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

Is it more than just constipation?

We report an infant presenting with constipation, whose history and physical examination initiated the investigation that led to the diagnosis of the Currarino triad in the proband and 2 other family members.

Comparison of polyethylene glycol 3350 and lactulose for treatment of chronic constipation in children

Polyethylene glycol (PEG) 3350 and lactulose were compared in an unblinded, randomized, crossover design for treatment of constipation in 37 children aged 2 to 16 years. Subjects received lactulose (1.3 g/kg/d divided twice daily up to 20 g) or PEG 3350 (10 g/m2/day) for 2 weeks. PEG 3350 significantly decreased the total colonic transit time compared to lactulose (47.6+/-2.7 vs 55.3+/-2.4 hours, mean +/- SE, PEG 3350 vs lactulose, respectively, p = 0.038). The stool frequency, form, and the ease of passage were similar for each laxative. Polyethylene glycol 3350 is an effective laxative for the treatment of chronic constipation in children.

Reactive nitrogen species modulate the effects of rhein, an active component of senna laxatives, on human epithelium in vitro

BACKGROUND

Senna laxatives are used worldwide. However, their misuse can lead to chronic mucosal inflammation with the accumulation of pigment-laden leukocytes and may cause colon cells to undergo apoptosis. This study explores the mechanisms by which rhein, an active component of senna, acts on a human intestinal cell line to induce ion secretion, apoptosis, and indirect chemotaxis of polymorphonuclear leukocytes.

METHODS

Human colonic adenocarcinoma (CaCo-2) monolayer cells, in the presence or in the absence of rhein, were used to monitor the production of reactive nitrogen species using the Griess reaction. Modified Ussing chambers were used to study electrolyte secretion. The capacity to recruit human polymorphonuclear leukocytes was evaluated using masked well chemotaxis chambers. Rhein-induced apoptosis was investigated by counting apoptotic nuclei stained with Hoechst 33258 dye.

RESULTS

Rhein caused a dose-dependent increase in short-circuit current that was abolished in chloride-free bathing buffer or by preincubating with 100 micromol/L NG-nitro-L-arginine (L-NAME) methyl ester. The concentration that maximally stimulated intestinal secretion, 50 micromol/L rhein, induced nitrate production. Supernatants obtained from CaCo-2 cultures after incubation with 50 micromol/L rhein stimulated a time-dependent polymorphonuclear leukocytes chemotaxis that was significantly decreased with 100 micromol/L L-NAME, whereas rhein per se was not active. Neutralizing antibodies anti-interleukin-8 (IL-8) and anti-ENA78 also inhibited chemotaxis. Overnight rhein incubation produced an increased number of apoptotic cells in the culture supernatant that was significantly decreased by preincubation with 100 micromol/L L-NAME. Light-degraded rhein had no effects on CaCo-2 monolayers.

CONCLUSIONS

The integrity of rhein is crucial to generating nitric oxide, which mediates, with different time courses, ion secretion, chemotaxis, and apoptosis of human-derived cells.

The physiology of continence: idiopathic fecal constipation and soiling

The anatomic and functional elements contributing to fecal continence and defecation are explored. The high incidence and importance of chronic idiopathic constipation as an entity in itself and a contributing factor to fecal incontinence are emphasized, and its management is discussed. The importance of a proper clinical history and examination is highlighted, and investigative modalities including radiology, transit studies, and anorectal manometry are described and placed in the context of practical clinical management.

Polyethylene glycol without electrolytes for children with constipation and encopresis

BACKGROUND

Children with functional constipation and encopresis benefit from behavior modification and from long-term laxative medication. Polyethylene glycol without electrolytes has become the first option for many pediatric gastroenterologists.

METHODS

Twenty-eight children treated with polyethylene glycol without electrolytes were compared with 21 children treated with milk of magnesia to evaluate the efficiency, acceptability, side effects, and treatment dosage of polyethylene glycol in long-term treatment of functional constipation and encopresis. Children were rated as "doing well," "improved," or "not doing well," depending on resolution of constipation and encopresis.

RESULTS

At the 1-, 3-, 6-, and 12-month follow-ups, bowel movement frequency increased and soiling frequency decreased significantly in both groups. At the 1-month follow-up, children on polyethylene glycol were soiling more frequently (P < 0.01) and fewer were improved (P < 0.01). At the 3- and 6-month follow-ups, both groups had similarly improved. At the 12-month visit, 61% of children on polyethylene glycol and 67% of children on milk of magnesia were doing well. Children on polyethylene glycol soiled more frequently (P < 0.01). None refused polyethylene glycol, but 33% refused to take milk of magnesia. The mean initial treatment dosage of polyethylene glycol was 0.6 +/- 0.2 g/kg daily. Polyethylene glycol had no taste, and no loss of efficacy occurred. Polyethylene glycol did not cause clinically significant side effects.

CONCLUSIONS

Polyethylene glycol without electrolytes is an alternative for long-term management of children with constipation and encopresis.

Early constipation and toilet training in children with encopresis

OBJECTIVE

To evaluate the frequency of predisposing factors for encopresis before and during toilet training, comparing children with primary and secondary encopresis.

METHODS

In this retrospective study, questionnaires from the initial evaluation at an encopresis clinic at a tertiary care pediatric hospital were reviewed for the presence or absence of factors in the first 2 years of life, for toilet training practices, and for disruptive events during the training process. Children younger than 48 months or those with organic defecation disorders were excluded.

RESULTS

In 411 children with encopresis, the reported frequency of predisposing factors included constipation in 35%, and previous treatment for constipation in 24%. Toilet training was initiated before age 2 years in 26% and after age 3 years in 14%. Interruption of toilet training and punishment were seen more in primary encopresis than in secondary encopresis (50% versus 23%; P < 0.05) and (52% versus 26%; P < 0.05) respectively. Constipation (30% versus 18%; P < 0.05) and abdominal pain (23% versus 9%; P <0.0:5) during toilet training were more common in primary encopresis as was fear of the toilet (47% versus 10%; P < 0.05).

CONCLUSIONS

In children with encopresis, early difficult defecation, previous treatment for constipation, and early initiation of toilet training were less common than expected. Children with primary encopresis did not have an increased incidence of early constipation or invasive treatments compared with those with secondary encopresis. However, children with primary encopresis did have more difficult and disruptive toilet training experiences.

Motility disorders. Diagnosis and treatment for the pediatric patient

Motility disorders are common in children and may affect any area of the GI tract. The past decade has brought significant advances in the understanding of motility disorders in pediatrics. More sophisticated testing techniques have helped to differentiate normal from abnormal motility in children of different ages. Manometry now may be used to clarify the pathophysiologic defect underlying chest pain, dysphagia, rumination, gastroparesis, chronic intestinal pseudo-obstruction, and colonic neuromuscular disorders. Motility testing also may be used to identify the motor defect responsible for persistence of symptoms after surgery for GER or HD. New investigational techniques and prokinetic agents likely to be available in the future also were discussed.

Colonic diversion for intractable constipation in children: colonic manometry helps guide clinical decisions

BACKGROUND

Colonic manometry helps discriminate functional and behavioral causes for childhood constipation from colonic neuromuscular disease.

METHODS

Of 375 colonic manometries performed for clinical indications, 12 could not be interpreted because of chronic colonic dilation. Based on colonic manometries that showed either no contractions or an absence of the gastrocolonic response or an absence of high-amplitude propagating contractions, the authors recommended diverting colostomies or ileostomies in 12 chronically constipated children (mean age, 4 years; range, 2-14 years, 5 boys). Before study, medical treatment was ineffective in all children. These children had persistently dilated colons with pathologic diagnoses of intestinal neuronal dysplasia (n = 4), hypoganglionosis (n = 2), hollow visceral myopathy (n = 1), and normal (n = 5).

RESULTS

Six to 30 months after diversion, the authors restudied all the children. Eleven of 12 diverted colons were no longer dilated. In two patients, abnormal motility involving the entire colon was unchanged from the initial study, small bowel motility was abnormal, and we recommended no further surgery. In two cases, the colon remained abnormal but small bowel motility was normal, and we recommended subtotal colectomy and ileoproctostomy. In four cases, the left colon remained abnormal, but the right colon was normal, and we recommended reanastomosis after left hemicolectomy. In four cases, motility in the diverted colons was normal, including a gastrocolonic response and high-amplitude propagating contractions, and the authors recommended reanastomosis. Defecation problems resolved in 10 of 12 when followed up 5 to 30 months after treatment.

CONCLUSION

These data suggest that in some cases of intractable childhood constipation associated with colonic distention, temporary diversion improved colonic motility. Colonic manometry may be used to predict which patients will benefit from resection or reanastomosis.

Childhood constipation: evaluation and treatment

Constipation is common in children. It is estimated that between 5% and 10% of pediatric patients have constipation and/or encopresis. Constipation is the second most referred condition in pediatric gastroenterology practices, accounting for up to 25% of all visits. In this article, a practical approach is laid out for those not familiar with constipation in children. Emphasis is placed on the evaluation and management options that are available to the treating practitioner. The diagnosis of constipation requires careful history taking and interpretation. Diagnostic tests are not often needed and are reserved for those who are severely affected. The daily bowel habits of children are extremely susceptible to any changes in routine environment. Constipation and subsequent fecal retention behavior often begins soon after a child has experienced a painful evacuation. Childhood constipation can be very difficult to treat. It often requires prolonged support by physicians and parents, explanation, medical treatment, and, most important, the child's cooperation.

Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children

OBJECTIVE

To determine efficacy, safety, and optimal dose of a laxative, polyethylene glycol (PEG) 3350, in children with chronic constipation.

STUDY DESIGN

Children with chronic constipation (n = 24) were treated with PEG for 8 weeks at an initial dose of 1 g/kg/d. The dose was adjusted every 3 days as required to achieve 2 soft stools per day. A diary was kept to monitor dose, stool frequency and consistency, soiling, and other symptoms. Stool consistency was rated from 1 (hard) to 5 (watery). Subjects were examined for fecal retention. The Student t test and the Fisher exact test were used for data analysis.

RESULTS

All 20 children who completed the study found PEG to be palatable and were satisfied with the treatment. There were no significant adverse effects. Weekly stool frequency increased from 2.3 +/- 0.4 to 16.9 +/- 1.6 (P <.0001) during treatment and stool consistency from 1.2 +/- 0.1 to 3.3 +/- 0.1 (P <.0001). In 9 children with soiling, weekly soiling events declined from 10.0 +/- 2.4 to 1.3 +/- 0.7 (P =.003). The mean effective dose was 0.84 g/kg/d (range, 0.27-1.42 g/kg/d).

CONCLUSION

Daily administration of PEG at a mean dose of 0.8 g/kg is an effective, safe, and palatable treatment for constipation.

American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics

Historically, fruit juice was recommended by pediatricians as a source of vitamin C and an extra source of water for healthy infants and young children as their diets expanded to include solid foods with higher renal solute. Fruit juice is marketed as a healthy, natural source of vitamins and, in some instances, calcium. Because juice tastes good, children readily accept it. Although juice consumption has some benefits, it also has potential detrimental effects. Pediatricians need to be knowledgeable about juice to inform parents and patients on its appropriate uses.

Pediatric anorectal disorders

Anorectal disorders are common in children. It has been estimated that 10% of children are brought to medical attention because of a defecation disorder, and constipation is the chief complaint in 3% to 5% of all visits to pediatricians. Most of these children suffer from functional constipation. There are substantial differences in the approach to children and adults with anorectal disorders. This article discusses the commonest pediatric anorectal disorders, emphasizing the differences between children and adults in terms of clinical presentations, pathophysiology, diagnosis, and treatment.

Behavioural and cognitive interventions with or without other treatments for defaecation disorders in children

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

The following databases were searched: the Cochrane Incontinence Group Trials Register (March 2001), the Cochrane Controlled Trials Register (Issue 4, 2000), The Enuresis Resource and Information Centre Register of studies of encopresis and soiling, AMED (1985 to April 2000), PsycINFO (1887 to June 2000), Index to Theses - Great Britain and Ireland (October 2000), Dissertation Abstracts (November 2000), EMBASE (January 1998 to October 1999), SIGLE (January 1980 to December 1996), BIOSIS (January 1998 to March 1999), Science Citation Index (January 1998 to March 1999), ISTP (January 1982 to March 1999). Date of the most recent searches: March 2001. Bibliographies of trials retrieved were also searched and colleagues and experts in the field were contacted for information.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies from the literature. One reviewer assessed the methodological quality of eligible trials and extracted data. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Sixteen randomised trials with a total of 843 children met the inclusion criteria. Sample sizes were generally small. Interventions varied among trials and few outcomes were shared by trials addressing the same comparisons. The synthesis of data from eight trials showed higher rather than lower rates of persisting problem up to 12 months when biofeedback was added to conventional treatment (OR 1.34 CI 95% 0.92 to 1.94). In two trials significantly more encopretic children receiving behavioural intervention plus laxative therapy improved compared with those receiving behavioural intervention alone at both the 6-month (OR 0.51 CI 95% 0.29 to 0.89) and the 12-month follow-up (OR 0.52 CI 95% 0.30 to 0.93). Similarly in another trial the addition of behaviour modifications to laxative therapy was associated with a marked reduction in children's soiling episodes (OR 0.14 CI 95% 0.04 to 0.51).

REVIEWER'S CONCLUSIONS

There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of encopresis and constipation in children. There is some evidence that behavioural intervention plus laxative therapy, rather than behavioural intervention or laxative therapy alone, improves continence in children with primary and secondary encopresis.

Are constipated children different from constipated adults?

Constipation represents a diagnostic category of high prevalence both in children and adults, but with low disability and hospitalization rates. This review is written to be a relatively practical guide to physicians providing information for the evaluation and management of one of the most common chronic digestive disorders. In this article we emphasize the differences between constipation in children and adults. The approach to childhood constipation needs to focus on the behavioral nature of this disorder. Diagnostic techniques often used in constipated adults may not provide useful data when applied to children. Treatment of childhood constipation requires a team effort involving the physician, parents and child.

Advances in the management of pediatric constipation

Constipation in children is a common concern. There is no single treatment; many children do not respond and continue to have chronic problems. This lack of response is multifactorial, but it is most likely related to the fact that the exact pathophysiology of constipation in children is not known. Diagnostic criteria (Rome II classification) and algorithms proposed by the North American Society for Pediatric Gastroenterology and Nutrition (NASPGN) for evaluation and treatment of children with constipation were recently published and are summarized here. The effectiveness of new treatments such as dietary interventions, prokinetic agents, biofeedback, and polyethylene-glycol electrolyte (PEG) solutions is discussed in this review.