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

Childhood functional gastrointestinal disorders: child/adolescent

The Rome II pediatric criteria for functional gastrointestinal disorders (FGIDs) were defined in 1999 to be used as diagnostic tools and to advance empirical research. In this document, the Rome III Committee aimed to update and revise the pediatric criteria. The decision-making process to define Rome III criteria for children aged 4-18 years consisted of arriving at a consensus based on clinical experience and review of the literature. Whenever possible, changes in the criteria were evidence based. Otherwise, clinical experience was used when deemed necessary. Few publications addressing Rome II criteria were available to guide the committee. The clinical entities addressed include (1) cyclic vomiting syndrome, rumination, and aerophagia; 2) abdominal pain-related FGIDs including functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain; and (3) functional constipation and non-retentive fecal incontinence. Adolescent rumination and functional constipation are newly defined for this age group, and the previously designated functional fecal retention is now included in functional constipation. Other notable changes from Rome II to Rome III criteria include the decrease from 3 to 2 months in required symptom duration for noncyclic disorders and the modification of the criteria for functional abdominal pain. The Rome III child and adolescent criteria represent an evolution from Rome II and should prove useful for both clinicians and researchers dealing with childhood FGIDs. The future availability of additional evidence-based data will likely continue to modify pediatric criteria for FGIDs.

5. Constipation and toileting issues in children

Constipation is common in children, with prevalences ranging from 0.3% up to 28%. In most children, constipation is functional (ie, without objective evidence of a pathological condition). Painful defecation has been proposed as the primary precipitant of functional faecal retention in early childhood. Faecal soiling is often secondary to constipation, and may occur during spontaneous relaxation of the sphincters precipitated by rectal distension. Management in general practice combines behavioural modification techniques with prolonged courses of laxatives. Treatment is usually successful, but may take up to 6-12 months. Significant numbers of children with initially good responses to therapy for constipation relapse in the long term. Long-term relapse is more frequent in children under 4 years at onset of symptoms and in whom there is a history of faecal soiling associated with constipation.

A dose determination study of polyethylene glycol 4000 in constipated children: factors influencing the maintenance dose

OBJECTIVES

To determine the doses of polyethylene glycol (PEG) 4000 without additional salts allowing normal bowel habits in childhood functional constipation.

METHODS

This multicenter noncomparative study allocated children to 4 groups: 6-12 months, 13 months-3 years, 4-7 years, and 8-15 years. Constipation was defined as <1 stool/d for more than 1 month in children aged 6-12 months and <3 stools/w for more than 3 months in older children. Children randomly received either a nominal or a double starting dose. Treatment scheduled for 3 months could be adapted. Data were collected daily by the parents and rated at each visit by the investigator.

RESULTS

In the 96 children included, the median (interquartile) effective daily doses were by groups; 3.75 (2.50-5.00) g, 6.00 (4.00-7.43) g, 11.71 (7.00-16.00) g, and 16.00 (16.00-24.00) g, respectively, i.e., around 0.50 g/day/kg with a potential increment of the maintenance dose with higher initial dosages. More children had a final dosage identical to the initial one when started on the nominal dose (73%) than with the double one (42%, P < 0.003). More than 90% of children recovered normal bowel habits. Fecal soiling ceased in >60% of children with this symptom at enrolment. Fecal mass in the rectum and abdominal pain were markedly reduced and appetite improved.

CONCLUSIONS

A daily dose of PEG 4000 around 0.50 g/day/kg in children aged 6 months to 15 years is effective in more than 90% of constipated children and 60% of those with fecal soiling.

Pancreatic exocrine function in patients with cystic fibrosis

Pancreatic insufficiency in cystic fibrosis (CF) is associated with more severe disease and requires replacement therapy. Outcome measures such as growth and number of stools, frequency of abdominal pain, and flatulence have often been used to identify pancreatic-insufficient patients and to adjust the dose of replacement enzymes. Unfortunately, some patients with CF are misclassified, and approximately 9% do not receive therapy appropriate for their pancreatic exocrine functional status. Growth, number of stools, frequency of abdominal pain, and flatulence cannot be used to adjust enzyme doses.

Double-blind randomized evaluation of clinical and biological tolerance of polyethylene glycol 4000 versus lactulose in constipated children

OBJECTIVES

To assess the safety of a polyethylene glycol (PEG) 4000 laxative without additional salts in pediatric patients.

STUDY DESIGN

This was a 3-month multicenter, randomized, double-blind, double-dummy, lactulose-controlled, parallel study enrolling 96 ambulatory constipated children aged 6 months to 3 years, treated daily with 4-8 g PEG or 3.33 g-6.66 g lactulose. Total protein, albumin, iron, electrolytes, and vitamins B9 (folates), A and D (25OHD3) were measured in blood before and after treatment (day 84) in a central laboratory.

RESULTS

The percentage of children with at least one value out of normal range at day 84 with respect to baseline status (with or without at least one value out of normal range), i.e. the primary endpoint, was 87% and 90% in the PEG and lactulose groups, respectively, without any difference between groups. The whole blood parameters showed no qualitative or quantitative treatment-related changes. Vitamin A values were above normal range in 56% and 41% of children at baseline versus 33% and 36% at day 84 in the PEG and lactulose groups, respectively. Iron values were similarly under normal range in 47% and 51% at baseline versus 42% and 51% at day 84. Clinical tolerance was similar for both treatments except for vomiting and flatulence, which were significantly higher with lactulose. Significantly higher improvements were evidenced with PEG regarding stool consistency, appetite, fecaloma and use of additional laxatives.

CONCLUSION

This 3-month study in 96 constipated children aged 6 months to 3 years confirms the long-term tolerance of PEG 4000 in pediatrics and indicates a PEG efficacy similar to or greater than that of lactulose.

Increased prevalence of obesity in children with functional constipation evaluated in an academic medical center

OBJECTIVE

The rapidly increasing prevalence of obesity in children is the most important problem facing pediatricians today. A recent study suggested an association of obesity and constipation in children but lacked a control group for comparison. The objectives of this study were to evaluate the prevalence of obesity in a large cohort of children with functional constipation and to compare it with a control group representative of the general population.

METHODS

Retrospective chart review was performed on 719 children, between the ages of 4 and <18 years, with chronic functional constipation seen in the general pediatric and pediatric gastroenterology clinics between July 2002 and June 2004. Data collected included age, gender, BMI, and signs and symptoms of constipation including fecal incontinence. Obesity was classified as a BMI of >95th percentile and severe obesity as a BMI of > or =5 kg/m2 above the 95th percentile for age and gender. The control group consisted of all 930 children (4 to <18 years of age) presenting to the pediatric clinic for a well-child visit between January and June 2004. The chi2 and t tests were used for analysis.

RESULTS

Overall prevalence of obesity was significantly higher in constipated children (22.4%) compared with control children (11.7%), and this higher prevalence was also seen for severe obesity. The prevalence rates of obesity were significantly higher in constipated males (25%) than in constipated females (19%) and were significantly higher compared with the control males (13.5%) and control females (9.8%). Constipated boys in all 3 age groups had significantly higher rates of obesity than the control boys; the constipated girls had significantly higher obesity rates for the age groups between 8 and <18 years. Fecal incontinence (encopresis) was present in 334 of 719 (46%) constipated children. The prevalence of obesity was similar in constipated children with and without fecal incontinence.

CONCLUSIONS

There is a significantly higher prevalence of obesity in children with constipation compared with age- and gender-matched controls. This higher prevalence is present in both boys (4 to <18 years of age) and girls (8 to <18 years of age) with constipation and is not related to the presence of fecal incontinence among constipated children. The higher prevalence of obesity may be a result of dietary factors, activity level, or hormonal influences and needs additional evaluation.

Comorbidities associated with constipation in children referred for colon manometry may mask functional diagnoses

BACKGROUND

In children with prolonged constipation of unclear pathogenesis or unresponsive to treatment, colon manometry can discriminate between functional fecal retention (FFR) and colon neuromuscular diseases.

AIM

To identify the clinical features precipitating referral for colon manometry in children with functional constipation.

METHOD

Retrospective medical record review of 173 constipated children (116 male, mean age 6.9 years, range 1-17 years) referred for colon manometry.

RESULTS

Manometry was normal in 121 (70%). In those with normal manometry, FFR was identified in 96, irritable bowel syndrome (IBS) in 10, and functional constipation in 15. Of the 96 children FFR, 72 (76%) had comorbid conditions that might have interfered with the clinician's ability to diagnose FFR. Of 52 children with colon neuromuscular disease, only 12 (23%) had comorbid conditions (P < 0.001 compared with FFR). Of children more than 4 years, those with FFR were more likely to have fecal incontinence (44 of 62; 71%) than those with other functional disorders (2 of 19; 10%; P < 0.001) or neuromuscular disease (6 of 23; 26%; P < 0.001).

CONCLUSIONS

Two thirds of children referred for colon manometry had normal studies and met criteria for a functional diagnosis. Three quarters of those with functional constipation had a comorbid condition that might alter the history sufficiently to obscure the diagnosis.

The association of constipation with childhood urinary tract infections

OBJECTIVE

Previous studies have suggested a correlation between constipation and urinary tract infections (UTIs) in children. However, historical information about constipation may be unreliable and the relationship between a history of constipation and radiographic findings of fecal load is unclear.

PATIENTS AND METHODS

A total of 133 children undergoing an abdominal X-ray were evaluated. Parents were asked to complete a questionnaire on bowel habits. Three observers using a documented objective scoring system evaluated plain films of the abdomen. The symptom and radiographic scores were compared with the history and each other.

RESULTS

Out of the 133 children, 100 had documented previous UTIs and 33 did not. Children with prior UTIs had significantly more symptoms of constipation than those without prior UTIs (p<0.02). Children with a history of UTIs tended to have more fecal loading on radiographic studies than those without, although this difference was not statistically significant (p<0.11). When only children of >3 years old are evaluated, the trends persist, but neither were statistically significant (p<0.11 and 0.56, respectively). There was a poor correlation between the symptoms of constipation and fecal load on abdominal X-rays (correlation coefficient of 0.08).

CONCLUSIONS

Our findings support the concept that children with UTIs have a higher rate of constipation, especially by history. However, diagnosing constipation in individual patients is difficult. Not only is there a poor correlation between history and radiographic findings of constipation in any individual patient, but at this time there is no gold standard.

Breath methane associated with slow colonic transit time in children with chronic constipation

OBJECTIVE

This study analyzed the relationship between methane production and colonic transit time in children with chronic constipation.

METHODOLOGY

Forty children, from 3 to 13 years of age, suffering from chronic constipation were included. Methane production was defined when the breath methane concentration was greater than 3 ppm. The total and segmental colonic transit times were measured with radio-opaque markers.

RESULTS

Soiling was present in 34 (85.0%) of 40 patients with constipation. Methane production was present in 25 of 34 (73.5%) patients with constipation and soiling and only in 1 (16.7%) of 6 with constipation but without soiling (P = 0.014). The medians of total colonic transit time were 80.5 and 61.0 hours, respectively (P = 0.04), in methane and nonmethane producers. Segmental colonic transit times were 17.5 and 10.5 hours, respectively (P = 0.580), in right colon, 29.5 and 10.5 hours (P = 0.001), respectively, in left colon, and 31.5 and 27.0 hours (P = 0.202), respectively, in the rectosigmoid. By the sixth week of treatment, the reduction in the total colonic transit time was greater in patients who had become nonmethane producers.

CONCLUSION

The presence of breath methane in children with chronic constipation may suggest the possibility of prolonged colonic transit time.

Psychological evaluation of children with idiopathic constipation and their parents

BACKGROUND

Constipation is one of the most common problems in childhood. In idiopathic constipation it is not possible to identify primary cause in every case. Child behavioral problems and disturbances in parent-child relationships have been cited as causes of constipation. Constipation is a source of anxiety to the child and to the family. The purpose of the present study was to evaluate psychological characteristics of constipated children and their parents.

METHODS

Thirty-two otherwise healthy children with idiopathic constipation over 4 years old were prospectively evaluated between January 2002 and June 2003. The Child Behavior Checklist (CBCL) and Symptom Checklist-90 revised (SCL-90-R) were used to assess the psychological profiles of the children and the parents, respectively. Thirty children with inguinal hernia who had no constipation or other problems, and their parents were asked to complete the checklists as controls. The scores of the constipation group were compared statistically with those of the control group.

RESULTS

In the constipation group there were 19 boys and 13 girls with a mean age of 7.3 years (4-14 years). All the patients responded to medical treatment. Constipated children and their parents were not found to have more behavior problems than the control group (P > 0.05).

CONCLUSIONS

Children with idiopathic constipation and their parents do not show significant behavioral and emotional problems. Their psychological profiles are not different from the general population.

Medical treatment of constipation

Various agents are used for the medical management of chronic constipation, but few of these have been adequately studied. This article specifically examines the medical treatment of chronic constipation and the available data concerning bulk agents, lubricating agents, stimulants, and osmotic laxatives, used alone and in combination. Most experts consider dietary fiber or medicinal bulk agents to be the initial therapeutic option for the treatment of chronic constipation. If fiber is not successful or poorly tolerated, subsequent treatments may include saline osmotic laxatives, lactulose, 5-hydroxytryptamine4 (5-HT(4)) agonists (tegaserod), or stimulants such as senna or bisacodyl. Recent data also demonstrate both polyethylene glycol laxative and tegaserod to be safe and effective as initial therapy for chronic constipation.

Quality of evidence-based pediatric guidelines

OBJECTIVE

To identify evidence-based pediatric guidelines and to assess their quality.

METHODS

We searched Medline, Embase, and relevant Web sites of guideline development programs and national pediatric societies to identify evidence-based pediatric guidelines. A list with titles of identified guidelines was sent to 51 leading pediatricians in the Netherlands, who were asked to select the 5 most urgent topics for guideline development. Three pediatrician reviewers appraised the available guidelines on the 10 most frequently mentioned topics with the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.

RESULTS

A total of 215 evidence-based pediatric guidelines were identified; of these, 17 guidelines on the 10 most frequently mentioned topics were appraised. The AGREE instrument rates guidelines among 6 domains. For the scope and purpose domain, the mean score was 84% of the maximal mark. For stakeholder involvement, the mean score was 42%, with 12 guidelines (71%) scoring <50%. For rigor of development, the mean score was 54%, with 5 guidelines (29%) scoring <50%. For clarity and presentation, the mean score was 78%, with 4 guidelines (24%) scoring <50%. For applicability and editorial independence, performance was poor, with mean scores of 19% and 40%, respectively. Low scores were partly attributable to poor reporting. After considering all domain scores, the reviewers recommended 14 of 17 guidelines (82%) to be used in local practice.

CONCLUSIONS

The current volume of pediatric guidelines categorized as evidence based in popular databases is large. Overall, these guidelines scored well, compared with other studies on guideline quality in fields outside pediatrics, when assessed for quality with the AGREE instrument. This holds especially for guidelines published or endorsed by the American Academy of Pediatrics or registered in the National Guideline Clearinghouse.

Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome

OBJECTIVE

Childhood constipation accounts for 3% of visits to general pediatric clinics and as many as 30% of visits to pediatric gastroenterologists. The majority of children who experience constipation and whose caregivers seek medical care are seen by primary care physicians such as pediatricians or family physicians. Little is known about how primary care physicians treat childhood constipation or the success of their treatments. With this study, we prospectively examined which treatments primary care physicians prescribe to children who present for the first time with constipation and how effective those treatments are.

METHODS

A total of 119 children who were between 2 and 7 years of age (mean: 44.1 +/- 13.6 months) and presented to 26 different primary care physicians (15 pediatricians and 11 family physicians) for the treatment of constipation for the first time participated in this study. Parents completed daily diaries of their child's bowel habits for 2 weeks before starting treatment recommended by their primary care physician and again 2 months after treatment. The prescribed treatment was identified by reviewing office records of the treating physicians.

RESULTS

After 2 months of treatment, 44 (37%) of 119 children remained constipated. In the majority (87%) of cases, physicians prescribed some form of laxative or stool softener. The most commonly prescribed laxatives were magnesium hydroxide (77%), senna syrup (23%), mineral oil (8%), and lactulose (8%). In nearly all cases, a specific fixed dose of laxative was recommended; in only 5% of cases were parents instructed clearly to adjust the dose of laxative up or down to get the desired effect. In approximately half of the cases, physicians recommended some sort of dietary intervention. Some form of behavioral intervention was mentioned in the office records of approximately one third of cases; however, in most cases, little detail was provided. In 45% of cases, physicians prescribed disimpaction using oral cathartics, enemas, or suppositories followed by daily laxatives. In 35% of cases, physicians prescribed daily laxatives without any disimpaction procedure. In the remainder, physicians prescribed only dietary changes (5%), the use of intermittent laxatives (9%), or no therapy (7%). Treatment success corresponded to how aggressively the child was treated. Specifically, children who underwent some form of colonic evacuation followed by daily laxative therapy were more likely to have responded to treatment than were those who were treated less aggressively.

CONCLUSION

Primary care physicians tend to undertreat childhood constipation. After 2 months of treatment, nearly 40% of constipated children remain symptomatic.

Ineffectiveness of Lactobacillus GG as an adjunct to lactulose for the treatment of constipation in children: a double-blind, placebo-controlled randomized trial

OBJECTIVE

To determine if Lactobacillus GG (LGG) is an effective adjunct to lactulose for treating constipation in children.

STUDY DESIGN

Eighty-four children (2-16 years of age) with constipation (<3 spontaneous bowel movements [BMs] per week for at least 12 weeks) were enrolled in a double-blind, randomized placebo-controlled trial in which they received 1 mL/kg/day of 70% lactulose plus 10 9 colony-forming units (CFU) of LGG (experimental group, n = 43) or a placebo (control group, n = 41) orally twice daily for 12 weeks. The primary outcome measure was treatment success, and analyses were performed on an intention-to-treat basis.

RESULTS

Treatment success, defined as >or=3 spontaneous BMs per week with no fecal soiling, was similar in the control and experimental groups at 12 weeks (28/41 [68%] vs 31/43 [72%], respectively; P = .7) and at 24 weeks (27/41 [65%] vs 27/42 [64%], respectively; P = 1.0]. Groups also did not differ in their mean number of spontaneous BMs per week or episodes of fecal soiling per week at 4, 8, and 12 weeks. Adverse events and overall tolerance did not differ between groups.

CONCLUSION

LGG, as dosed in this study, was not an effective adjunct to lactulose in treating constipation in children.

Prevalence, symptoms and outcome of constipation in infants and toddlers

OBJECTIVE

To determine the prevalence of constipation in children <or=2 years, describe the symptoms of constipation, and review how often specific interventions were effective.

STUDY DESIGN

Retrospective chart review.

RESULTS

Of 4,157 children <2 years of age, 185 children had constipation. The prevalence rate for constipation in the first year of life was 2.9%, and in the second year of life, the rate was 10.1%. Functional constipation was the cause in 97% of the children. Boys and girls were affected with equal frequency. Constipation was caused by an underlying organic disease in 1.6% of cases, and 97% of the children had functional constipation. Dietary changes and corn syrup were the initial treatment suggestions for 116 children; 93% of these children underwent follow-up examinations, and the constipation resolved in 25% of the children. Of 100 children treated with milk of magnesia or polyethylene glycol 3350 without electrolytes, 93 children underwent follow-up examinations, and the constipation was resolved with treatment in 92% of the children.

CONCLUSIONS

Dietary changes, corn syrup, or both resolved constipation in 25% of children, and laxatives resolved constipation in 92% of children. Both milk of magnesia and polyethylene glycol were efficient and safe in infants and toddlers.

A comparative study: the efficacy of liquid paraffin and lactulose in management of chronic functional constipation

OBJECTIVES

To determine and compare efficacy, safety and optimal dose of two laxatives, liquid paraffin and lactulose, in 40 children with chronic functional constipation.

METHODS

A total of 20 children were treated with liquid paraffin and 20 with lactulose for 8 weeks and at an initial dose of 1 mL/kg per day for both drugs. The dose was adjusted every 3 days as required and a diary was kept to monitor dose, side-effects, stool frequency and consistency, and other symptoms.

RESULTS

During first 4 weeks, improvement in stool consistency and frequency was significantly higher in liquid the paraffin group (P < 0.01 and P < 0.05, respectively). Improvement in the number of stools per week was also significantly higher in the liquid paraffin group during the last 4 weeks of therapy (P < 0.05). Compliance rates averaged 95% in the liquid paraffin group and 90% in the lactulose group during the first 4 weeks of therapy and 90% in the liquid paraffin group and 60% in the lactulose group during the last 4 weeks of therapy (chi(2) = 4.8, SD = 1, P = 0.02). During the first 4 weeks of therapy and during the last 4 weeks of therapy, mostly side-effects and poor symptom control, respectively, influenced the compliance in the liquid paraffin group.

CONCLUSIONS

Liquid paraffin is more effective in the treatment of children with constipation. Patients treated with liquid paraffin responded more rapidly than patients responding to lactulose and showed fewer side-effect. It is considered that late response and side-effects in conjunction with poor symptom control influence the patient compliance and the successful treatment of childhood constipation.

The diameter of the rectum on ultrasonography as a diagnostic tool for constipation in children with dysfunctional voiding

PURPOSE

We proved the accuracy of the transverse diameter of the rectum on ultrasonography as an additional parameter for diagnosing constipation in children with lower urinary tract dysfunction.

MATERIALS AND METHODS

The diameter of the rectum on bladder ultrasonography in a constipated group of patients with dysfunctional voiding was compared to this diameter in a control group of patients with a normal defecation pattern. A total of 49 children were included. Group 1 consisted of 23 patients with a positive history of dysfunctional voiding and, according to pediatric gastroenterological practice, constipation. Control group 2 consisted of 26 patients without lower urinary tract dysfunction and a normal defecation pattern. In each group a defecation questionnaire was administered and physical examination of the abdomen was done. In all patients a 7.5 MHz probe was used to measure the transverse diameter of the rectum behind the bladder on ultrasonography. The probe was applied on the abdominal skin approximately 2 cm above the symphysis. Measurement was performed with a filled bladder at an angle of about 15 degrees downward from the transverse plane.

RESULTS

In constipated group 1 the mean diameter of the rectum was 4.9 cm (95% CI 4.4 to 5.3). In the control group the mean diameter of the rectum was 2.1 cm (95% CI 1.8 to 2.4). In group 1 the diameter of the rectum was significantly larger than in group 2 (p < 0.001). None of the patients had a sensation to defecate during the investigation. There was no significant difference in age between the 2 groups (p = 0.20) and no significant difference between them in the period between the last time that stool was passed prior to the time of rectal measurement (p = 0.16).

CONCLUSIONS

The transverse diameter of the rectum measured by lower abdominal ultrasound provides an additional accurate parameter with which to diagnose constipation in patients with nonneurogenic bladder-sphincter dyssynergia.

Assessment of the effectiveness of biofeedback in children with dyssynergic defecation and recalcitrant constipation/encopresis: does home biofeedback improve long-term outcomes

The purpose of this study was to determine whether biofeedback benefits children with dyssynergic defecation and constipation/encopresis, and whether home biofeedback improves long-term outcomes. Thirty-six patients with chronic constipation who had failed at least 6 months of conventional treatment and demonstrated dyssynergic defecation at anorectal manometry were randomized to biofeedback in the laboratory alone (group 1, n=24) or in the laboratory and at home (group 2, n=12) and followed up at 2, 4, and a mean of 44 months. Thirty patients were available for long-term follow-up. Bowel movements increased in all from a mean of 1.4/week to 5.1, 5.8, and 5.1 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Soiling decreased in all from a mean of 5.5/week to 0.6, 0.1, and 1 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Laxative use decreased from a mean of 4.1 days/week to 0.6, 0.3, and 0.7 per week at 2 months, 4 months, and long-term, respectively (p < or = 0.001). Twenty-seven of 30 parents ranked their satisfaction a mean of 2.2 (range 1-excellent to 3-good). There were no significant differences in outcomes between the laboratory alone group and the laboratory plus home group. Biofeedback is beneficial for some children with chronic constipation and dyssynergic defecation. Supplemental home biofeedback does not improve long-term outcomes.

Polyethylene glycol 3350 without electrolytes for the treatment of functional constipation in infants and toddlers

OBJECTIVES

We have recently reported the safety and efficacy of polyethylene glycol 3350 without electrolytes (PEG) for the daily treatment of constipation in older children. Because there are very few data available on the use of PEG in infants and toddlers, we evaluated the efficacy and safety of PEG for the treatment of constipation in children <2 years of age.

METHODS

This is a retrospective chart review of 75 constipated children <2 years of age at start of PEG therapy. PEG was started at an average dose of 1 g/kg body weight/d and parents were asked to adjust the dose to yield 1 to 2 soft painless stools/d. Data from the history and physical examination were collected initially and at short-term (<or=4 months) and long-term (>or=6 months) follow-up.

RESULTS

75 otherwise healthy children received PEG for functional constipation. The mean age was 17 months (range, 1 to 24 months) and the mean duration of constipation was 10 months (range, 0.5 to 23 months). The mean duration of short-term follow-up was 2 months and mean duration of long-term follow-up was 11 months. The mean effective short-term PEG dose was 1.1 g/kg body weight/d and the mean long-term dose was 0.8 g/kg body weight/d. Constipation was relieved in 85% with short-term and in 91% with long-term PEG therapy. Adverse effects were mild and included diarrhea, which disappeared with lowering the dose. No subjects stopped PEG because of adverse effects.

CONCLUSION

PEG is effective, well tolerated and appeared safe for the treatment of functional constipation in children <2 years of age.

Incidence of spinal cord lesions in patients with intractable constipation

Abstract Spinal magnetic resonance imaging of children with intractable constipation was reviewed. Nine percent of patients had spinal cord abnormalities. Tethered cord was the most common lesion in 75% of patients. Magnetic resonance imaging is a useful tool to evaluate children with intractable constipation.

FUNCTIONAL CONSTIPATION IN CHILDREN

PURPOSE

Constipation in children increases the likelihood of urinary incontinence, bladder overactivity, dyscoordinated voiding, a large capacity, poorly emptying bladder, recurrent urinary tract infection and deterioration of vesicoureteral reflux. We present a consensus related to the assessment, diagnosis and treatment of children with bowel dysfunction coexisting with a known disorder of urinary continence or voiding coordination.

MATERIALS AND METHODS

A panel of international multidisciplinary clinicians working on pediatric continence care was invited to participate in the First International Children's Continence Society Bowel Dysfunction Workshop. The seminar sought to address the interrelationship of bowel dysfunction with disorders of urinary continence or voiding mechanics.

RESULTS

Constipation is an end point defined by a constellation of symptoms, including infrequent passage of stool, difficulty passing stool, feces that are either large and hard or in small pieces, abdominal pain, palpable stool in the abdomen, stool in the rectal vault, loading on x-ray or fecal soiling. Assessment was done to identify potential organic causes of constipation, clarify symptoms, and identify altered motor behavior and abdomino/pelvic floor muscle incoordination. Whether the underlying problem was one of stool consistency, poor cognition, motivation or fear on the part of the child, or whether it related to gut motility, rectal sensation, stool retention or disordered emptying mechanics, the definitive therapy begins with rectal emptying of impacted stool followed by maintenance of regular soft stools to eliminate fear of pain with defecation.

CONCLUSIONS

Constipation is a challenge to the clinician but with comprehensive assessment and systematic intervention children can achieve independent bowel emptying, which positively impacts bladder function.

Pediatric Constipation Therapy Using Guidelines and Polyethylene Glycol 3350

OBJECTIVE

To review current guidelines on the treatment of functional constipation in pediatric patients, with an emphasis on the role of polyethylene glycol 3350 (PEG 3350).

DATA SOURCES

Primary medical literature published in English was identified by MEDLINE search (1980—May 2003).

STUDY SELECTION AND DATA EXTRACTION

Recently published treatment guidelines relating to pediatric functional constipation and its pharmacotherapy are assessed and compared. Published trials evaluating PEG 3350 in pediatric subjects are discussed and their results applied to the clinical role and use of this new agent.

DATA SYNTHESIS

Constipation is a common disorder among children. A number of factors may play a role. A variety of medications are commonly used for this disorder, although few treatments have undergone evaluation by controlled clinical trials. Consensus guidelines recommend either osmotic laxatives, mineral oil, or their combination for maintenance treatment in concert with patient and parental education and behavioral training. PEG 3350 solution (MiraLax) has been shown in recent clinical studies to be an effective maintenance treatment for pediatric constipation.

CONCLUSIONS

PEG 3350 is an effective and well-tolerated treatment choice for pediatric constipation, especially as an adjunct to education and behavioral training. PEG 3350 is an option for children with constipation who have failed or are intolerant of other pharmacotherapies. THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT ACPE UNIVERSAL PROGRAM NUMBER: 407-000-04-016-H01

Dermatóglifos em crianças com constipação crônica

RACIONAL: Os dermatóglifos podem ser utilizados na avaliação da transmissão genética de determinadas doenças, sendo controversa na literatura a associação entre o padrão arco e constipação. OBJETIVO: Comparar os padrões de dermatóglifos de crianças com constipação crônica com os de crianças sem constipação e com o hábito intestinal e padrões de dermatóglifos de suas mães. MÉTODOS: Foram estudados três grupos de crianças com idade entre 2 e 12 anos e suas respectivas mães: 35 pacientes com constipação grave, 45 crianças com constipação leve e 51 crianças com hábito intestinal normal, que constituíram o grupo-controle. Preencheu-se ficha padronizada com informações gerais e do hábito intestinal das crianças e de suas mães. Obtiveram-se as impressões digitais das crianças e de suas mães, que foram classificadas em arco, presilha radial, presilha ulnar, verticilo e outros. RESULTADOS: A freqüência do padrão arco foi semelhante nos três grupos estudados: constipação grave (25,7%), constipação leve (28,9%) e controles (23,5%). Hábito intestinal compatível com constipação foi observado em 51,9% (68/131) das mães. Arco foi observado em 35,3% das mães com constipação e em 42,9% das com hábito intestinal normal. Foi observada concordância muito leve entre a ocorrência de constipação na criança e na mãe. CONCLUSÃO: Não se observou associação entre a presença de arco e constipação, tanto nas crianças como em suas mães, sendo muito leve a concordância entre a ocorrência de constipação na criança e em suas mães biológicas.

Fiber (glucomannan) is beneficial in the treatment of childhood constipation

OBJECTIVE

Constipation and encopresis are common problems in children. Still today, the role of fiber in the treatment of chronic constipation in childhood is controversial. The aim of our study was to evaluate whether fiber supplementation is beneficial in the treatment of children with functional constipation with or without encopresis. We used glucomannan as the fiber supplement.

METHODS

We evaluated the effect of fiber (glucomannan, a fiber gel polysaccharide from the tubers of the Japanese Konjac plant) and placebo in children with chronic functional constipation with and without encopresis in a double-blind, randomized, crossover study. After the initial evaluation, the patients were disimpacted with 1 or 2 phosphate enemas if a rectal impaction was felt during rectal examination. Patients continued with their preevaluation laxative. No enemas were given during each treatment period. Fiber and placebo were given as 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg for 4 weeks each. Parents were asked to have children sit on the toilet 4 times daily after meals and to keep a stool diary. Age, frequency of bowel movements into the toilet and into the undergarment, presence of abdominal pain, dietary fiber intake, medications, and the presence of an abdominal and/or a rectal fecal mass were recorded on a structured form at the time of recruitment and 4 weeks and 8 weeks later. Children were rated by the physician as successfully treated when they had > or =3 bowel movements/wk and < or =1 soiling/3 weeks with no abdominal pain in the last 3 weeks of each 4-week treatment period. Parents made a global assessments to whether they believed that the child was better during the first or second treatment period.

RESULTS

Forty-six chronically constipated children were recruited into the study, but only 31 children completed the study. These 31 children (16 boys and 15 girls) were 4.5 to 11.7 years of age (mean: 7 +/- 2 years). All children had functional constipation; in addition, 18 had encopresis when recruited for the study. No significant side effects were reported during each 4-week treatment period. Significantly fewer children complained of abdominal pain and more children were successfully treated while on fiber (45%) as compared with placebo treatment (13%). Parents rated significantly more children (68%) as being better on fiber versus 13% as being better on placebo. The initial fiber intake was low in 22 (71%) children. There was no difference in the percentage of children with low fiber intake living in the United States (70%) and Italy (71%). Successful treatment (physician rating) and improvement (parent rating) were independent of low or acceptable initial fiber intake. The duration of chronic constipation ranged from 0.6 to 10 years (mean: 4.0 +/- 2.5 years). Duration of constipation did not predict response to fiber treatment. Children with constipation only were significantly more likely to be treated successfully with fiber (69%) than those with constipation and encopresis (28%).

CONCLUSION

We found glucomannan to be beneficial in the treatment of constipation with and without encopresis in children. Symptomatic children who were already on laxatives still benefited from the addition of fiber. Therefore, we suggest that we continue with the recommendation to increase the fiber in the diet of constipated children with and without encopresis.

Pathophysiology of pediatric fecal incontinence

This article addresses the diagnosis and treatment of pediatric fecal incontinence in 4 main categories: (1) Functional fecal retention, the withholding of feces because of fear of painful defecation, results in constipation and overflow soiling. Treatment includes dietary changes, use of laxatives, and cognitive and behavioral interventions such as toilet training, which diminishes phobia and provides positive reinforcement through a rewards system. (2) For functional nonretentive fecal soiling (encopresis), antidiarrheal agents can increase the consistency of stools and facilitate continence. Anorectal biofeedback for children has been proposed, but its efficacy remains unproven. Parents should be educated to conduct nonaccusatory toilet training and help children alleviate guilt and enhance self-esteem. Appropriately constructed trials are necessary to gauge the effect of adding prolonged use of enemas to an intensive toilet training program. (3) Surgery can correct minor congenital anorectal anomalies by identifying the external sphincter, separating the rectum from the genitourinary tract, and reconstructing the anus. However, there is great variation in postsurgical functional outcomes for anorectal malformations. Double-blinded, randomized controlled trials could help define the role of appendicostomy, cecostomy, sphincter reconstruction, colostomy, and artificial sphincters. (4) Children with spina bifida and fecal incontinence may benefit from techniques that teach them how to defecate. A continent appendicostomy (Malone procedure) is a promising treatment that completely cleanses the colon, increases the child's autonomy, and decreases the chance of soiling. A cecostomy can be performed surgically, endoscopically, or radiologically to provide some of the same benefits.

Management of functional constipation in childhood

Functional constipation is a common condition. In the majority of cases the constipation develops as a result of a complex weave of factors including specific triggers, e.g. reduced fluid intake following a viral infection or periods of restricted access to the toilet. The passage of large painful stools perpetuates the problem when the child begins to associate pain with defecation. The management of constipation can often be a challenge in children, who initially may be reluctant to sit on the toilet. This article will discuss the contributory factors to the cause of constipation and identify the keys to successful treatment, including ensuring a holistic child-focused approach with effective initial evacuation and appropriate maintenance therapy.

Management of childhood constipation: parents’ experiences

BACKGROUND

Constipation in childhood is common and places a burden on child health services. Whilst constipation can have a variety of causes, for most children it is usually non-organic and requires limited intervention. It has been suggested that health professionals can resent consultations for such a common problem, believing them to be inappropriate. However, they can underestimate the impact of this condition, leading to adverse clinical effects, as well as parental dissatisfaction. Little research has explored parents' experiences of consulting health professionals about the management of childhood constipation.

AIM

To explore parents' experiences of consulting health professionals about management of childhood constipation and to use the findings to inform more effective therapeutic encounters when responding to parental concerns.

METHODS

A phenomenological approach was adopted, using in-depth interviews with parents of 14 children receiving health interventions for constipation.

FINDINGS

Six themes emerged from analysis including: 'enduring and extreme constipation', which reflected the substantial and sustained impact of the child's constipation; 'dismissed and fobbed off', which captured parents' feelings that their concerns were frequently dismissed by health professionals; 'asserting the need for action', a perception that they had reached a point at which they had to demand some intervention; and 'validation and acknowledgement', which reflected acknowledgment that, finally, their concerns for their child had been taken seriously and acted on.

DISCUSSION

The findings indicate a failure by some health professionals to appreciate fully the significance of childhood constipation, thereby appearing to be unconcerned and insensitive to the needs of child and family. The impact of this is a potential loss of trust in health professionals by parents, which can then have implications for how they perceive and access health services for management of this common childhood problem. The findings offer an insight into parental experiences and indicate the need for a more sensitive approach during health consultations.

Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis

Seventy-four children (43 with chronic constipation, 31 with constipation and encopresis) treated with polyethylene glycol 3350 (PEG) for longer than 3 months were studied to assess long-term efficacy. The mean duration of PEG therapy was 8.4 months (range, 3-30). Weekly stool frequency, stool consistency, and symptoms associated with constipation improved significantly with PEG therapy in all 74 patients. In 31 children with encopresis, soiling ceased completely in 16 patients and frequency of soiling decreased significantly in all others. The average effective long-term dose of PEG was 0.7 g/kg/day. Long-term PEG therapy is effective for the treatment of chronic constipation with and without encopresis in children.

Constipation with acquired megarectum in children with autism

OBJECTIVE

Recent evidence suggests that autistic children may have significant gastrointestinal symptoms. Although constipation occurs in 2% to 5% of healthy children, its clinical diagnosis is often difficult in children with behavioral disorders. We thus aimed to assess the prevalence of fecal loading in autistic children with gastrointestinal symptoms and to identify possible predictors of constipation.

METHODS

We studied abdominal radiographs of 103 autistic children (87 boys) who were referred for gastroenterological assessment, in comparison with 29 control radiographs from children who were referred to the emergency department, most with abdominal pain. Radiographs were scored independently, in blinded manner, by 4 pediatric gastroenterologists and a radiologist. The severity of constipation was determined using a validated index. Details of stool habit, abdominal pain, dietary history, and laxative use were obtained from case notes.

RESULTS

The incidence of constipation in the control subjects with abdominal pain was higher than reported for normal children. Despite this, moderate or severe constipation was more frequent in the autistic group than in the control subjects (36% vs 10%). Analysis of rectosigmoid loading showed more striking differences (54.4% of autistic children had moderate/severe loading or acquired megarectum compared with 24.1% of control subjects). Multivariate regression analysis showed consumption of milk to be the strongest predictor of constipation in the autistic group, whereas stool frequency, gluten consumption, soiling, and abdominal pain were not predictive of constipation.

CONCLUSIONS

Constipation is a frequent finding in children with gastrointestinal symptoms and autism, particularly in the rectosigmoid colon, often with acquired megarectum. The absence of any correlation between the clinical history and the degree of fecal impaction in autistic children confirms the importance of an abdominal radiograph in the assessment of their degree of constipation.

Treatment of Gastrointestinal Problems in Cystic Fibrosis

The gastrointestinal (GI) manifestations of cystic fibrosis (CF) are varied and include pancreatic insufficiency, meconium ileus, distal intestinal obstruction syndrome (DIOS), liver disease, and other less common manifestations. Treatment of pancreatic insufficiency consists of providing appropriate pancreatic enzyme replacement therapy and may include raising duodenal pH to allow for optimal action of these enzymes. Despite a number of pancreatic enzyme replacement products, malabsorption cannot be normalized. Management of DIOS depends on the severity of the symptoms; adequate hydration is very important. Polyethylene glycol solutions are being increasingly used. The precipitating cause of the episode of DIOS should be looked for so future episodes can be prevented. Liver disease is relatively silent and annual monitoring of liver function and status is recommended. Treatment is mainly supportive and the role of ursodeoxycholic acid in the prevention of cirrhosis needs to be better defined. Nutritional status is an important part of management of all GI and liver manifestations of CF. A team approach and the assistance of a registered dietitian are extremely valuable in managing the GI and liver manifestations of CF.

Dietary fiber, energy intake and nutritional status during the treatment of children with chronic constipation

The present prospective study was carried out to determine dietary fiber and energy intake and nutritional status of children during the treatment of chronic constipation. Twenty-five patients aged 2 to 12 years with chronic constipation were submitted to clinical evaluation, assessment of dietary patterns, and anthropometry before and after 45 and 90 days of treatment. The treatment of chronic constipation included rectal disimpaction, ingestion of mineral oil and diet therapy. The standardized diet prescribed consisted of regular food without a fiber supplement and met the nutrient requirements according to the recommended daily allowance. The fiber content was 9.0 to 11.9 g for patients aged less than 6 years and 12.0 to 18.0 g for patients older than 6 years. Sixteen patients completed the 90-day follow-up and all presented clinical improvement. The anthropometric variables did not change, except midarm circumference and triceps skinfold thickness which were significantly increased. Statistically significant increases were also found in percent calorie intake adequacy in terms of recommended daily allowance (55.5 to 76.5% on day 45 and to 68.5% on day 90; P = 0.047). Percent adequacy of minimum recommended daily intake of dietary fiber (age + 5 g) increased during treatment (from 46.8 to 52.8% on day 45 and to 56.3% on day 90; P = 0.009). Food and dietary fiber intake and triceps skinfold thickness increased during follow-up. We conclude that the therapeutic program provided a good clinical outcome.

Trends in referral to a single encopresis clinic over 20 years

OBJECTIVE

To compare the characteristics of children with encopresis referred to a single encopresis clinic over the course of 20 years, including symptoms, previous diagnostic and therapeutic interventions, and parental attitudes.

METHODS

A retrospective study was conducted of an encopresis clinic at a tertiary care pediatric hospital. Questionnaires at initial evaluation elicited information about bowel habits, soiling, previous evaluations, previous treatments, and parental attitudes.

RESULTS

In 503 children with encopresis, the average age of referral dropped from 115 months during the earliest 5 years to 77 months during the most recent 5 years. Children who had soiling for >3 years before referral decreased from 63% to 12%. The use of barium enema before referral decreased from 14% to 5%, as did psychological evaluation, from 25% to 14%. Previous therapy with enemas decreased from 45% to 27%. Mineral oil use remained at approximately 50%, and 20% of children had no previous treatment. Symptoms at referral and parental attitudes did not change across the years.

CONCLUSIONS

Children are now referred at an earlier age to our tertiary encopresis clinic. The number of invasive and psychological evaluations has decreased before referral. However, treatment by many primary care providers before the referral has not changed. These data may suggest that pediatricians have increased awareness of encopresis and greater appreciation of its primarily physical rather than psychological nature. Additional studies will be needed to determine how these factors affect outcome.

Colonic manometry in children with defecatory disorders. role in diagnosis and management

OBJECTIVE

The aim of this study was to evaluate the role of colonic manometry in clarifying pathophysiology of childhood defecatory disorders and to evaluate its impact on management.

METHODS

We conducted a retrospective review of medical records of children referred to undergo colonic manometry to a tertiary care Motility Center from 1996 to 2001. Families were followed up a median of 20 months after evaluation (range 3-60 months).

RESULTS

A total of 150 colonic manometries were performed in 146 children (74 male, median age 79 months, range 4-225 months). Colonic manometry had been requested to clarify the pathophysiology of lower GI symptoms in 68%; as part of diagnostic workup for chronic intestinal pseudo-obstruction in 11%; to decide about reanastomosis of a diverted colon in 7%; and to clarify the pathophysiology of persisting symptoms after surgery for Hirschsprung's disease in 14%. Normal motility was found in the entire colon in 38% of children. In 17%, there was normal motility in the proximal colon with abnormality limited to the dilated distal colon. Abnormal motility was found in 45% of children. After colonic manometry, treatment changes were recommended in 93% of patients. We were able to follow up 65% of the families. When recommendations were followed (96% of the contacted patients), the symptoms improved in 78%, were unchanged in 18%, and were worse in 4% of patients. Among the parents, 88% believed that the suggestions given after colonic manometry had been helpful in improving their children's health.

CONCLUSIONS

Colonic manometry may provide information useful in guiding therapy in a subgroup of patients with defecatory disorders.

Cardiopulmonary compromise associated with milk and molasses enema use in children

OBJECTIVE

Constipation is a common childhood problem that frequently confronts pediatric practitioners. When enema treatment is indicated to treat constipation, milk and molasses enemas are sometimes used. Side effects and adverse outcomes have been described with many types of enemas, but not with milk and molasses. The purpose of this study is to describe five children who acutely decompensated after receiving milk and molasses enemas.

METHODS

Retrospective review of the medical records of children with constipation who received milk and molasses enema with subsequent PICU admission at Cincinnati Children's Hospital Medical Center between 1994 and 2000.

RESULTS

Five children developed significant hemodynamic deterioration after receiving milk and molasses enemas. One of these children died and the others recovered after aggressive resuscitation.

CONCLUSIONS

Milk and molasses enema administration can be associated with significant hemodynamic compromise. These risks appear similar to those risk observed with the use of other enema preparations.

Treatment Options for Refractory Childhood Constipation

Constipation in children is very common. Childhood constipation responds successfully to medical therapies, behavioral modifications, or a combination of both in approximately 70% of children within 2 years of diagnosis. Persistence of constipation is associated with fecal incontinence, recurrent fecal impactions, and significant emotional problems. Refractory constipation that interferes with both the child's function and the family's life requires extensive evaluations in order to uncover its cause and devise appropriate therapeutic strategies. Children with persistent constipation can be divided into three broad categories: 1) those who have functional constipation, 2) those affected by enteric neuromuscular disorders, and 3) those whose constipation is associated with neurologic handicaps. Treatment options vary widely. The majority of patients require more aggressive medical and more intense behavioral interventions. Others benefit from novel approaches, including surgical intervention.

Encopresis

A careful history and physical examination will help to differentiate between encopresis with or without constipation and fecal incontinence caused by anatomic or organic disease. Most children with encopresis with or without functional constipation require no or minimal laboratory workup. Successful treatment of encopresis requires a combination of parent and child education, behavioral intervention, medical therapy, and long-term compliance with the treatment regimen. The conventional treatment approach consists of behavior modification and laxative for children with encopresis with constipation and behavior modification alone for the few children with encopresis without constipation. Almost every patient will experience dramatic improvement in encopresis. Recovery rates are 30% to 50% after 1 year and 48% to 75% after 5 years.

Quantitation of colonic luminal synthesis of butyric acid in piglets

OBJECTIVES

Butyric acid, synthesized via bacterial fermentation in colonic lumen, may play an important role in the nutrition of the colonic mucosa. Since disaccharides, especially lactose, are the principal dietary carbohydrates during infancy, it is important to determine if their fermentation is associated with butyric acid synthesis. The objective of this paper is to describe a newly developed stable isotope method for quantifying butyric acid synthesis in the colonic lumen and to demonstrate its application during cecal infusions of lactose and lactulose in piglets.

METHODS

Nine piglets aged 21 to 30 days were studied during acute anesthesia. The C enrichment of butyric acid was monitored in the portal vein before and during a 120 minutes cecal infusion of [1- C]-butyric acid and either unlabeled lactose (N = 4) or lactulose (N = 5).

RESULTS

The luminal synthesis of BA (micromol x kg x min ) (Mean +/- S.D.) was respectively 1.5 +/- 0.9 and 1.2 +/- 0.6 during lactulose and lactose infusion.

CONCLUSIONS

This study provides new quantitative data on in vivo butyric acid production in the mammalian colon.

Dose response of PEG 3350 for the treatment of childhood fecal impaction

OBJECTIVE

To investigate the efficacy and safety of polyethylene glycol (PEG) 3350 in the treatment of childhood fecal impaction.

METHODS

This was a prospective, double-blind, parallel, randomized study of 4 doses of PEG 3350; 0.25 g/kg per day, 0.5 g/kg per day, 1 g/kg per day, 1.5 g/kg per day, given for 3 days in children with constipation for >3 months and evidence of fecal impaction.

RESULTS

Forty patients completed the study (27 boys, median age 7.5, range 3.3-13.1 years). Disimpaction occurred in 75% of children, with a significant difference between the two higher doses and the lower doses (95% vs 55%, P <.005). All groups had an increased number of bowel movements during the 5-day study versus baseline, respectively: 6.5 versus 1.1 (P <.005), 8.0 versus 1.3 (P <.005), 10.9 versus 1.7 (P <.005), and 12.3 versus 1.4 (P <.005). Adverse effects included nausea (5%), vomiting (5%), bloating (18%), cramping (5%), and diarrhea (13%). Diarrhea and bloating were more prevalent (P <.02) in the higher-dose than in the lower-dose group. No clinically significant changes in electrolytes were noted.

CONCLUSIONS

The 3-day administration of PEG 3350 is safe and effective in the treatment of childhood fecal impaction at doses of 1 and 1.5 g/kg per day.