Association between childhood constipation and exposure to stressful life events: a systematic review

Anxiety disorders presenting as gastrointestinal symptoms in children - a scoping review

Functional gastrointestinal disorders (FGID) and their association with anxiety disorders in children significantly impact a child's functioning and treatment response. This study aimed to scope the evidence of anxiety disorders manifesting as FGID in children up to 16 years old. A comprehensive search strategy was conducted on Embase (1974-2024), MEDLINE (via EBSCOHost 1946-2024), and APA PsycINFO (via EBSCOHost 1967-2024). Articles were retrieved, screened, and assessed for bias using the GRADE system. Our initial search yielded 1984 articles. After screening titles and abstracts, 53 articles remained. Full-text screening further narrowed this to 4 eligible studies. The first study found that anxiety indirectly influenced abdominal pain severity in children with irritable bowel syndrome. The second study reported an association between anxiety and abdominal pain but found that anxiety might not predict abdominal pain in later childhood. The third study suggested FGID could be a risk factor for anxiety, with higher anxiety rates in children with FGID compared to those without. The fourth study found no significant difference in pain intensity between children with functional abdominal pain disorders (FAPD) alone and those with FAPD and anxiety. The reviewed studies indicate a relationship between anxiety and FGID but lack clarity on directionality or causation. The limited number of studies calls for more research, including case-control studies with large sample sizes and longitudinal cohort studies to investigate the incidence and causation.

The psychosocial impact of childhood constipation on the children and family: A scoping review

BACKGROUND

Constipation is a common and complex health issue among children that negatively affects multiple domains of children's and families' lives. Emotional, psychological, and behavioural problems in children, as well as anxiety, distress and frustration in parents, are some of the reported effects.

AIM

This manuscript presents a systematic scoping review synthesising current evidence on the psychosocial impact of childhood constipation on children and their families.

METHODS

This review was guided by Arksey and O'Malley's five-stage framework, updated by Levac, Colquhoun and O'Brien and the Joanna Briggs Institute. Five databases were systematically searched: PUBMED, CINAHL, ASSIA, PsycINFO and Google Scholar, which yielded 2836 records. Following a systematic screening process, 32 articles met the inclusion criteria. Results were analysed, discussed and presented using the PAGER framework.

RESULTS

The four key patterns that emerged were the psychosocial impact of childhood constipation on children, their parents, and school and academic life, and parental factors associated with childhood constipation.

CONCLUSION

Childhood constipation significantly impacts the quality of life for both children and their parents, as well as the school life and academic performance. Various parental factors are linked to a higher prevalence of constipation in children.

IMPLICATIONS

Neglecting to assess and address psychosocial issues in children with constipation can prolong the condition and significantly reduce their overall quality of life, contributing to multimorbidity. Adopting a holistic approach to managing constipation in children and their families is essential for promoting overall well-being.

Psycho-gastroenterological profile of an Italian population of children with disorders of gut-brain interaction: A case-control study

BACKGROUND

Disorders of gut-brain interaction (DGBI) are common, but knowledge about their physiopathology is still poor, nor valid tools have been used to evaluate them in childhood.

AIM

To develop a psycho-gastroenterological questionnaire (PGQ) to assess the psycho-gastroenterological profile and social characteristics of a pediatric population with and without DGBI.

METHODS

One hundred and nineteen Italian children (age 11-18) were included: 28 outpatient patients with DGBI (Rome IV criteria) and 91 healthy controls. They filled the PGQ, faces pain scale revised (FPS-R), Bristol stool chart, gastrointestinal symptoms rating scale, state-trait anxiety inventory, Toronto alexithymia scale 20, perceived self-efficacy in the management of negative emotions and expression of positive emotions (APEN-G, APEP-G), irritable bowel syndrome-quality of life questionnaire, school performances, tobacco use, early life events, degree of digitalization.

RESULTS

Compared to controls, patients had more medical examinations (35% of them went to the doctor more than five times), a higher school performance (23% vs 13%, P < 0.05), didn't use tobacco (never vs 16%, P < 0.05), had early life events (28% vs 1% P < 0.05) and a higher percentage of pain classified as 4 in the FPS-R during the examination (14% vs 7%, P < 0.05).

CONCLUSION

Pediatric outpatients with DGBI had a higher prevalence of early life events, a lower quality of life, more medical examinations rising health care costs, lower anxiety levels.

Functional Gastrointestinal Disorders and Childhood Obesity: The Role of Diet and Its Impact on Microbiota

Introduction Emerging evidence suggests an association between obesity and Functional Gastrointestinal Disorders (FGIDs). Childhood obesity and FGIDs share many common features, such as high prevalence in the pediatric population, risk factors related to diet and lifestyle, gut microbiota impairments, and psychological distress. This narrative review aims to summarize the main evidence regarding FGIDs in childhood obesity, with a specific focus on the role of diet and its impact on the microbiota. Additionally, the review highlights potential common-ground solutions for preventing and managing both obesity and FGIDs. Methods A comprehensive PubMed search was conducted. Keywords used included terms related to children and adolescents, obesity, functional gastrointestinal disorders, and microbiota. Results The review emphasizes the importance of holistic, multidisciplinary approaches to managing symptoms. In addition to nutrition education, physical activity, and medical care, complementary strategies such as psychological interventions and personalized dietary modifications (e.g., low-FODMAP and fiber-enriched diets) are critical. Given the interplay between gut microbiota alterations, obesity, and FGIDs, microbiota modulation through probiotics, prebiotics, and integrative support shows significant promise. However, the variability in current evidence underlines the need for robust longitudinal studies to develop standardized protocols and maximize treatment efficacy. Conclusions Bridging gaps in knowledge and practice with an integrated, evidence-based framework could improve patient outcomes and deepen understanding of the complex relationship between metabolic and gastrointestinal health in children and adolescents.

Facilitators and barriers of adherence to rectal interventions by parents of young children with functional constipation: a qualitative study

Background

Functional constipation in children is a worldwide problem that impacts both children's gastrointestinal function and the quality of family life. The treatment of this condition often depends on parental involvement to administer rectal interventions to their children to stimulate defecation. However, adherence to rectal interventions is currently suboptimal. We sought to explore the factors that facilitate and hinder parents from adherence to rectal interventions.

Methods

A descriptive qualitative study was conducted involving semi-structured interviews with parents of infants and young children with functional constipation requiring rectal interventions from March to May 2023. The data were analyzed using content analysis.

Results

Fourteen parents participated in the study. Parents reported the main facilitators of adherence to prescribed rectal interventions as recognition of illness severity, support from family and friends, and medical resource support and e-health literacy. Parents reported the primary barriers as information barriers, family conflict, cognitive misalignment, and difficulties in accessing healthcare services.

Conclusion

Rectal interventions are often essential in managing constipation in young children, with parental compliance being crucial for effective treatment. Healthcare providers must consider the psychosocial aspects of parents' perceptions, adhere to guidelines to standardize communication, and ensure comprehensive education to improve medication literacy.

Stool-toileting refusal in preschool age children: A follow-up study

BACKGROUND

Stool-toileting refusal in preschool-aged children is a significant issue that strongly impacts both the child and the family, signaling a challenging period. We investigated the relationships between temperament, traumatic life events, parental sociodemographic characteristics, and psychological burdens and these behaviors. Our goal was to identify factors that may contribute to the chronicity of this stool-toileting refusal behavior.

METHODS

Conducted as a single-center, prospective, controlled design, the research involved children exhibiting stool-toileting refusal for at least one month, alongside healthy individuals of similar age and sex. Evaluation covered sociodemographic characteristics, parental psychopathologies, children's temperament features, and life events. Follow-up questionnaires, administered one year later, assessed stool-toileting refusal behavior.

FINDINGS

An evaluation at the end of one year revealed that stool-toileting refusal behavior persisted in 11 of the 31 children. A family history of constipation, comorbid enuresis in the child, maternal psychiatric disorders, and rhythmic temperament features were significantly higher than in the healthy group. Children with persistent stool-toileting refusal behavior exhibited notably lower activity levels.

DISCUSSION

The study's results indicated associations between the TSC rhythmicity score, comorbid constipation and enuresis, and maternal psychiatric illness in preschool-aged children with stool-toileting refusal behavior. A notable association was identified between the continuation of stool-toileting refusal behavior and a low TSC activity score. Advanced statistical methods did not reveal significant differences, highlighting the need for larger sample studies.

IMPLICATIONS TO PRACTICE

Applying the study's findings to clinical practice involves considering factors such as a family history of constipation, comorbid enuresis in the child, maternal psychiatric disorders, and rhythmic temperament features as potential indicators of persistent stool-toileting refusal in preschool-aged children, guiding healthcare professionals in tailored assessments and interventions.

Building public trust and confidence in secondary use of health data for healthcare improvement and research: a qualitative study pre-protocol

Background  Secondary use of health data provides opportunities to drive improvements in healthcare provision, personalised medicine, comparative effectiveness research, health services innovation, and policy and practice. However, secondary data use requires compliance with relevant legislation, implementation of technical safeguards, ethical data management, and respect for data sharers. Existing evidence suggests widespread support for secondary use of health data among the public, which co-exists with concerns about privacy, confidentiality and misuse of data. Balancing the protection of individuals' rights against the use of their health data for societal benefits is of vital importance, and trust underpins this process. The study protocol explores how to build public trust and confidence in the secondary use of health data through all key stakeholder groups in Ireland, towards developing a culture that promotes a safe and trustworthy use of data. Methods  This study will adopt a qualitative cross-sectional approach conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research COREQ guidelines. Participants in the study will include academics and researchers; healthcare professionals, data protection, ethics and privacy experts and data controllers; pharmaceutical industry and patients and public. Purposive and convenience sampling techniques will be utilised to recruit the participants, and data will be collected utilizing focus groups that may be supplemented with semi-structured interviews. Data will be coded by themes using reflexive thematic analysis (TA) and collective intelligence (CI) will be convened post-analysis to explore the preliminary findings with the participants. Ethics and Dissemination  Ethical approval was obtained from the Royal College of Surgeons in Ireland Research Ethics Committee (REC202208013). Final data analysis and dissemination is expected by Q1 2024. Findings will be disseminated through peer-reviewed journal publications, presentations at relevant conferences, and other academic, public and policy channels. Lay summaries will be designed for Public and Patient Involvement (PPI) contributors and general public.

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis

Background

Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear.

Objective

To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented.

Methods

Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains.

Results

Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps.

Scoping review

651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations.

Effectiveness systematic reviews

studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators.

Conclusions

Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children.

Study registration

This study is registered as PROSPERO CRD42019159008.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

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.

Childhood constipation: Current status, challenges, and future perspectives

Constipation in children is a major health issue around the world, with a global prevalence of 9.5%. They present to clinicians with a myriad of clinical signs. The Rome IV symptom-based criteria are used to diagnose functional constipation. Functional constipation is also a huge financial burden for healthcare system and has a detrimental impact on health-related quality of life of children. There are various risk factors identified globally, including centrally connected factors such as child abuse, emotional and behavioral issues, and psychological stress. Constipation is also precipitated by a low-fiber diet, physical inactivity, and an altered intestinal microbiome. The main pathophysiological mechanism is stool withholding, while altered rectal function, anal sphincter, pelvic floor, and colonic dysfunction also play important roles. Clinical evaluation is critical in making a diagnosis, and most investigations are only required in refractory patients. In the treatment of childhood constipation, both nonpharmacological (education and de-mystification, dietary changes, toilet training, behavioral interventions, biofeedback, and pelvic floor physiotherapy), and pharmacological (osmotic and stimulant laxatives and novel drugs like prucalopride and lubiprostone) interventions are used. For children with refractory constipation, transanal irrigation, botulinum toxin, neuromodulation, and surgical treatments are reserved. While frequent use of probiotics is still in the experimental stage, healthy dietary habits, living a healthy lifestyle and limiting exposure to stressful events, are all beneficial preventive measures.