyols. Improved glycated haemoglobin as a marker of glycaemic control was found in a 12-week study of type 2 diabetes mellitus patients consuming polyol, adding to other studies showing improved glucose control on ingestion of low-GI carbohydrate. In general some improvement in long-term glycaemic control was discernible on reducing the glycaemic load via GI by as little as 15–20 g daily. Similar amounts of polyols are normally acceptable. Although polyols are not essential nutrients, they contribute to clinically recognised maintenance of a healthy colonic environment and function. A role for polyols and polyol foods to hydrate the colonic contents and aid laxation is now recognised by physicians. Polyols favour saccharolytic anaerobes and aciduric organisms in the colon, purifying the colon of endotoxic, putrefying and pathological organisms, which has clinical relevance. Polyols also contribute towards short-chain organic acid formation for a healthy colonic epithelium. Polyol tooth-friendliness and reduced energy values are affirmed and add to the potential benefits. In regard to gastrointestinal tolerance, food scientists and nutritionists, physicians, and dentists have in their independent professional capacities each now described sensible approaches to the use and consumption of polyols.

[Encopresis]

Encopresis is defined as functional faecal incontinence at 4 years of age or older and affects 1-3% of all school children. The two most important subtypes are encopresis with and without constipation. In preschoolers toilet refusal syndrome can occur. Comorbid behavioural disorders and urinary incontinence are common. The current state-of-the-art regarding aetiology, assessment and therapy is presented in this overview. A symptom-oriented behavioural approach (toilet training) is most successful, with the addition of laxatives (polyethylene glycol) if constipation is present. Biofeedback is not effective. Other forms of psychotherapy are indicated only in case of comorbid behavioural disorders. The long-term outcome has been poor and needs improvement.

Functional defecation disorders in children: PACCT criteria versus Rome II criteria

OBJECTIVES

To evaluate the clinical validity and applicability of the Paris Consensus on Childhood Constipation Terminology (PACCT) versus the Rome II criteria for pediatric functional defecation disorders (FDDs).

STUDY DESIGN

Children from infancy to 17 years who had been referred to a tertiary center for chronic constipation were recruited for the study. A prospective longitudinal design was used. The Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) for parents of children age 0 to 4 and 4 to 17 years and for children age 10 to 17 years was used for diagnosis of FDDs.

RESULTS

Children (n = 128; mean age, 67.2 months; 62 males) were screened consecutively. FDDs were diagnosed significantly more often by PACCT than by the Rome II criteria (112 [88.9%] vs 60 [47.6%]; P = .001). The agreement Cohen's kappa test showed kappa = .173. A statistically significant difference was reported between Rome II and PACCT in the 4- to 17-year-old group (P = .001). Scybalous, pebble-like stools and defecation with straining were the main symptoms reported (80%), followed by painful defecation (66%).

CONCLUSIONS

The PACCT criteria show greater applicability than the Rome II criteria for FDDs. The poor agreement implies that they do not identify the same types of patients. Because such a high percentage of constipated children reported the symptoms of defecation with straining, scybalous pebble-like stools, and painful defecation, including these symptoms in any revised criteria should be taken into consideration.

Childhood and adolescent constipation: Review and advances in management

Constipation is a common symptom throughout all ages in the pediatric population, both sexes, and all educational and socioeconomic levels. It is estimated that 12% to 30% of the general population suffers from functional constipation. A practical overview of pathogenic mechanisms contributing to constipation is presented, with emphasis on evaluation and management options available to the treating practitioner. The evaluation of constipation requires careful history taking and interpretation. Diagnostic tests such as manometry and colonic scintigraphy are reserved for those severely affected. Constipation can be challenging to treat, especially if pain and discomfort are predominant features. Therapy requires early recognition of the problem; support by physicians and family members; identification and explanation of contributing factors; and the providing of medications, including osmotic and/or stimulant laxatives. When constipation becomes refractory to standard medical treatment, more novel considerations may include probiotics, botulinum toxin, mind-body interventions, electrical stimulation of the intestine, and surgery.

Neto MC, Pinto EALC. Estudo prospectivo de pacientes pediátricos com dor abdominal crônica

OBJETIVO: Classificar a dor abdominal crônica em crianças e adolescentes por meio dos critérios de Roma II e definir o desfecho diagnóstico em três anos de seguimento. MÉTODOS: Durante um ano, 71 pacientes com dor abdominal crônica foram atendidos como casos novos num ambulatório terciário de gastroenterologia pediátrica. Causas orgânicas foram excluídas por bases clínicas e laboratoriais, e relatos clínicos foram avaliados especificamente quanto à possibilidade de preencherem os Critérios de Roma II para dor abdominal em crianças. Para estabelecer o diagnóstico definitivo, os pacientes foram seguidos por três anos, em média. RESULTADOS: A alocação dos 71 pacientes segundo Roma II foi: doença orgânica (n=12), remissão dos sintomas após a primeira consulta (n=7), ou preencheram os critérios para dor funcional (n=52). Dos 12 pacientes de doença orgânica, nove foram diagnosticados como intolerantes à lactose, mas foram re-alocados para doença funcional no seguimento, visto que a dieta de isenção não aliviou a queixa. Dos 52 pacientes com doença funcional (idade mediana=9,3 anos, 50% meninos), nove, que inicialmente preencheram o critério para dor abdominal funcional, foram re-alocados no diagnóstico de constipação funcional e 43 mantiveram o diagnóstico funcional: 24 com dispepsia funcional, 18 com dor abdominal funcional e um com síndrome do intestino irritável. CONCLUSÕES: Dentre os casos de dor abdominal crônica, a dor do tipo funcional foi mais comum que as causas orgânicas e, dentre os seus subgrupos, a dispepsia funcional foi mais freqüente. O seguimento em longo prazo permitiu estabelecer o diagnóstico definitivo da origem da dor abdominal nessas crianças.

Colonic manometry catheter placement with primary fluoroscopic guidance

The purpose of this paper is to describe our experience with a new technique of colonic manometry catheter placement using fluoroscopic guidance. Between 2000 and 2004, 44 colonic manometry catheters were placed with primary fluoroscopic guidance in 38 patients (25 males; median age, 7 years; range, 0.4-31 years) with severe defecation disorders. Fourteen colonoscopic placements were reviewed to compare the different procedures. Manometry catheters were inserted through the rectum (16 patients), cecostomy (9), ileostomy (2), and colostomy (17). Placements through diverted colons were successful in 24 of 28 (86%). Insertion through the rectum was successful in 10 of 16 (63%) fluoroscopic-guided placements vs. 12 of 14 (86%) colonoscopic placements (P=0.23). Significantly longer fluoroscopic exposure was required for fluoroscopic compared to colonoscopic placement (P=0.004). In conclusion, placement of colonic manometry catheters with primary fluoroscopic guidance is feasible in children. An important disadvantage of the fluoroscopic methodology is the prolonged fluoroscopic exposure time.

Chronic childhood constipation: a review of the literature and the introduction of a protocolized behavioral intervention program

OBJECTIVE

To release a newly protocolized behavioral intervention program for children with chronic constipation aged 4-18 years with guidance from literature about underlying theories from which the treatment techniques follow.

METHODS

Articles until July 2006 were identified through electronic searches in Medline, PsychInfo and Picarta. There was no limit placed on the time periods searched. Following keywords were used: constipation, encopresis, fecal incontinence, psychotherapy, emotions, randomized controlled trials, parent-child relations, parents, family, psychology, behavioral, behavioral problems, psychopathology, toilet, social, psychosocial, pain, retentive posturing, stool withholding, stool toileting refusal, shame, stress, anxiety. A filter was used to select literature referring to children 0-18 years old. Key constructs and content of sessions for a protocolized behavioral intervention program are derived from literature.

RESULTS

Seventy-one articles on chronic childhood constipation are critically reviewed and categorized into sections on epidemiology, symptomatology, etiology and consequences, treatment and effectivity, and follow-up on chronic childhood constipation. This is followed by an extensive description of our protocolized behavioral intervention program.

CONCLUSION

This is the first article on childhood constipation presenting a full and transparent description of a behavioral intervention program embedded in literature. In addition, a theoretical framework is provided that can serve as a trial paradigm to evaluate intervention effectiveness.

PRACTICE IMPLICATIONS

This article can serve as an extensive guideline in routine practice to treat chronically constipated children. By releasing our protocolized behavioral intervention program and by offering a theoretical framework we expect to provide a good opportunity to evaluate clinical effectivity by both randomized controlled trials and qualitative research methods. Findings will contribute to the implementation of an effective treatment for chronic constipation in childhood.

Primary care of the child with cerebral palsy: a review of systems (part II)

Cerebral palsy (CP) is a disorder of movement and posture with additional potential to affect cognitive status. Thus, the goals for management of the child with CP include the following: to promote optimal function; to maintain general health; to foster acquisition of new skills; to assist and educate parents and caregivers; and to anticipate, prevent, and treat the complications of this disorder. Pediatric management of the child with CP should begin at the time of diagnosis. This article is the second of two articles on CP. The first article focused on the diagnosis of CP, and this article will focus on a review of systems approach for management as well as resources for the family and the nurse practitioner.

Therapeutic effect of Novalac-IT in infants with constipation

OBJECTIVE

Infant constipation is a frequent condition in formula-fed infants.

METHODS

A prospective randomized clinical trial was performed in infants who had constipation with Novalac-IT (IT group) versus a 20% strengthened formula (S group). Enrolled subjects had difficulties in defecating, hard stools, or low frequency of defecation (< or =3 times/wk).

RESULTS

Ninety-three infants (47 boys, mean age 3.8 +/- 1.7 mo) were included because of hard consistency of (50.5%), low frequency in (44.1%), or painful (33.3%) defecation. A statistically significant improvement was observed after 4 and 8 wk of intervention in the IT group (P = 0.014 and P < 0.001, respectively). In the IT group, significantly more infants were symptom free at 4 wk (82.9% versus 50%, P = 0.029) and at 8 wk (89.1% versus 54.1%, P < 0.001). Increased stool weight was significant in the IT group after 4 and 8 wk (P = 0.048 and 0.029).

CONCLUSION

Novalac-IT decreases constipation in formula-fed infants.

At what age is a suction rectal biopsy less likely to provide adequate tissue for identification of ganglion cells?

OBJECTIVE

The objective of this study was to determine at what age suction rectal biopsy is less likely to provide adequate tissue to detect submucosal ganglion cells in a child being evaluated for Hirschsprung disease.

PATIENTS AND METHODS

Children > or =1 year of age undergoing a rectal biopsy at a single children's hospital had 1 biopsy each obtained simultaneously with a suction biopsy device and a grasp biopsy forceps. The biopsies were examined by 2 pathologists for adequacy of the submucosa (none, scant, adequate, or ample) and the presence of ganglion cells. The 2 specimens were compared with each other.

RESULTS

One hundred fifty-two children 1 to 17 years of age were included. Fifty-three were female. Subjects were grouped into 4 age categories: 1 to 3 years (group A), 4 to 6 years (group B), 7 to 9 years (group C), and > or =10 years (group D). Similar numbers of patients were recruited for each group. Ganglion cells were identified in 73% and 90% by the suction and grasp devices, respectively, in group A. In groups B through D, ganglion cells were identified in 50% to 53% vs 92% to 97% of the suction and grasp biopsies, respectively (P < 0.001). Submucosa was present in 88% (suction) vs 98% (grasp) in group A, 70% vs 95% in group B, 69% vs 94% in group C, and 45% vs 92% in group D.

CONCLUSION

The suction rectal biopsy is less likely to provide adequate submucosa for identification of ganglion cells after 3 years of age.

Emergency department management and short-term outcome of children with constipation

BACKGROUND

Constipation is a common diagnosis made in the pediatric emergency department (ED). Specific evidence-based standards for evaluation and treatment are lacking.

OBJECTIVE

To describe variation in evaluation and treatment of constipation and characteristics and treatments associated with improvement.

METHODS

This single-site descriptive study examined constipated children discharged from the ED. Chart review provided history, examination, evaluation, and treatment. Symptoms and on-going treatment were assessed by telephone interview at 4 to 6 weeks. Patients were dichotomized to poor versus adequate responders. Poor responders had 2 or more of the following: overall constipation, persistent presenting symptom, bowel movement frequency of less than once every other day, painful defecation, and/or abdominal pain.

RESULTS

The study group had 121 patients, with mean age of 6.4 years; 54% were female. Abdominal pain was the most common complaint (66%); 46% reported hard/infrequent stools. Most (67%) had symptoms for less than 1 week. Many (41%) previously sought care for the same problem. Most (70%) had abdominal radiographs. One third received an enema in the ED, and most patients were prescribed laxatives, most commonly polyethylene glycol (80%). After an enema, 28% were discharged without constipation medication. At follow-up, 35% were using laxatives, and 27% had sought additional care. Nearly half (42%) were poor responders. Poor responders were younger (5.1 vs. 7.3 years; P < 0.01). There was no difference in response based upon sex, duration of symptoms, or ED treatment.

CONCLUSIONS

Although older children are more likely to improve, many constipated children continue to have symptoms. Type of ED therapy is unrelated to on-going symptoms at 4 to 6 weeks.

Darmentleerung, Sauberkeitsentwicklung bei Kindern und ihre Störungen (Obstipation und Enkopresis)

Zusammenfassung. Verstopfung und Stuhlinkontinenz bei Kindern stellen für die Betroffenen und deren Familien eine schwere Belastung dar. In den meisten Fällen liegen funktionelle Störungen ohne organische Erkrankungen zugrunde. Trotzdem muss bei jedem Kind eine zielgerichtete somatische Diagnostik erfolgen. Rein psychische Ursachen für Obstipation und Inkontinenz sind eher selten. Nach Eingrenzen der Diagnose kann durch verschiedene Therapieansätze eine Besserung der Symptomatik erfolgen. Neben medikamentösen und diätetischen Maßnahmen stehen verhaltenstherapeutische Ansätze im Vordergrund. Der vorliegende Text gibt einen Überblick über den aktuellen Stand der wissenschaftlichen Erkenntnisse zu Kontinenzentwicklung, Physiologie und Pathophysiologie der Darmentleerung sowie Diagnostik und Behandlung von Obstipation und Enkopresis aus pädiatrisch-gastroenterologischer Sicht.

The safety of mineral oil in the treatment of constipation--a lesson from prolonged overdose

There have been concerns regarding the interference in the absorption of fat-soluble vitamins in long-term treatment with mineral oil; however, there is no clear evidence in the literature to support this claim. We present a case report illustrating the effect of prolonged (5 months) large doses of mineral oil on the fat-soluble vitamin absorption in a 17-year-old girl.

Motility disorders of the gastrointestinal tract

Over the past decades our knowledge of normal and abnormal gastrointestinal motility has increased tremendously. The availability of manometry to study bowel contraction patterns, laparoscopy to perform full thickness bowel biopsies for histological examination, have added to the investigative armamentarium and helped better diagnose motility disorders. However, the development of newer therapies for bowel motility disorders has been disappointingly slow. Newer modalities such as gastric and bowel pacing provides some hope for the future. In this article we have provided an overview of some of the common motility disorders in children and discussed their management.

Epidemiology of childhood constipation: a systematic review

OBJECTIVE

A systematic review of the published literature was performed to assess the prevalence, incidence, natural history, and comorbid conditions of functional constipation in children.

METHODS

Articles were identified through electronic searches in Medline, Embase, Cochrane Central Library, Cinhal and PsychInfo databases. Study selection criteria included: (1) epidemiology studies of general population, (2) on the prevalence of constipation without obvious organic etiology, (3) in children from 0 to 18 yr old, and (4) published in English and full manuscript form.

RESULTS

Eighteen studies met our inclusion criteria. The prevalence of childhood constipation in the general population ranged from 0.7% to 29.6% (median 8.9; inter quartile range 5.3-17.4). The prevalence of constipation defined as defecation frequency of < 3/wk varied from 0.7% to 29.6% (median 10.4; inter quartile range 1.3-21.3). Identified studies originated from North America (N = 4), South America (N = 2), Europe (N = 9), the Middle-East (N = 1), and Asia (N = 2). Variance of gender specific prevalence was reported in seven studies and five of seven studies reported no significant difference between boys and girls. The age group in which constipation is most common could not be assessed with certainty. Socioeconomic factors were not found to be associated with constipation.

CONCLUSION

Childhood constipation is a common problem worldwide. Most studies report similar prevalence rates for boys and girls. Large epidemiologic studies with the use of generally accepted diagnostic criteria are needed to define the precise prevalence of constipation.

A controlled, randomized, double-blind trial to evaluate the effect of a supplement of cocoa husk that is rich in dietary fiber on colonic transit in constipated pediatric patients

OBJECTIVE

Although a diet that is rich in fiber is widely recommended for preventing and treating constipation, the efficacy of fiber supplements have not been tested sufficiently in children. Our aim with this pilot study was to evaluate if fiber supplementation is beneficial for the treatment of children with idiopathic chronic constipation.

METHODS

Using a parallel, randomized, double-blind, controlled trial, we conducted an interventional study to evaluate the efficacy of a supplement of cocoa husk rich in dietary fiber on intestinal transit time and other indices of constipation in children with constipation. After screening, the patients were randomly allocated to receive, for a period of 4 weeks, either a cocoa husk supplement or placebo plus standardized toilet training procedures. Before and after 4 weeks of treatment, we (1) performed anthropometry, a physical examination, and routine laboratory measurements, (2) determined total and segmental colonic transit time, (3) evaluated bowel movement habits and stool consistency using a diary, and (4) received a subjective evaluation from the parents regarding the efficacy of the treatment. The main variable for verifying the efficacy of the treatment was the total colonic transit time.

RESULTS

Fifty-six chronically constipated children were randomly assigned into the study, but only 48 children completed it. These children, who were aged between 3 and 10 years, had a diagnosis of chronic idiopathic constipation. With respect to total, partial colon, and rectum transit time, there seemed to be a trend, although statistically nonsignificant, toward faster transit times in the cocoa husk group than in the placebo group. When we analyzed the evolution of the intestinal transit time throughout the study of children whose total basal intestinal transit time was > 50th percentile, significant differences were observed between the groups. The total transit time decreased by 45.4 +/- 38.4 hours in the cocoa husk group and by 8.7 +/- 28.9 hours in the placebo group (-38.1 hours). In the case of the right colon, changes in transit time also were significant between groups. Mean changes tended toward faster transit times in the left colon and the rectum, although the differences were not statistically significant. The children who received cocoa husk supplements tended to increase the number of bowel movements by more than that of the children of the placebo group. We also observed a reduction in the percentage of patients who reported hard stools (hard scybalous or pebble-like stools), although this reduction was significantly greater in the cocoa husk group. At the end of the intervention, 41.7% and 75.0% of the patients who received cocoa husk supplementation or placebo, respectively, reported having hard stools. Moreover, a significantly higher number of children (or their parents) reported a subjective improvement in stool consistency. No significant adverse effects were reported during the study.

CONCLUSIONS

This study confirms the beneficial effect of a supplement of cocoa husk that is rich in dietary fiber on chronic idiopathic constipation in children. These benefits seem to be more evident in pediatric constipated patients with slow colonic transit time.

Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Constipation is a common pediatric problem. To assist health care professionals who care for children with constipation, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) previously published a clinical guideline based on an integration of medical evidence with expert opinion. To evaluate studies published since then, the NASPGHAN Constipation Guideline Committee performed a comprehensive and systematic review of the medical literature since 1997, to identify, review and rate the quality of new evidence. Based on this review, the recommendations of the original clinical guideline were reaffirmed with several modified according to the new evidence. Below is a summary of the evidence reviewed for this update. The complete revised guideline is available online in its entirety.

Constipation in children

Constipation is a common problem throughout the world. It occurs in about 10-20% of adults in Western Countries and 0.3% to 28% of children worldwide. Most childhood constipation results from intentional withholding of stool following a painful experience with defecation. Thus, an extensive evaluation is often not necessary in a child presenting with constipation. Treatment should include education, evacuation of the rectum with oral or rectal laxatives if an impaction is present, laxatives to ensure soft stools and behavior modification.

A randomized, prospective, comparison study of polyethylene glycol 3350 without electrolytes and milk of magnesia for children with constipation and fecal incontinence

OBJECTIVE

Our aim was to compare 2 laxatives, namely, polyethylene glycol 3350 without electrolytes and milk of magnesia, evaluating the efficacy, safety, acceptance, and 1-year outcomes.

METHODS

Seventy-nine children with chronic constipation and fecal incontinence were assigned randomly to receive polyethylene glycol or milk of magnesia and were treated for 12 months in tertiary care pediatric clinics. Children were counted as improved or recovered depending on resolution of constipation, fecal incontinence, and abdominal pain after 1, 3, 6, and 12 months. An intent-to-treat analysis was used. Safety was assessed with evaluation of clinical adverse effects and blood tests.

RESULTS

Thirty-nine children were assigned randomly to receive polyethylene glycol and 40 to receive milk of magnesia. At each follow-up visit, significant improvement was seen in both groups, with significant increases in the frequency of bowel movements, decreases in the frequency of incontinence episodes, and resolution of abdominal pain. Compliance rates were 95% for polyethylene glycol and 65% for milk of magnesia. After 12 months, 62% of polyethylene glycol-treated children and 43% of milk of magnesia-treated children exhibited improvement, and 33% of polyethylene glycol-treated children and 23% of milk of magnesia-treated children had recovered. Polyethylene glycol and milk of magnesia did not cause clinically significant side effects or blood abnormalities, except that 1 child was allergic to polyethylene glycol.

CONCLUSIONS

In this randomized study, polyethylene glycol and milk of magnesia were equally effective in the long-term treatment of children with constipation and fecal incontinence. Polyethylene glycol was safe for the long-term treatment of these children and was better accepted by the children than milk of magnesia.

The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society

PURPOSE

We updated the terminology in the field of pediatric lower urinary tract function.

MATERIALS AND METHODS

Discussions were held of the board of the International Children's Continence Society and an extensive reviewing process was done involving all members of the International Children's Continence Society as well as other experts in the field.

RESULTS AND CONCLUSIONS

New definitions and a standardized terminology are provided, taking into account changes in the adult sphere and new research results.

Treatment of faecal impaction with polyethelene glycol plus electrolytes (PGE + E) followed by a double-blind comparison of PEG + E versus lactulose as maintenance therapy

OBJECTIVES

To assess the efficacy of polyethylene glycol 3350 plus electrolytes (PEG + E; Movicol) as oral monotherapy in the treatment of faecal impaction in children, and to compare PEG + E with lactulose as maintenance therapy in a randomised trial.

PATIENTS AND METHODS

An initial open-label study of PEG + E in the inpatient treatment of faecal impaction (phase 1), followed by a randomised, double-blind comparison between PEG + E and lactulose for maintenance treatment of constipation over a 3-month period (phase 2) in children aged 2 to 11 years with a clinical diagnosis of faecal impaction.

RESULTS

Disimpaction on PEG + E was achieved in 58 (92%) of 63 of children (89% of 2-4 year olds and 94% of 5-11 year olds) without additional interventions. A maximum dose of 4 sachets (for 2-4 year olds) or 6 sachets (for 5-11 year olds) was required; median time to disimpaction was 6 days (range, 3-7 days). Seven children (23%) reimpacted whilst taking lactulose, whereas no children reimpacted while taking PEG + E (P = 0.011). The total incidence rate of adverse events seen was higher in the lactulose group (83%) than in the PEG + E group (64%).

CONCLUSIONS

PEG + E is safe and highly effective in the management of childhood constipation. It allows a single orally administered laxative to be used for disimpaction without recourse to invasive interventions. It is significantly more effective than lactulose as maintenance therapy, both in efficacy in treating constipation and efficacy in preventing the recurrence of faecal impaction.

The value of the abdominal radiograph in children with functional gastrointestinal disorders

Functional gastrointestinal disorder is a common problem in childhood. The symptoms vary from a relative mild gastrointestinal problem such as abdominal pain or infrequent defecation to severe problems with fecal impaction and fecal incontinence. The aim of this review is to describe and evaluate the value of the different existing methods to assess fecal loading on an abdominal radiograph with or without the use of radio-opaque markers in the diagnosis of functional abdominal pain, functional constipation and functional non-retentive fecal incontinence. In our opinion, the abdominal radiograph has limited value in the diagnostic work-up of children with functional gastrointestinal disorders.

Gastroesophageal reflux disease, colic and constipation in infants with food allergy

PURPOSE OF REVIEW

This review assesses the role of food allergy in the pathophysiology of gastroesophageal reflux disease, colic and constipation in infancy.

RECENT FINDINGS

Frequent regurgitation, persistent crying and constipation are common clinical problems in infancy. A subgroup of infants with these conditions may respond to hypoallergenic diets, but only few randomized clinical trials have been conducted. Skin prick testing and food-specific antibody levels are usually not elevated in these infants, whereas atopy patch testing may diagnostic. The mechanisms by which cow's milk and other food allergens induce gastrointestinal motility disorders are not understood. Apart from cell-mediated reactions, non-immunological effects of food constituents on gastrointestinal motility and gut microbiota may be involved in the pathogenesis. In the absence of reliable diagnostic tests, dietary elimination and re-challenge are usually required to confirm food allergy. A trial of amino acid-based formula or an oligoantigenic maternal elimination diet may be indicated in infants who have failed conventional medical treatment.

SUMMARY

Food allergy may contribute to gastroesophageal reflux disease, colic or constipation in infancy. Infants with these conditions often respond to hypoallergenic formula or a maternal elimination diet. Further research is needed to define the mechanisms and clinical markers of gastrointestinal food allergy in infancy.

Digital rectal examination and the primary care physicians: a lost art?

Digital rectal examination (DRE) in children is crucial to differentiate between simple (habitual) and complicated constipation. Previous experience suggests that primary care physicians (PCPs) avoid DRE in children with constipation before referral. We evaluated the rate of DRE performance by West Virginian PCPs in patients referred to our gastroenterology clinic. Data were collected from the physicians' referral letters and parental reports. We found that the vast majority (85%) of WV-PCPs do not perform DRE before referring their patients, resulting in missed diagnoses and treatment. We concluded that the lack of DRE in children with constipation may result in unnecessary referral to the specialist. To improve standard of care for children with constipation, an educational campaign for PCPs is clearly warranted.

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 STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 February 2006).

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

Eighteen randomised trials with a total of 1168 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.

Polyethylene glycol 4000 vs. lactulose for the treatment of neurogenic constipation in myelomeningocele children: a randomized-controlled clinical trial

AIM

To compare the therapeutic effectiveness and tolerability of low daily doses of polyethylene glycol 4000 vs. lactulose in the treatment of neurogenic constipation in children with myelomeningocele.

METHODS

Sixty-seven children with chronic neurogenic constipation were randomized allocated to receive either polyethylene glycol 4000 (0.50 g/kg) or lactulose (1.5 g/kg) for 6 months. Patients or their parents reported frequency and modality of evacuation and side effects on a diary card. Primary outcome was bowel frequency > or =3/week, and the second one was side effects at the end of treatment.

RESULTS

Complete remission of constipation was reported by a significantly (P < 0.01) higher number of patients treated with polyethylene glycol compared with lactulose. At the end of the study, 46% patients of polyethylene glycol group and 22% of the lactulose group were asymptomatic. Compared with lactulose, patients treated with polyethylene glycol reported higher bowel frequency (5.1 vs. 2.9 bowel movements/week, P < 0.01) and reduction of encopresis. Neither lactulose nor polyethylene glycol caused clinically-significant serious side effects and palatability was similar.

CONCLUSIONS

Polyethylene glycol 4000 compared with lactulose provided a higher success rate, without significant side effects, for the treatment of constipation in myelomeningocele children.

Colonic manometry as predictor of cecostomy success in children with defecation disorders

PURPOSE

The aim of this study was to define the predictive value of colonic manometry and contrast enema before cecostomy placement in children with defecation disorders.

METHODS

Medical records, contrast enema, and colonic manometry studies were reviewed for 32 children with defecation disorders who underwent cecostomy placement between 1999 and 2004. Diagnoses included idiopathic constipation (n = 13), Hirschsprung's disease (n = 2), cerebral palsy (n = 1), imperforate anus (n = 6), spinal abnormality (n = 6), and anal with spinal abnormality (n = 4). Contrast enemas were evaluated for the presence of anatomic abnormalities and the degree of colonic dilatation. Colonic manometry was considered normal when high-amplitude propagating contractions (HAPC) occurred from proximal to distal colon. Clinical success was defined as normal defecation frequency with no or occasional fecal incontinence.

RESULTS

Colonic manometry was done on 32 and contrast enema on 24 patients before cecostomy. At follow-up, 25 patients (78%) fulfilled the success criteria. Absence of HAPC throughout the colon was related to unsuccessful outcome (P = .03). Colonic response with normal HAPC after bisacodyl administration was predictive of success (P = .03). Presence of colonic dilatation was not associated with colonic dysmotility.

CONCLUSION

Colonic manometry is helpful in predicting the outcome after cecostomy. Patients with generalized colonic dysmotility are less likely to benefit from use of antegrade enemas via cecostomy. Normal colonic response to bisacodyl predicts favorable outcome.

Variability in the management of childhood constipation

To assist primary care providers, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) published clinical practice guidelines for management of childhood constipation. A cross-sectional survey of pediatricians from across the United States was conducted to assess pediatricians' constipation management strategies, whether pediatricians are familiar with the NASPGHAN constipation guidelines, and reasons pediatricians refer constipated patients to a pediatric gastroenterologist. Overall, 75% of pediatricians used polyethylene glycol without electrolytes to treat childhood constipation, 8% of pediatricians were aware NASPGHAN had published constipation guidelines, and parental pressure was just one reason pediatricians referred constipated patients to a pediatric gastroenterologist.