Health-Related Quality of Life and Parental Stress in Children With Fecal Incontinence: A Normative Comparison

"The People Criticized Me and Insulted Me Due to Having a Child with Defect": Experiences of Somali Parents of Children with Anorectal Malformation

Background

Treatment of anorectal malformations (ARM) and the management of clinical outcomes are challenging for families. While most studies focus on mothers suffering from care burden, high stress, and low quality of life, there is limited knowledge of what fathers of children with ARM experience; therefore, this study aimed to examine how both mothers and fathers have experience caring for children with ARM and how beliefs and cultural issues affect the perception of congenital anomalies.

Methods

A qualitative design. Consolidated criteria for reporting the qualitative research guidelines were used in this study. The guidelines for thematic analysis were followed for data analysis.

Results

Ten mothers and six fathers were interviewed, and their mean age was 32.5 ± 4.2 years. Of the 75% (n = 12) illiterate and 93.7% (n = 15) had an expanded family type, all their religious affiliations were Muslim. The four main themes were (1) ambiguity, (2) challenges, (3) stigma, and (4) coping, which were determined in line with the results of the data analysis of parents' views on having and caring for children with ARM.

Conclusion

In this study, many Somali parents reported that they lacked disease and treatment knowledge, physical exhaustion, and some difficulties related to a lack of access to the hospital because of living in rural areas, caring for the child, and dealing with long-term complications, colostomy, anal dilatation, and enema before or after anoplasty. While all parents mentioned that having a child with ARM was a fate, it was seen as punishment by their close social environment. Consequently, this study could serve as a foundation for planning comprehensive healthcare and physical and psychosocial support for multidisciplinary health professionals.

Anorectal malformation and Hirschsprung's disease: a cross-sectional multicentre comparison of quality of life and bowel function to a healthy population

PURPOSE

Children with anorectal malformation (ARM) and Hirschsprung's disease (HD) often experience bowel symptoms into adulthood, despite definitive surgery. This study evaluates the quality of life (QOL) and bowel functional outcome of children treated for ARM and HD in comparison to healthy controls.

METHODS

Between December 2020 and February 2023, we recruited patients with ARM and HD aged 3-17 years at four tertiary referral centres, who had primary corrective surgery done >12 months prior. Healthy controls were age-matched and sex-matched. All participants completed the Pediatric Quality of Life Inventory Generic Core Scales 4.0, General Well-Being (GWB) Scale 3.0 and Family Impact (FI) Module 2.0 Questionnaires. Bowel Function Score (BFS) Questionnaires were also administered. We also performed subgroup analysis according to age categories. Appropriate statistical analysis was performed with p<0.05 significance. Ethical approval was obtained.

RESULTS

There were 306 participants: 101 ARM, 87 HD, 118 controls. Patients with ARM and HD had significantly worse Core and FI Scores compared with controls overall and in all age categories. In the GWB Scale, only ARM and HD adolescents (13-17 years) had worse scores than controls. ARM and HD had significantly worse BFSs compared with controls overall and in all age categories. There was significant positive correlation between BFS and Core Scores, GWB Scores and FI Scores.

CONCLUSION

Patients with ARM and HD had worse QOL than controls. Lower GWB Scores in adolescents suggests targeted interventions are necessary. Bowel function influences QOL, indicating the need for continuous support into adulthood.

Efficacy of transcutaneous posterior tibial nerve stimulation in functional constipation

Most children with functional constipation (FC) improve with conventional treatments. However, a proportion of children have poor treatment outcomes. Management of intractable FC may include botulinum toxin injections, transanal irrigation, antegrade enemas, colonic resections, and in some cases sacral nerve stimulation (SNS). SNS is surgically placed, not readily available and expensive. Posterior tibial nerve stimulation (PTNS) allows transmission of electronic impulses and retrograde stimulation to the sacral nerve plexus in a portable, simple and non-invasive fashion. To assess the efficacy and safety of transcutaneous PTNS for the treatment of FC in children. Single-center, prospective interventional study. Children 4-14 years with Rome IV diagnosis of FC received ten daily PTNS (30 min/day) sessions. Electrodes placed over skin of ankle. Strength of stimulus was below pain threshold. Outcomes were assessed during treatment and 7 days after. Twenty-three subjects enrolled. Two children excluded (acute gastroenteritis, COVID-19 contact). Twenty completed the study (4-14 years), (8.4 ± 3.2 years, 71.4% female). We found significant improvement in the consistency of bowel movements (BM) (p = 0.005), fecal incontinence (FI) (p = 0.005), abdominal pain presence (p = < 0.001) and intensity (p = 0.005), and a significant for improvement in blood in stools (p = 0.037). There was 86.3% improvement in abdominal pain. 96.7% reported treatment satisfaction. Only one child required rescue therapy.

CONCLUSION

We found significant improvement in stool consistency, FI, abdominal pain, and hematochezia. This suggests that transcutaneous PTNS could be a promising noninvasive treatment for FC in children. Large studies are needed.

WHAT IS KNOWN

• Functional constipation is one of the most common disorders in children. • Current management of functional constipation consists of an integrative approach that includes medications, diet and behavioral strategies.

WHAT IS NEW

• Posterior tibial nerve stimulation is a novel noninvasive and easy to use therapy that can improve stool consistency, fecal incontinence and blood in stools.

Prospective quality of life outcomes in pediatric fecal incontinence following bowel management

BACKGROUND

Severe fecal incontinence (FI) is common in patients both with and without anorectal malformations. Whether a formal bowel management program (BMP) has significant effects on FI, psychosocial development of the child, and caregiver stress is poorly understood. We hypothesize that BMP participation results in long-term clinical and quality of life (QOL) improvements for patients and caregivers.

METHODS

Using a prospective cohort study over three years, 342 children (age 3-12 years) and caregivers were followed for one year after attending a week-long BMP, during which a regimen was tailored to promote daily stool evacuation.FI QOL was measured with the validated Cincinnati Fecal Incontinence Scale (CINCY-FIS), evaluating multiple subscales, including parental stress. Scores were obtained at multiple timepoints following BMP (baseline, 2 weeks, 3 months, 1 year).

RESULTS

Within 2 weeks, BMP participation significantly improved FI with increased frequency of daily daytime voluntary bowel movements (20%-70%, p < 0.001) and decreased daily daytime and nighttimeinvoluntary bowel movements (60%-20%, p < 0.001; 30%-10%, p < 0.05). Marked improvements in CINCY-FIS were observed across multiple QOL subscales, with the greatest in parental stress, and sustained through one year.

CONCLUSIONS

BMP results in significant and sustained improvement in FI and QOL for patients and caregivers.

Psychopathology and Parental Stress in 3-6-Year-Old Children with Incontinence

Objective: Incontinence and functional gastrointestinal disorders are common in young children and are associated with higher rates of psychological symptoms and mental disorders. This article focuses on the mutual association between incontinence and related toilet refusal syndrome, parental stress, and children's psychopathology especially in young children. Methods: Children's psychological symptoms, mental disorders, and parental stress levels were assessed in 38 parent-child dyads involving children with incontinence and 42 dyads of typically developing (TD) children. Results: Compared to TD children, patients had higher internalizing and externalizing CBCL scores and higher rates of clinically relevant externalizing problems. However, the rates of clinically relevant internalizing problems and mental disorders did not differ. The parents of children with incontinence reported significantly higher stress levels regarding child-related stress factors (PSI-CD) than did parents of TD children. However, there were no clinically relevant parental stress scores on a group level, which remained below the clinical range (T-value < 60). When simultaneously analyzed, children's (comorbid) mental disorders but not incontinence had a major impact on parental stress. Conclusions: Despite moderate stress levels, incontinence symptoms, urinary and fecal incontinence are highly prevalent in young children. However, stress among parents of young children was mainly elicited by any (comorbid) mental disorder.

Analysis of patients' and caregivers' psychosocial functioning in colorectal conditions: comparison of diagnosis, gender, and developmental functioning

PURPOSE

To evaluate the psychosocial functioning of caregivers and patients with anorectal malformation (ARM), Hirschsprung disease (HD), spinal conditions, and idiopathic constipation (IC) during the beginning of participation in bowel management program (BMP).

METHODS

In this retrospective study, Parent Stress Scale (PSS, parent-report) and Strengths and Difficulties Questionnaire (SDQ, parent-proxy; SDQ-S, self-report for 11 years and older) were used to evaluate parental stress levels and behavioral functioning, respectively. Descriptive and comparative statistical approaches were applied to summarize the data and to determine differences in scores between diagnoses, gender, and developmental functioning.

RESULTS

Two hundred patients and caregivers participated in BMP during the study period. PSS scores were significantly higher for caregivers of patients with IC than ARM. Statistical differences in SDQ were found for patients with IC versus those with ARM, male versus female patients, and patients with developmental delays versus those without delays. No significant differences were found in SDQ-S scores between these groups.

CONCLUSION

Key findings suggest that level of parental stress and behavioral concerns were significantly influenced by diagnoses, and partly by gender and presence of developmental delay. Thus, psychosocial support may need to be tailored based on these findings to provide optimum quality of care for patients and families.

Constipation

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

Bladder and Bowel Dysfunction in Korean Children with Down Syndrome and Parental Quality of Life

PURPOSE

Children with Down syndrome (DS) are more likely to experience bladder bowel dysfunction (BBD) than typically developing children, which could in turn have a serious effect on children with DS and on their parents and other family members. This study aimed to explore the prevalence of BBD in Korean children with DS and its effect on parental quality of life (QOL).

DESIGN AND METHODS

To assess BBD and parental QOL, we used self-administered questionnaires (Dysfunctional Voiding Symptom Score [DVSS], Rome IV criteria, and World Health Organization Quality of Life scale [WHOQOL-BREF]) for parents of children with DS. We collected data from 86 parents between September and October 2017 through an online community website.

RESULTS

DVSS was elevated in 26.7% of the children with DS. Specifically, 14% had daytime urinary incontinence, and 33.7% had functional constipation. Moreover, 18.6% of children had BBD according to the DVSS and Rome IV criteria. The sensitivity and specificity of DVSS to functional constipation was 55.17% and 87.72%, respectively. The BBD score and total parental QOL score were statistically correlated (r = 0.291, p = 0.007).

CONCLUSIONS

Although children with DS are a high-risk group for BBD, their BBD symptoms are often overlooked because of their intellectual disability. Consequently, this could negatively affect children's and family's health and QOL in the long term.

PRACTICE IMPLICATIONS

Health-care providers should reconsider a routine check-up of BBD in children with DS. If a child has BBD, health-care providers should consult a urologist to determine the appropriate diagnosis and intervention.

Using a Decision Tree to Guide Bowel Management in Spina Bifida

BACKGROUND

When born with spina bifida, there are numerous neurologic disorders that accompany this birth defect, including neurogenic bowel. Proactive, systematic, and rational approaches can lead to continence and a more functional lifestyle [1].

METHODS

Based on the evidence in the literature and expert experience, our approach to bowel management was developed as a step by step, individualized approach. This was converted to a decision tree for easy guidance of treatment decisions. The approach includes teaching patients and families normal bowel function, changes resulting from neurogenic bowel, common pitfalls in bowel management, and techniques that may improve outcomes. The decision tree, starting with dietary management, breaks into a two-fold attack, oral and rectal. Our data as part of the National Spina Bifida Patient Registry (NSBPR) database was compared to public data from the NSBPR.

RESULTS

Preliminary data from the NSBPR in 2011 reported bowel continence in 42.1% (n = 898) compared to our clinical outcomes of 72.1% (n = 43). As the variable of bowel continence was further defined and more patients were enrolled, the clinic results were comparable to the national reports.

CONCLUSION

Consistency among providers and caregivers is critical to evaluating the management of continence in spina bifida. While this protocol warrants further evaluation, it is offered as an evidence-based, step by step, approach to bowel management in spina bifida with good outcomes for patient management.

Initial development and validation of a fecal incontinence-specific quality of life measure

BACKGROUND/PURPOSE

Fecal incontinence is a prevalent pediatric condition with psychosocial impacts on both children and their caregivers. We sought to develop and validate the Cincinnati Fecal Incontinence Scale (CINCY-FIS) as a psychometrically valid measure to assess the quality of life and caregiver impacts of pediatric fecal incontinence.

METHODS

Items were generated through review of previous measures, expert consensus, and pilot testing with feedback from 8 families. Initial study measures were completed by 222 caregivers. Following item reduction, 18 items were subjected to confirmatory factor analysis. Convergent and criterion validity were assessed using correlation. Reliability was established using internal consistency statistics and test-retest reliability at baseline and 2-week follow-up.

RESULTS

A five factor first-order structure with two higher-order factors demonstrated acceptable fit to the data, was consistent with a priori hypotheses, and was more parsimonious than the alternative model. Convergent validity and criterion-related validity were established for all of the CINCY-FIS scales. Reliability was high and consistent across both measurement occasions.

CONCLUSIONS

The CINCY-FIS is a reliable and valid assessment of pediatric fecal incontinence-specific quality of life and parenting stress. The score is highly sensitive to patient changes making it suitable for both clinical and research purposes.

TYPE OF STUDY

Prospective observational.

LEVEL OF EVIDENCE

Study of Diagnostic Test Level II.

Long-term bowel function, quality of life and sexual function in patients with anorectal malformations treated during the PSARP era

Anorectal malformations are an important group of congenital anomalies that vary widely in their anatomical characteristics and complexity. Understanding the long-term functional outcomes after modern treatments, and how these compare to the general population, are essential for ensuring that patients receive optimal, evidence-based care. With increasing appreciation of the wider impact of the illness on patients and their families, minimizing social disability from fecal incontinence and enabling normal social integration from the outset are key management concerns. This review summarizes the current knowledge on the functional outcomes by type of malformation, reflecting on the literature, and our institutional experience over a follow-up period of nearly 30 years.

Pediatric Patient and Caregiver Preferences in the Development of a Mobile Health Application for Management of Surgical Colorectal Conditions

Patient-centered frameworks are an effective way to engage patients in treatment plans, strengthen adherence behaviors, and improve disease outcomes. These frameworks can also be applied in the design of mobile technology disease management applications. However, the utilization of these frameworks is rare and frequently overlooked in existing colorectal mobile health (mHealth) applications. The purpose of this study was to utilize a patient-centered framework to facilitate the development of a valid, appropriate, and feasible mHealth tool for pediatric patients and their caregivers. To inform application design and production, in-depth interviews were conducted with pediatric patients and their caregivers to capture management experiences, application preferences, and barriers and facilitators to application use. Patient ages ranged from 3 to 16. Six caregivers and 2 adolescent patients participated in the interviews. Patients and caregivers reported various management styles and desired an application that is not only user-friendly and customizable, but also able to facilitate communication and information sharing with other patients, caregivers, and providers. Older patients also wanted the application to give them more independence in managing their disease. Employing patient-centered frameworks is context-specific, but holds much promise at the intersection of mobile technology and healthcare. By incorporating pediatric patient experiences and viewpoints, we identified important components for inclusion in a mHealth surgical colorectal disease management application. Patients and caregivers wanted a mHealth application that was unique to their needs and easy to use. They suggested that the application include treatment tracking, note taking, and provider communication features.

Gastrointestinal symptoms predictors of health-related quality of life in pediatric patients with functional gastrointestinal disorders

OBJECTIVES

To investigate the patient-reported multidimensional gastrointestinal symptoms predictors of generic health-related quality of life (HRQOL) in pediatric patients with functional gastrointestinal disorders (FGIDs).

METHODS

The Pediatric Quality of Life Inventory™ (PedsQL™) Gastrointestinal Symptoms Scales and PedsQL™ 4.0 Generic Core Scales were completed in a 9-site study by 259 pediatric patients with functional constipation, functional abdominal pain (FAP), or irritable bowel syndrome (IBS). Gastrointestinal Symptoms Scales measuring stomach pain, stomach discomfort when eating, food and drink limits, trouble swallowing, heartburn and reflux, nausea and vomiting, gas and bloating, constipation, blood in poop, and diarrhea were identified as clinically important symptom differentiators from healthy controls based on prior findings, and subsequently tested for bivariate and multivariate linear associations with overall HRQOL.

RESULTS

Gastrointestinal symptoms were differentially associated with decreased HRQOL in bivariate analyses for the three FGIDs. In predictive models utilizing hierarchical multiple regression analyses controlling for age, gender, and race/ethnicity, gastrointestinal symptoms differentially accounted for an additional 47, 40, and 60 % of the variance in patient-reported HRQOL for functional constipation, FAP, and IBS, respectively, reflecting large effect sizes. Significant individual gastrointestinal symptoms predictors were identified after controlling for the other gastrointestinal symptoms in the FGID-specific predictive models.

CONCLUSIONS

Gastrointestinal symptoms represent potentially modifiable predictors of generic HRQOL in pediatric patients with FGIDs. Identifying the condition-specific gastrointestinal symptoms that are the most important predictors from the patient perspective facilitates a patient-centered approach to targeted interventions designed to ameliorate impaired overall HRQOL.