Bowel habits and toilet training in a diverse population of children

How do we define normal bowel frequency from newborn to teens?: A Bayesian meta-analysis

OBJECTIVES

Defecation disorders are a common pediatric problem and bowel frequency is crucial in identifying them. The aim of this analysis is to define normal bowel frequencies in healthy children ranging from newborns to adolescents.

METHODS

A literature search was conducted using MEDLINE, SCOPUS, EMBASE, Cochrane Library, and Web of Science from their inception to February 2024, aiming to identify studies reporting bowel habits of healthy children (0-18 years). A Bayesian distribution modeling approach was adopted to pool the mean frequency of bowel opening using inverse-variance weighing. A subgroup analysis and a meta-regression were performed with Bayesian generalized additive mixed distributional models. The methodological quality of the articles was evaluated using the Newcastle-Ottawa Scale modified for cross-sectional studies.

RESULTS

Seventeen studies were included in the analysis, including 22,698 children aged from 0 to 18 years. The subgroup meta-analysis showed mean bowel frequencies for newborns, 1-6 months, 6-12 months, 1-2 years, 2-5 years, and over 5 years are 3.24 (95% credible interval [CrI]: 2.83-3.63), 1.99 (95% CrI: 1.77-2.19), 1.66 (95% CrI: 1.45-1.88), 1.53 (95% CrI: 1.37-1.7), 1.15 (95% CrI: 0.99-1.31), and 1.02 (95% CrI 0.88-1.18), respectively. Between studies, heterogeneity demonstrated a near-normal distribution with a mean of 0.16 and a 95% CrI of 0.04-0.28. The variance of the distribution of mean bowel frequency reduced with age.

DISCUSSION

In this Bayesian meta-analysis, we found that younger children have a higher bowel frequency. The reported bowel frequencies for each age group could serve as normal values in clinical practice to differentiate health and disease.

Improving Participation in Toileting Routines in a Child with Functional Constipation: A Case Study Using the Integrated Sensory Toileting® Approach

This article presents a case report of a three and half year-old boy with functional constipation and sensory hyperreactivity. The Integrated Sensory Toileting® approach was used to guide clinical reasoning and identify the sensory underlying factors that were impacting the child's ability to acquire age-appropriate toileting habits and gastrointestinal health. The six months of treatment in occupational therapy and gastroenterology, as well as six months of follow-up are described. Improvements in sensory reactivity are documented using the Sensory Processing Measure-2 and the Toileting Habit Profile Questionnaire-Revised and corroborate with improvements in the child's ability to participate in toileting routines and improved gastrointestinal health.

Association between dietary copper intake and constipation in US adults

Dietary micronutrients are integral to the development and progression of constipation; however, the specific relationship between dietary copper intake and constipation has not been thoroughly investigated. This study aims to examine the correlation between dietary copper intake and constipation among U.S. adults, thereby offering novel insights and recommendations for the clinical management and prevention of constipation. Bowel health data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2010 were analyzed. Subjects' dietary information was collected through questionnaire records. Multivariate logistic regression analysis, subgroup analysis, and curve fitting analysis were used to assess the correlation between dietary copper intake and chronic constipation. After adjusting for all possible confounders, each unit increase in dietary copper intake (converted to natural logarithms) was associated with a 20% reduction in the prevalence of constipation (OR = 0.80; 95% CI 0.65-0.98; P = 0.037). The interaction P-values for all subgroups were greater than 0.05, indicating that the findings were stable and consistent across subgroups. The present study showed a significant negative association between dietary copper intake and chronic constipation in adults. This finding raises clinical and healthcare professionals' awareness of the impact of dietary trace elements on intestinal health and has important implications for the development of personalized meal plans and rational supplementation of trace copper in patients with constipation.

Faecal incontinence: Retentive, non-retentive and when to suspect organic pathology

BACKGROUND

Faecal incontinence is a highly prevalent and very distressing condition that occurs throughout the entire paediatric age.

AIM

To summarise advances in the understanding of the epidemiology, pathophysiology, evaluation and treatment of children with faecal incontinence due to either disorders of gut-brain interaction or organic diseases.

METHODS

Literature review on prevalence, impact, diagnosis and treatment options for children with faecal incontinence, interspersed with observations from the author's lifelong career focused on evaluation of children with motility disorders.

RESULTS

Faecal incontinence in children is most commonly due to unrecognised or insufficiently treated functional constipation with overflow incontinence. Non-retentive faecal incontinence (NRFI) is probably more common than previously thought and is particularly challenging to treat. Organic diseases such as anorectal malformations (ARMs), Hirschsprung disease and spinal defects are often associated with faecal incontinence; in these conditions, faecal incontinence has a profound impact on quality of life. Recognition of the different pathophysiologic mechanisms causing the incontinence is essential for a successful treatment plan. A thorough physical examination and history is all that is needed in the diagnosis of the causes of faecal incontinence related to disorders of gut-brain interaction. Colonic transit studies or x-rays may help to differentiate retentive from NRFI. Manometry tests are helpful in determining the mechanisms underlying the incontinence in children operated on for ARMs or Hirschsprung diseases. Multiple behavioural, medical and surgical interventions are available to lessen the severity of faecal incontinence and its impact on the daily life of affected individuals.

CONCLUSIONS

Recent advances offer hope for children with faecal incontinence.

Constipation: A Pristine Universal Pediatric Health Delinquent

Constipation suffered by children is a global public health problem. Functional constipation (FC) brings about deteriorating effects in the children's lives who suffer from it. The risk factors for the development of constipation include the consumption of a diet low in fiber and high in calories (such as the consumption of fast food), a sedentary lifestyle with a lack of exercise, a family history of constipation, and emotional and psychological stress endured by children in their families. It is one of the most common causes of stomachaches in children. FC may lead to fecal incontinence (FI), anal fissures, recurrent urinary tract infections (RUTI), and enuresis in children. Severe constipation may result in stool becoming rock-hard and inflexible in the rectum, which is clinically identified as fecal impaction. It is imperative to perform clinical evaluation and treatment, including pharmacological (the use of stimulant and osmotic laxatives) and non-pharmacological (education, changes in diet, intervention to promote positive behavior and address any emotional issues, toilet training, and physiotherapy for the pelvic floor) interventions. In the case of refractory patients, neuromodulation, the irrigation of the anal canal, and surgical management may be needed. It is essential to lead a healthy, stress-free lifestyle with plenty of exercise and a balanced diet rich in fiber (such as fruits and vegetables) so children can have regular bowel habits and thrive.

What are Normal Defecation Patterns in Healthy Children up to Four Years of Age? A Systematic Review and Meta-Analysis

OBJECTIVE

To summarize available data on defecation frequency and stool consistency of healthy children up to age 4 in order to estimate normal references values.

STUDY DESIGN

Systematic review including cross-sectional, observational, and interventional studies published in English, that reported on defecation frequency and/or stool consistency in healthy children 0-4 years old.

RESULTS

Seventy-five studies were included with 16 393 children and 40 033 measurements of defecation frequency and/or stool consistency. Based on visual inspection of defecation frequency data, a differentiation was made between two age categories: young infants (0-14 weeks old) and young children (15 weeks-4 years old). Young infants had a mean defecation frequency of 21.8 per week (95 % CI, 3.9-35.2) compared with 10.9 (CI, 5.7-16.7) in young children (P < .001). Among young infants, human milk-fed (HMF) infants had the highest mean defecation frequency per week (23.2 [CI, 8.8-38.1]), followed by formula-fed (FF) infants (13.7 [CI 5.4-23.9]), and mixed-fed (MF) infants (20.7 [CI, 7.0-30.2]). Hard stools were infrequently reported in young infants (1.5%) compared with young children (10.5%), and a reduction in the frequency of soft/watery stools was observed with higher age (27.0% in young infants compared with 6.2% in young children). HMF young infants had softer stools compared with FF young infants.

CONCLUSIONS

Young infants (0-14 weeks old) have softer and more frequent stools compared with young children (15 weeks-4 years old).

The Prevalence of Bowel and Bladder Function During Early Childhood: A Population-Based Study

OBJECTIVES

Our primary aim was to determine bowel and bladder function in children aged 1 month to 7 years in the general Dutch population. Second, we aimed to identify demographic factors associated with the presence of bowel and bladder dysfunction, and their coexistence.

METHODS

For this cross-sectional, population-based study, parents/caregivers of children aged from 1 month to 7 years were asked to complete the Early Pediatric Groningen Defecation and Fecal Continence questionnaire. Different parameters of bowel and bladder function were assessed using validated scoring systems such as the Rome IV criteria.

RESULTS

The mean age of the study population (N = 791) was 3.9 ± 2.2 years. The mean age at which parents/caregivers considered their child fully toilet-trained was 5.1 ± 1.5 years. Prevalence of fecal incontinence among toilet-trained children was 12%. Overall prevalence of constipation was 14%, with a constant probability and severity at all ages. We found significant associations between fecal incontinence and constipation [odds ratio (OR) = 3.88, 95% CI: 2.06-7.30], fecal incontinence and urinary incontinence (OR = 5.26, 95% CI: 2.78-9.98), and constipation and urinary incontinence (OR = 2.06, 95% CI: 1.24-3.42).

CONCLUSIONS

Even though most children are fully toilet-trained at 5 years, fecal incontinence is common. Constipation appears to be common in infants, toddlers, and older children. Fecal incontinence and constipation frequently coexist and are often accompanied by urinary incontinence. Increased awareness of bowel and bladder dysfunction in infants, toddlers, and young children is required to prevent these problems from continuing at older ages.

Myths and misconceptions about childhood constipation

Many widely held beliefs and assumptions concerning childhood constipation continue to interfere with rational management of childhood constipation. Although many still believe that constipation is not a common disease, about 9.5% of the world's children suffer from chronic constipation. Most of these children live in non-Western countries. There are major misconceptions about the etiology of constipation as a significant proportion of clinicians still believe that constipation is caused by some form an organic pathology, whereas in reality, the majority have functional constipation. Contrary to a commonly held belief that children outgrow constipation without long-term problems, there is evidence that constipation leads to significant bowel and psychological consequences and has a major impact on the quality of life which detrimentally affects future health and education. Finally, ineffective management strategies such as increasing fiber and water in the diet, and short duration of treatment owing to the fear that long-term laxative treatment leads to colonic dysfunction, interfere with effective therapeutic strategies.   Conclusions: It is apparent that myths and misconception often lead to wrong assumptions regarding the distribution of the disease, its etiology, pathophysiology, and management leading to ordering incorrect investigations and ineffective therapeutic strategies while spending large sums of public funds unnecessarily. Poorly treated constipation leads to deleterious psychological consequences predisposing children to develop significant psychological damage and bowel dysfunctions. This review aims to challenge these myths about various elements of constipation by exploring the existing literature and encouraging clinicians to have a fresh look at old concepts that could interfere with the well-being of children with constipation. What is Known: • Childhood constipation is a growing problem in the world leading to significant suffering and high healthcare expenditure • Myths and misconceptions lead to poor management strategies causing psychological and bowel damage What is New: • Organic, systemic, and bowel disorders leading to constipation are uncommon, and in the majority, it arises due to deliberate fecal withholding and most investigations ordered by clinicians are not very helpful in the management • Most non-pharmacological interventions are not effective in the day-to-day management of childhood constipation. The use of laxatives is considered to be the first-line management strategy.

Blood lead level evaluation in children presenting with chronic constipation in Tehran-Iran: a cross-sectional study

Constipation is a common reason for children seeking medical care worldwide. Abdominal complaints and constipation are also common in lead-poisoned children. This study evaluates the prevalence of abnormal blood lead levels (BLL) among pediatric and adolescent patients and examines the association of constipation with elevated BLL. This was a prospective data collection of patients younger than 18 years old with the chief complaint of constipation seen in the Mofid Children's Hospital gastroenterology clinic and Loghman Hakim pediatric and pediatric gastroenterology clinics were eligible for enrollment in this study. Constipation was defined as infrequent or difficult defecation according to ROME IV criteria lasting 2 months or more. BLL was measured with a fresh capillary whole blood capillary sample. The LeadCare II device assays BLL using an electrochemical technique (anodic stripping voltammetry). A total of 237 patients were enrolled in the study. 122 (51.48%) were female and 115 (48.52%) were male. About one fifth of patients (49; 20.67%) had BLL ≥ 5 µg/dL. The mean BLL in the sample was 3.51 µg/dL. Abdominal pain was the most common symptom accompanying constipation (134; 56%). Multivariate analysis found endoscopic evaluation (P values 0.024, OR 3.646, 95% CI 1.189-11.178), muscle pain (P values 0.020, OR 24.74, 95% CI 1.67-365.83), and maternal education (P values 0.02, OR 4.45, 95% CI 1.27-15.57) with significant differences in groups of patients with normal and elevated BLL. Elevated BLL necessitates an assessment and plans to reduce childhood lead exposure. BLL screening in childhood constipation with refractory chronic abdominal pain may also eradicate the need for invasive procedures like endoscopic evaluation.

Subtyping intractable functional constipation in children using clinical and laboratory data in a classification model

Background

Children with intractable functional constipation (IFC) who are refractory to traditional pharmacological intervention develop severe symptoms that can persist even in adulthood, resulting in a substantial deterioration in their quality of life. In order to better manage IFC patients, efficient subtyping of IFC into its three subtypes, normal transit constipation (NTC), outlet obstruction constipation (OOC), and slow transit constipation (STC), at early stages is crucial. With advancements in technology, machine learning can classify IFC early through the use of validated questionnaires and the different serum concentrations of gastrointestinal motility-related hormones.

Method

A hundred and one children with IFC and 50 controls were enrolled in this study. Three supervised machine-learning methods, support vector machine, random forest, and light gradient boosting machine (LGBM), were used to classify children with IFC into the three subtypes based on their symptom severity, self-efficacy, and quality of life which were quantified using certified questionnaires and their serum concentrations of the gastrointestinal hormones evaluated with enzyme-linked immunosorbent assay. The accuracy of machine learning subtyping was evaluated with respect to radiopaque markers.

Results

Of 101 IFC patients, 37 had NTC, 49 had OOC, and 15 had STC. The variables significant for IFC subtype classification, according to SelectKBest, were stool frequency, the satisfaction domain of the Patient Assessment of Constipation Quality of Life questionnaire (PAC-QOL), the emotional self-efficacy for Functional Constipation questionnaire (SEFCQ), motilin serum concentration, and vasoactive intestinal peptide serum concentration. Among the three models, the LGBM model demonstrated an accuracy of 83.8%, a precision of 84.5%, a recall of 83.6%, a f1-score of 83.4%, and an area under the receiver operating characteristic curve (AUROC) of 0.89 in discriminating IFC subtypes.

Conclusion

Using clinical characteristics measured by certified questionnaires and serum concentrations of the gastrointestinal hormones, machine learning can efficiently classify pediatric IFC into its three subtypes. Of the three models tested, the LGBM model is the most accurate model for the classification of IFC, with an accuracy of 83.8%, demonstrating that machine learning is an efficient tool for the management of IFC in children.

Management Approach of Pediatric Constipation

Constipation is a common challenge in pediatrics. Abdominal radiographs are frequently taken in the pediatric emergency department for diagnosis despite their inadequate reliability to detect the pathology or the degree of constipation. Misdiagnosis of constipation may cause multiple vague physician visits, deployment of emergency medical services, use of radiation, unnecessary laboratory tests, and even surgical procedures. The primary evidence-based suggestions are based on published guidelines that include management of constipation in children divided into three stages of therapy: (1) disimpaction, (2) maintenance therapy, and (3) behavior modification, and special care should be given to neonates and to children with pre-existing medical problems.

Personal and familial factors associated with toilet training

Purpose:

Toilet training (TT) is an important marker in a child's physical and psychosocial development. The present study aimed to evaluate aspects associated to delayed TT.

Material and Methods:

We interviewed 372 parents of children who had completed TT up to 48 months before the interview. The questionnaires were applied at school exits when parents went to pick their children up and at public parks. Questions included demographics, aspects related to TT, dysfunction voiding symptom score and evaluation of constipation.

Results:

The interviews were performed at a mean of 15.3±10.4 (0 to 47) months after the end of TT. Girls accounted for 53% of the sample. The mean age at finishing TT was 31.6±9.3 months and similar in both genders (p=0.77). TT occurred before school entry in 45.7% of the children and medical advice for TT was sought only by 4.8% of the parents. No association was observed of age at completing TT and presence of lower urinary tract symptoms (LUTS) (p=0.57) and/or constipation (p=0.98). In the univariate analysis, prematurity (OR=2.7 [95% CI 2.3-3.1], p <0.0001) and mothers who work outside their household (OR=1.8 [95% CI 1.4-2.3], p <0.0001) were associated to delayed TT.

Conclusion:

Children completed TT at a mean of 2 years and 7 months of age. The age of completing TT was not related to LUTS and/or constipation. Premature children and those whose mothers work outside the home finish TT later.

The treatment of functional constipation significantly increased quality of life in children aged 4-17 years

BACKGROUND/AIMS

In this study, it was aimed to investigate the effect of 6-week treatment on quality of life in 4-17-year-old children with functional constipation.

MATERIALS AND METHODS

The children 4-17 years old diagnosed as functional constipation according to Rome IV criteria, between June and December 2018 were included in the study. KINDL scales were applied to patients and their parents before starting treatment for 6 weeks and after the end of the treatment.

RESULTS

The study was completed with 42 patients. The majority of the patients (54,8%) were female cases and the general part of them (45,2%) were between 4-6 years old. The age at onset of constipation was found to be 5,19±3,658 years. Total KINDL scores of both children and parents were lower before the treatment. Significant improvement was observed in the symptoms of constipation after 6 weeks of treatment. There was a statistically significant (p<0,05) increase in children's subgroup and total KINDL scores after treatment. Parental subgroup and total KINDL scores also showed a statistically significant (p<0,05) increase after treatment. The treatment of functional constipation was found to be highly effective with the eyes of both children and parents in improving the quality of life. (Eta value, η2. >0,25) Conclusion: A significant increase was observed in all areas of life quality and total score in children with functional constipation after a regular treatment. We think that the treatment of children with functional constipation will significantly improve their quality of life.

Development Signs in Healthy Toddlers in Different Stages of Toilet Training: Can They Help Define Readiness and Probability of Success?

There is much uncertainty about when to start toilet training. Age cannot be a strict stand-alone criterion, as every child has its own pace of development. We observed toilet training (TT) related development signs (DS) in healthy toddlers and determined which can help to define the proper time to start TT and to predict success. The study group consisted of 269 healthy children, in different stages of TT: not started, during, and after completion. Sitting stable, picking up small objects, and spontaneously putting objects in containers were present in all children and had no predictive value. All other DS were significantly more present in those who had started and became more prevalent during completion of TT. Age had a significant association with 13/15 DS. Understanding and following instructions, and having a broader vocabulary were significantly more present when TT had been started. Dry during midday nap reached no significance.

Parent-reported toilet training practices and the role of pediatric primary care providers

BACKGROUND

Toilet training is a universal developmental milestone and a stressful period for families with few empirically based guidelines.

PURPOSE

This study identified currently used methods of toilet training and sources used for parental guidance.

METHODOLOGICAL ORIENTATION

A descriptive, qualitative design was used.

SAMPLE

Participants included 479 parents of children aged 2-6 years.

CONCLUSIONS

Parents described diverse toilet training strategies, most of which were behavioral and inconsistent with recommendations of the American Academy of Pediatrics. Most children were toilet trained between 24 and 36 months within 5 weeks. Forty-one percent of parents relied on the Internet for toilet training information, and fewer than half reported involvement of their child's primary care provider.

IMPLICATIONS FOR PRACTICE

Parents in the community would likely benefit from additional education and anticipatory guidance from primary care providers about normative toilet training. Further work is needed to understand the effectiveness of different methods of training and improve adherence to AAP recommendations.

Management of functional constipation in children and adults

Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.

Should Children With Constipation Undergo Blood Lead Level Screening?

This study aimed to compare the prevalence of elevated blood lead level in children with constipation to the population prevalence. We reviewed the charts of 441 children who were screened with a blood lead level on presenting to the gastroenterology clinic at UPMC Children's Hospital of Pittsburgh for evaluation of constipation. The prevalence of blood lead level greater than 5 µg/dL was 1.36% (6/441; 95% confidence interval = 1.23% to 1.49%), which is significantly lower than the 4.01% prevalence in the population reported by the Center for Disease Control and Prevention. No patients had a blood lead level greater than 10 µg/dL. Age under 5 years old showed an increased odds of lead level greater than 5 µg/dL (odds ratio = 7.5; 95% confidence interval = 1.2 to 47.3, P < .05). We concluded that children seen in the gastroenterology clinic for constipation are unlikely to have an elevated blood lead level on routine screening.

Clinical Characteristics of Children Needing Inpatient Treatment after Failed Outpatient Treatment for Fecal Impaction

PURPOSE

Treatment of chronic constipation and fecal impaction is usually outpatient and requires high or frequent doses of laxatives. However, there are children who fail outpatient treatments, sometimes repeatedly, and are ultimately hospitalized. We sought to compare the characteristics of the children who failed outpatient treatment and needed inpatient treatment vs those who achieved success with outpatient treatment, in an effort to identify attributes that might be associated with a higher likelihood towards hospitalization.

METHODS

In this retrospective cohort study, we reviewed the medical records of all patients aged 0 to 21 years, with chronic functional constipation and fecal impaction seen in the pediatric gastroenterology clinic over a period of 2 years.

RESULTS

Total of 188 patients met inclusion criteria. While 69.2% were successfully treated outpatient (referred to as the outpatient group), 30.9% failed outpatient treatment and were hospitalized (referred to as the inpatient group). The characteristics of the inpatient group including age at onset of 3.6±3.6 years (p=0.02); black ethnicity (odds ratio [OR] 4.31, 95% confidence interval [95% CI] 2.04-9.09); p<0.001); prematurity (OR 2.39, 95% CI 1.09-5.26; p=0.02]; developmental delay (OR 2.20, 95% CI 1.12-4.33; p=0.02); overflow incontinence (OR 2.26, 95% CI 1.12-4.53, p=0.02); picky eating habits (OR 2.02, 95% CI 1.00-4.08; p=0.04); number of ROME III criteria met: median 4, interquartile range 3-5 (p=0.04) and 13±13.7 constipation related prior encounters (p=0.001), were significantly different from the outpatient group.

CONCLUSION

Identification of these characteristics may be helpful in anticipating challenges and potential barriers to effective outpatient treatment.

Gastrointestinal Symptoms in Children and Adolescents With Neurofibromatosis Type 1

OBJECTIVES

Neurofibromatosis type 1 (NF1) is a complex genetic disorder characterized by symptoms of the skin and nervous system. A previous study indicated that constipation is common in children with NF1. The aim of the present study was to investigate the phenotype and prevalence of gastrointestinal (GI) symptoms in a population of 4 to 17-year-olds with NF1 compared with their unaffected siblings.

METHODS

GI symptoms were assessed with a web-based, parent or self-administered, validated, Rome III diagnostic questionnaire. Participants were recruited from 1 of 2 Danish National Centers of Expertise for NF1. Logistic regression was used to estimate the prevalence of functional dyspepsia, irritable bowel syndrome (IBS), and constipation in each group and the groups were compared using odds ratio (OR).

RESULTS

We compared 102 NF1 patients (median age 10.3 years) and 46 of their unaffected siblings (median age 10 years). The overall likelihood of having GI symptoms usually attributed to either functional dyspepsia, IBS, or constipation was 30.4% in patients versus 10.9% in siblings, OR 3.58 (95% confidence interval 1.30 to 9.79). The prevalence of constipation was 22.5% in patients and 4.3% in siblings, OR 6.41 (95% confidence interval 1.45 to 28.24). The use of laxatives was 16% (n = 16) in patients and 2% (n = 1) in siblings.

CONCLUSIONS

Overall, GI symptoms attributed to functional dyspepsia, IBS or constipation are more common in 4 to 17-year-olds with NF1 when compared with their unaffected siblings. The high prevalence indicates that GI dysfunction in NF1 is not functional but may be part of the underlying NF1 disorder.

Motility disorders in infants

Gastrointestinal motility disorders are common in the pediatric population and may affect the entire gastrointestinal tract and can vary from mild to severe conditions. They may clinically manifest as gastro-esophageal reflux symptoms, feeding difficulties and failure to thrive, constipation and diarrhea amongst others. This review first highlights the embryologic development of the gastrointestinal tract, after which the prenatal and neonatal development of gastrointestinal motility is discussed. Normal motility patterns as seen in (preterm) infants are described as a background for the discussion of the most common congenital and acquired motility disorders in infancy. This review specifically focuses on the role of preterm birth on the development of these disorders.

Prevalence and risk factors for functional constipation in adolescent Nigerians

OBJECTIVES

To determine the prevalence and risk factors for functional constipation (FC) in adolescent Nigerians.

METHOD

A cross-sectional study was conducted in rural and urban areas of two states in the southern part of Nigeria. Adolescents aged 10-18 years were recruited from 11 secondary schools, using a stratified random sampling technique. A validated self-administered questionnaire on Rome III criteria for diagnosing FC and its predisposing factors was filled by each participant in a classroom setting.

RESULTS

A total of 874 questionnaires was distributed and 818 (93%) properly filled questionnaires were included in the analysis. The mean age of the participants was 14.6±2.0 years with 409 (50%) being boys. FC was present in 223 (27%) with no difference in prevalence between sexes. Prevalence of FC was 29% in urban areas and 26% in rural areas (p>0.05). The condition was significantly associated with low social class (p=0.013). Exposure to stressful life events at home and school did not predispose the participants to develop FC.

CONCLUSIONS

FC is a significant health problem among adolescent Nigerians. The condition is associated with low social class.

Examining Sensory Overresponsiveness in Preschool Children With Retentive Fecal Incontinence

The development of bowel control is an important activity of daily living in early childhood, and challenges in this area can limit participation in key occupations. Retentive fecal incontinence (RFI) is a common disorder in children. Up to 50% of children do not respond adequately to initial medical intervention, and behaviors around toileting, some related to sensory overresponsivity (SOR), may be partly responsible. Therefore, this study investigated the relationship between RFI and SOR and also examined the discriminative validity of the Toileting Habit Profile Questionnaire (THPQ). Per parent report, children with RFI (n = 16) showed significantly more behaviors related to SOR compared with typically developing children (n = 27). In addition, results indicated that the THPQ effectively discriminates between children with RFI and typically developing children. Results are discussed regarding RFI and SOR, the impact of RFI on childhood occupational engagement, and the role of occupational therapy with this population.

Childhood constipation as an emerging public health problem

Functional constipation (FC) is a significant health problem in children and contrary to common belief, has serious ramifications on the lives of children and their families. It is defined by the Rome criteria which encourage the use of multiple clinical features for diagnosis. FC in children has a high prevalence (0.7%-29%) worldwide, both in developed and developing countries. Biopsychosocial risk factors such as psychological stress, poor dietary habits, obesity and child maltreatment are commonly identified predisposing factors for FC. FC poses a significant healthcare burden on the already overstretched health budgets of many countries in terms of out-patient care, in-patient care, expenditure for investigations and prescriptions. Complications are common and range from minor psychological disturbances, to lower health-related quality of life. FC in children also has a significant impact on families. Many paediatric clinical trials have poor methodological quality, and drugs proved to be useful in adults, are not effective in relieving symptoms in children. A significant proportion of inadequately treated children have similar symptoms as adults. These factors show that constipation is an increasing public health problem across the world with a significant medical, social and economic impact. This article highlights the potential public health impact of FC and the possibility of overcoming this problem by concentrating on modifiable risk factors rather than expending resources on high cost investigations and therapeutic modalities.

Fifteen-minute consultation: problems in the healthy child-toilet training

Toilet training is a process that all healthy children go through. It is one of the developmental milestones for which parents most often seek medical help. Despite this, many paediatricians feel unconfident managing children presenting with a toilet training problem. We address some common questions arising when assessing and managing such a child, including identifying rare but important diagnoses not to miss.

Bowel Disorders

Functional bowel disorders are highly prevalent disorders found worldwide. These disorders have the potential to affect all members of society, regardless of age, gender, race, creed, color or socioeconomic status. Improving our understanding of functional bowel disorders (FBD) is critical as they impose a negative economic impact to the global health care system in addition to reducing quality of life. Research in the basic and clinical sciences during the past decade has produced new information on the epidemiology, etiology, pathophysiology, diagnosis and treatment of FBDs. These important findings created a need to revise the Rome III criteria for FBDs, last published in 2006. This manuscript classifies the FBDs into five distinct categories: irritable bowel syndrome (IBS); functional constipation (FC); functional diarrhea (FDr); functional abdominal bloating/distention (FAB/D); and unspecified FBD (U-FBD). Also included in this article is a new sixth category, opioid induced constipation (OIC) which is distinct from the functional bowel disorders (FBDs). Each disorder will first be defined, followed by sections on epidemiology, rationale for changes from prior criteria, clinical evaluation, physiologic features, psychosocial features and treatment. It is the hope of this committee that this new information will assist both clinicians and researchers in the decade to come.

Effects of cereal fiber on bowel function: A systematic review of intervention trials

AIM

To comprehensively review and quantitatively summarize results from intervention studies that examined the effects of intact cereal dietary fiber on parameters of bowel function.

METHODS

A systematic literature search was conducted using PubMed and EMBASE. Supplementary literature searches included screening reference lists from relevant studies and reviews. Eligible outcomes were stool wet and dry weight, percentage water in stools, stool frequency and consistency, and total transit time. Weighted regression analyses generated mean change (± SD) in these measures per g/d of dietary fiber.

RESULTS

Sixty-five intervention studies among generally healthy populations were identified. A quantitative examination of the effects of non-wheat sources of intact cereal dietary fibers was not possible due to an insufficient number of studies. Weighted regression analyses demonstrated that each extra g/d of wheat fiber increased total stool weight by 3.7 ± 0.09 g/d (P < 0.0001; 95%CI: 3.50-3.84), dry stool weight by 0.75 ± 0.03 g/d (P < 0.0001; 95%CI: 0.69-0.82), and stool frequency by 0.004 ± 0.002 times/d (P = 0.0346; 95%CI: 0.0003-0.0078). Transit time decreased by 0.78 ± 0.13 h per additional g/d (P < 0.0001; 95%CI: 0.53-1.04) of wheat fiber among those with an initial transit time greater than 48 h.

CONCLUSION

Wheat dietary fiber, and predominately wheat bran dietary fiber, improves measures of bowel function.

Normal Bowel Pattern in Children and Dietary and Other Precipitating Factors in Functional Constipation

AIM

To study the bowel pattern of children in general population and children with habit constipation with respect to food habits and regarding psychosocial aspect of toileting.

MATERIALS AND METHODS

A prospective descriptive study was done in the Institute of child health and hospital for children, Chennai, with two groups, Functional constipation group and Normal bowel pattern group. The functional group included the children with the age group of 2-12 years, of either sex who fulfilled the ROME III criteria for constipation. Normal bowel pattern group had school children of age group 6-12 years of age and 2-5-year-old children attending OPD for minor ailments. The demographic profile, socioeconomic status, complaints, psychosocial aspects affecting bowel pattern and diet chart were collected and recorded from the parents in proforma. Stool frequency and type of stool passed were recorded for a week, with Bristol stool chart.

RESULTS

A total of 523 and 131 children were analysed for normal bowel pattern and functional constipation respectively. Data analysis done using SPSS version 15. The prevalence of functional constipation was noted in 13.5% with female preponderance and in the age group of 2-4 years.

CONCLUSION

Constipation continues to be a problem, mostly under recognised in older population. Psychosocial factors had a significant effect on functional constipation. Skipping breakfast, early toilet training, low intake of vegetables and fruits were other factors of significance leading to constipation.

Association Between Dysfunctional Elimination Syndrome and Sensory Processing Disorder

OBJECTIVE. We explored whether sensory processing disorder (SPD) is related to dysfunctional elimination syndrome (DES).

METHOD. We used the Vancouver Nonneurogenic Lower Urinary Tract Dysfunction/Dysfunctional Elimination Syndrome Questionnaire and the Short Sensory Profile with participants who sought treatment of DES (n = 19) and healthy control participants (n = 55).

RESULTS. Significantly more children with DES (53%) had SPD than was reported for the general population (p &lt; .001; Ahn, Miller, Milberger, & McIntosh, 2004). Control participants did not have a greater rate of SPD (p = .333). We found a significant association between the occurrence of DES and SPD, χ2(1) = 20.869, p &lt; .001, and a significant correlation between test scores (Spearman’s ρ = −.493, Rs2 = .243, p &lt; .001).

CONCLUSION. Many children with DES may also have SPD, suggesting that a child’s sensory processing pattern would be an important aspect that could influence the plan of care.

Characteristics of intestinal habits in children younger than 4 years: detecting constipation

OBJECTIVES

The aim of the present study was to describe the prevalence of childhood constipation, stool characteristics, and their relationship with toilet training and age of introduction of cow's milk.

METHODS

A total of 4231 children born in 2004, from a birth cohort study, were assessed at 12, 24, and 48 months of age, when their mothers provided information on sociodemographic characteristics, bowel habits, toilet training, and age of introduction of cow's milk and other foods.

RESULTS

The prevalence of constipation was 27.3% and 31.0% at 24 and 48 months of age, respectively. Among girls, at 48 months of age, it was 34.4% versus 27.4% in boys (P<0.001). The most common features of constipation were scybalous stools (47.7% and 41.0% at 24 and 48 months, respectively), evacuation difficulty (24.3% and 23.1%), and hard stools (17.8% and 34.1%). Toilet training starting before 24 months was associated with constipation at 24 months and its persistence up to 48 months. Among children who did not receive cow's milk in their first year of life, 22% had constipation at 24 months, 22.6% at 48 months, and 8.3% at 24 and 48 months. Among children who started cow's milk before 30 days of life, the respective proportions of children with constipation was 28.2%, 33%, and 12.4%.

CONCLUSIONS

The prevalence of constipation increases with age and cannot be detected using only information on evacuation interval. Toilet training before 24 months and introduction of cow's milk before 1 year of age is positively associated with constipation at 24 months and its persistence up to 48 months.

Socioenvironmental factors associated with constipation in Hong Kong children and Rome III criteria

OBJECTIVE

Data regarding the prevalence of constipation in the general population of Asian children using internationally standardized definitions are scarce. Environmental factors surrounding a child's day to day living may trigger or perpetuate constipation and encourage postponement of defecation.

METHODS

A territory-wide cross-sectional questionnaire survey was conducted in 2318 Hong Kong Chinese elementary school students. Constipation was defined by pediatric Rome III criteria.

RESULTS

The mean age of the children was 9 ± 1.9 years; 51% were boys. Two hundred eighty-two children (12.2%, 95% confidence interval [CI] 10.9%-13.5%) were found to have constipation. Children ages 6 to 7 years had the highest prevalence (16.8%, 95% CI 13.8%-19.8%). There was no difference in prevalence between boys and girls (11.6% vs 12.3%; P > 0.05) and between obese and nonobese children (11.5% vs 11.1%; P > 0.05). In univariate analysis, constipation was found to be significantly more prevalent among those children who lived with neither parent, had inadequate company of parents at home, refused to pass bowel movements in school, spent long hours doing homework, had inadequate sleep, and had decreased fiber intake and frequent consumption of fast food (P < 0.05). Multivariate analysis identified refusal to pass bowel movements in school toilets (odds ratio [OR] 1.97, 95% CI 1.42%-2.74%), having dinner with one/both parents <50% of time (OR 1.52, 95% CI 1.01%-2.31%), nighttime sleep <7 hours (OR 1.87, 95% CI 1.04%-3.33%), and frequent consumption of fast food (OR 1.14, 95% CI 1.03%-1.26%) to be independent factors associated with constipation.

CONCLUSIONS

Socioenvironmental factors are associated with childhood constipation, and bringing them to the awareness of the public may help prevent or stop the progression of childhood constipation at its early stages.

Lower urinary tract symptoms from childhood to adulthood: a population based study of 594 Finnish individuals 4 to 26 years old

PURPOSE

We evaluated voiding habits and lower urinary tract symptoms by age and gender in a large population of individuals from childhood to adulthood.

MATERIALS AND METHODS

We studied a cross-sectional sample of 594 individuals 4 to 26 years old randomly selected from the population register of Finland. Participants anonymously answered a detailed postal questionnaire on lower urinary tract symptoms. Parents assisted respondents younger than 16 years. Results were analyzed by age group (4 to 7, 8 to 12, 13 to 17 and 18 to 26 years) and gender. A p value of less than 0.05 was considered statistically significant.

RESULTS

The prevalence of urge incontinence significantly decreased with age (45% in respondents 4 to 7 years vs 10% in respondents 13 to 17 years, p <0.05). Urinary tract infections and urge and stress incontinence were more common in females (16% to 32%) than in males (2% to 4%) older than 12 years (p <0.05). The occurrence of some type of minor daytime urinary incontinence was reported by approximately a fourth of the study population, with a significant decline in prevalence between ages 4 to 7 years and 8 to 12 years (p <0.05). Minor urinary incontinence was significantly more common in females older than 12 years. Frequent urinary incontinence affected only 4% of respondents, most of whom were younger than 12 years.

CONCLUSIONS

Bladder control and urinary function exhibit considerable variation with age and gender. Due to the imperfections in bladder control in the general population, the evaluation of urinary tract disorders and outcomes of surgery in children and adolescents should be conducted with reference to control data according to age and gender.

Evaluation of bowel function and fecal continence in 594 Finnish individuals aged 4 to 26 years

BACKGROUND

Limited information exists on what constitutes normal bowel function in children and adolescents. This information is essential for determining outcomes of surgery for anorectal malformations and other colonic disorders.

OBJECTIVE

The aim of this study was to define bowel function and fecal continence in a large sample of individuals aged 4 to 26 years.

DESIGN

This investigation is a cross-sectional cohort study.

SETTINGS

Five hundred ninety-four individuals aged 4 to 26 years were randomly selected from the population register of Finland. Participants anonymously answered a previously validated 7-item postal questionnaire on bowel function.

MAIN OUTCOME MEASURES

The primary outcomes measured were bowel function score, fecal continence, stooling frequency, constipation, and social problems in relation to bowel function.

RESULTS

Recognition of the need to defecate was well established by age 4, but the ability to hold back defecation improved with age. Fecal accidents decreased from 11% in preschool children to 2% by 13 to 17 years (p = 0.02). Fecal staining of underwear was common (33%); the prevalence of soiling decreased with age. Stooling frequency was normal in 92%. Constipation was more common in females. Problems restricting social life in relation to bowel function were rare (0.5%).

CONCLUSIONS

The fine-tuning of fecal continence continues to develop during childhood. Minor soiling is common in healthy individuals. Because of the changes with age, the evaluation of functional outcomes in patients who have undergone surgical treatment of anorectal malformations or other colonic disorders should include comparison with data from age-matched controls.

Validation and clinical utility of a bowel habit questionnaire in school-age children

OBJECTIVES

The aim of the study was to validate a brief Bowel Habit Questionnaire (BHQ) with prospectively obtained data from a 14-day diary and to determine whether the BHQ predicts the development of medically significant constipation (MSC) during the following year.

MATERIALS AND METHODS

The BHQ was distributed to parents of children ages 5 to 8 years during health supervision visits. Both the BHQ and subsequent diary were scored to indicate constipation if at least 2 of the following were reported: infrequent bowel movements, stool accidents, straining, avoidance, discomfort with defecation, or passing large stools >25% of the time. One year later, the BHQ was repeated to assess for MSC, defined as medical encounters about constipation or use of enemas, suppositories, laxatives, or stool softeners.

RESULTS

MSC was reported for 57 (13.7%) of 416 children on the first BHQ. Paired BHQ and diary data were obtained for 269 children; 54 (20.1%) had diary scores indicating constipation. BHQ had a sensitivity of 59.6% (95% confidence interval [CI] 46.7%-71.4%) and a specificity of 82.6% (95% CI 77.0%-87.1%). One year later, 11 children (5.2%) had developed new-onset MSC; 7 (63.6%) of these children had initial BHQ scores of at least 2. Positive and negative predictive values for MSC were 19.4% (95% CI 9.8%-35.0%) and 97.7% (94.2%-99.1%), respectively.

CONCLUSIONS

Parents often do not recognize constipation in young school-age children and most constipated children remain untreated. A brief screening questionnaire in this population proved to be valid but only moderately sensitive; efforts to improve sensitivity are needed before recommending it for routine use.

Constipation in childhood

Constipation in children is an often long-lasting pediatric functional gastrointestinal disorder with a worldwide prevalence varying between 0.7% and 29.6%, and estimated health-care costs of US$3.9 billion per year in the USA alone. The pathophysiology of childhood constipation is multifactorial and remains incompletely understood; however, withholding of stools, starting after an experience of a hard, painful, or frightening bowel movement is the most common cause found in children. A thorough medical history and physical examination, including a rectal examination in combination with a bowel diary, is sufficient in the majority of cases to diagnose constipation. The current standard treatment consists of education, toilet training, disimpaction, maintenance therapy and long-term follow-up. In the past decade, well-designed treatment trials in the pediatric population have emerged and long-term outcome studies have been completed. This Review summarizes the current knowledge of the clinical aspects of childhood constipation, including pathogenesis, diagnosis and treatment, with particular emphasis on the latest available data.

Bowel habits and behaviors related to defecation in 10- to 16-year-olds: impact of socioeconomic characteristics and emotional stress

OBJECTIVES

Bowel habits vary depending on food consumption and genetic factors. The knowledge regarding this physiological phenomenon is limited. Thorough understanding of normal bowel habits is essential for correct diagnosis of defecation disorders. This study evaluated the normal bowel habits of Sri Lankan children.

PATIENTS AND METHODS

Children ages 10 to 16 years were randomly selected from 5 schools in 4 districts. Those without defecation disorders were recruited. Details regarding their bowel habits during previous 2 months were collected using a validated, self-administered questionnaire.

RESULTS

A total of 2273 children were enrolled (mean age 13.2 years, SD 1.7 years, boys 49.7%). Of them, 1748 (76.9%) opened bowels once daily, whereas 149 (6.6%) and 11 (0.5%) had <3/week and >3/day defecations, respectively. Stool consistency was normal in 1997 (87.9%), hard in 86 (3.8%), and changing consistency in 163 (7.1%). Straining was present in 639 (28.1%), painful defecation in 241 (10.6%), and bleeding in 49 (2.2%). One hundred six (4.7%) children reported stool withholding. Bulky stool was present in 158 (7.0%). Straining, bulky stools, and withholding posture were more common in boys, whereas painful defecation and bleeding were reported more often in girls (P<0.05). Defecation frequency was lower in those from a poor socioeconomic background and war-affected areas (P < 0.05). Bowel frequency < 3/week, bulky stools, painful defecation, straining, and withholding posture were more common in those exposed to stressful life events (P < 0.05).

CONCLUSIONS

The present study provides data on normal bowel habits of Sri Lankan schoolchildren and provides a firm platform to evaluate defecation disorders in them.

Epidemiology of constipation in children and adults: a systematic review

We aimed to review the published literature regarding the epidemiology of constipation in the general paediatric and adult population and to assess its geographic, gender and age distribution, and associated factors. A search of the Medline database was performed. Study selection criteria included: (1) studies of population-based samples; (2) containing data on the prevalence of constipation without obvious organic aetiology; (3) in paediatric, adult or elderly population; (4) published in English and full manuscript form. Sixty-eight studies met our inclusion criteria. The prevalence of constipation in the worldwide general population ranged from 0.7% to 79% (median 16%). The epidemiology of constipation in children was investigated in 19 articles and prevalence rate was between 0.7% and 29.6% (median 12%). Female gender, increasing age, socioeconomic status and educational level seemed to affect constipation prevalence.

Constipation in children: novel insight into epidemiology, pathophysiology and management

Constipation in children is a common health problem affecting 0.7% to 29.6% children across the world. Exact etiology for developing symptoms is not clear in children and the majority is considered to have functional constipation. Alteration of rectal and pelvic floor function through the brain-gut axis seems to play a crucial role in the etiology. The diagnosis is often a symptom-based clinical process. Recently developed Rome III diagnostic criteria looks promising, both in clinical and research fields. Laboratory investigations such as barium enema, colonoscopy, anorectal manometry and colonic transit studies are rarely indicated except in those who do not respond to standard management. Treatment of childhood constipation involves several facets including education and demystification, toilet training, rational use of laxatives for disimpaction and maintenance and regular follow-up. Surgical options should be considered only when medical therapy fails in long standing constipation. Since most of the management strategies of childhood constipation are not evidence-based, high-quality randomized controlled trials are required to assess the efficacy of currently available or newly emerging therapeutic options. Contrary to the common belief that children outgrow constipation as they grow up, a sizable percentage continue to have symptoms beyond puberty.