Vermont Continence Project Online Resource Library
Promoting positive, person-centered, science-driven toileting supports for Vermont’s children and youth.
For comprehensive recommendations on the treatment of functional constipation, we suggest this guide by Children’s Mercy Gastroenterology.
We also suggest referencing the Children’s Mercy functional constipation treatment algorithm, available at https://www.childrensmercy.org/health-care-providers/pediatrician-guides/managing-functional-constipation/
Background: Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines.
Methods: Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to the classification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.
Results: This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants <6 months of age and the other for older infants and children.
Conclusions: This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.
For full text access:
Objectives: With a disease-specific questionnaire, this study aimed to evaluate health-related quality of life (HRQoL) in children with constipation in association with clinical characteristics.
Study design: Children with constipation-associated fecal incontinence (n = 114), 8 to 18 years, filled out the Defecation Disorder List at a Dutch tertiary hospital. Correlations and linear regression analysis between clinical characteristics and scores on emotional and social functioning were calculated. Specific concerns of children were described by individual item scores of these domains.
Results: Higher frequency of fecal incontinence episodes was associated with lower emotional and social functioning. Linear regression analysis showed a significant association between social functioning and fecal incontinence, but the variance of the model was low (adjusted R(2)= 0.08). Between 70% to 80% of children were concerned about experiencing fecal incontinence unnoticeably and the attendant social consequences. Children did not report having fewer friends and participated well in social events.
Conclusion: Lower HRQoL regarding disease-specific emotional and social functioning was reported in children with frequent episodes of constipation-associated fecal incontinence. However, other nonspecified factors may also influence HRQoL of these children. Most children reported relatively more emotional concerns than social consequences.
Click the link for access to full text article: https://pubmed.ncbi.nlm.nih.gov/19150085/
Aim: Constipation studies have only evaluated behavioural difficulties in children with faecal incontinence. This study evaluated changes in behavioural difficulties in childhood with functional constipation (FC) with and without faecal incontinence, based on treatment outcomes.
Methods: Children aged five to 16 years who fulfilled the Rome III criteria for FC received conventional treatment. The Strength and Difficulties Questionnaire was completed at inclusion and at the 12-month follow-up.
Results: We included 116 children. The behaviour scores decreased in successfully treated boys (10.3 versus 7.9; p < 0.001) and girls (10.0 versus 7.4; p = 0.0001) with and without faecal incontinence. There was no decrease in the behaviour scores in children with unsuccessful outcomes. Unsuccessfully treated boys had significantly higher behaviour scores than successfully treated boys at inclusion (13.2 versus 10.3; p = 0.006) and after 12 months (11.4 versus 7.9; p = 0.02). No difference was found between unsuccessfully treated and successfully treated girls at inclusion (10.5 versus 10.0; p = 0.77) or after 12 months (10.3 versus 7.4; p = 0.18).
Conclusion: Our findings indicate that conventional treatment of FC had a positive impact on behavioural difficulties in constipated children with and without faecal incontinence. This study highlights the importance of proactive detection and treatment of FC in paediatric patients.
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Objective: Parenting factors are assumed to play a role in the development and maintenance of childhood constipation. However, knowledge about the association between parenting factors and childhood constipation is limited. This study investigates the association between parental child-rearing attitudes and prominent symptoms of functional constipation and assesses the strength of this association.
Design: Cross-sectional data of 133 constipated children and their parents were collected.
Setting: The gastrointestinal outpatient clinic at the Emma Children’s Hospital in the Netherlands.
Patients: Children with functional constipation aged 4-18 years referred by general practitioners, school doctors and paediatricians.
Main outcome measures: Parental child-rearing attitudes were assessed by the Amsterdam version of the Parental Attitude Research Instrument (A-PARI). Symptoms of constipation in the child were assessed by a standardised interview. Negative binomial and logistic regression models were used to test the association between child-rearing attitudes and constipation symptoms.
Results: Parental child-rearing attitudes are associated with defecation and faecal incontinence frequency. Higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence. More and stronger associations were found for children aged ≥6 years than for younger children.
Conclusions: Parental child-rearing attitudes are associated with functional constipation in children. Any parenting issues should be addressed during treatment of children with constipation. Referral to mental health services is needed when parenting difficulties hinder treatment or when the parent-child relationship is at risk.
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https://pubmed.ncbi.nlm.nih.gov/25359759/
For social-behavioral resources related to toileting, see our “Behavior and Positive Reinforcement” category of resources.
Objective: To implement and to evaluate the effectiveness of the Uniformed Services Constipation Action Plan (USCAP) in our gastroenterology clinic for children with functional constipation.
Study design: This implementation science study included toilet-trained subjects aged 4 years and older who met the Rome IV criteria for functional constipation. Children were block randomized to receive either the USCAP or control. All clinic functional constipation plans recommended subjects continue pharmacotherapy for 4 months. Endpoints measured were clinical outcomes (resolution of functional constipation and achievement of a Pediatric Bristol Stool Form Scale [PBSFS] score of 3 or 4), patient-related outcomes (health-related quality of life [HRQoL] total scale score), and health confidence outcomes (Health Confidence Score [HCS]).
Results: Fifty-seven treatment group subjects (44%) received a USCAP (52% male; mean age, 10.9 [4.9] years) compared with 73 controls (56%; 48% male; mean age,10.9 [5.3] years). A PBSFS score of 3 or 4 was achieved by 77% of the treatment group compared with 59% of controls (P = .03). Subjects from the treatment group were more likely than the controls to endorse adherence to the 4-month course of pharmacotherapy (P < .001). Subjects who received a USCAP had greater improvements in HRQoL total scale score by the end of the project (P = .04).
Conclusions: The USCAP is a simple, inexpensive tool that has the potential to improve global outcomes for functional constipation in children and should be recommended as standard clinical practice.
For access to full text, click this link:
https://pubmed.ncbi.nlm.nih.gov/36115625/
To see the Vermont Continence Project’s “Constipation Traffic Lights Form and a plain language video describing its use, go to Constipation Treatment: Bowel Maintenance
Background: Despite being a common problem in childhood, functional constipation is often difficult to manage. This article provides a narrative updated review on the evaluation, diagnosis and management of childhood functional constipation.
Methods: A PubMed search was performed with Clinical Queries using the key term ‘functional constipation’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and to the paediatric population. The information retrieved from the above search was used in the compilation of the present article.
Results: A detailed history and thorough physical examination are important in the evaluation of a child with constipation to establish the diagnosis of functional constipation as per the Rome IV criteria and to catch ‘red flags’ suggestive of organic causes of constipation. These ‘red flags’ include delayed passage of meconium, ribbon stool, rectal bleeding/blood in the stool unless attributable to an anal fissure, failure to thrive, severe abdominal distension, absent anal wink/cremasteric reflex, tight and empty rectum on digital examination and explosive expulsion of liquid stool and gas on withdrawal of the finger, hair tuft/dimple/lipoma/haemangioma in the lumbosacral area, and an anteriorly displaced anus. For functional constipation, pharmacological therapy consists of faecal disimpaction and maintenance therapy. This can be effectively accomplished with oral medications, rectal medications or a combination of both. The most commonly used and most effective laxative is polyethylene glycol. Non-pharmacological management consists of education, behavioural modification and dietary interventions. The combination of pharmacological therapy and non-pharmacological management increases the chance of success.
Conclusion: Polyethylene glycol is the medication of first choice for both disimpaction and maintenance therapy. If polyethylene glycol is not available or is poorly tolerated, lactulose is the preferred alternative. Other laxatives may be considered as second-line therapy if treatment with osmotic laxatives fails or is insufficient. Maintenance treatment should be continued for at least 2 months. Early treatment will result in a faster and shorter treatment course.
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Alison P, Thompson, Eytan Wine, Shannon E MacDonald, Alyson Campbell, Shannon D. Scott
Pediatric functional constipation (FC) reportedly affects at least 1 in 10 children worldwide. Parent and family education is a key component for successful treatment, yet there is little research exploring what information families need and how to best support them. The aim of this review is to synthesize current evidence on the experiences and information needs of parents caring for a child with FC. We systematically searched published research and completed screening against a priori inclusion criteria. Thirteen studies (n = 10 quantitative, n = 3 qualitative) were included. We found 2 main themes, precarious footing and profound and pervasive effects. Heavy caregiving burdens fueled doubts, misinformation, relationship breakdown, and treatment deviation. In light of clinical recommendations, our findings reveal a potential mismatch between parents’ needs and care provision for FC. It is likely that both parents and health care providers would benefit from resources and interventions to improve care related to pediatric FC.
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What are signs that your child’s urination is healthy? This video describes the signs of healthy urination, and indicators that your child’s urination is not functioning quite right.
00:00:00:00 – 00:00:26:00
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Hi, my name is Haya Lickteig. I’m an occupational therapist and I’m the director of the Vermont Continence Project. In this video, Urination questions and Concerns, we are going to talk about some signs that you may need to pay more attention to your child’s bladder function or may want to check in with your child’s medical provider. First, let’s review how the bladder works.
00:00:26:03 – 00:00:55:12
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Urine is made in the kidneys and drips down, drop by, drop through tubes called ureters. Urine then collected in the bladder, which is basically a muscular pouch like a water balloon while urine is collecting, the walls of the bladder are relaxed and stretching out. At the same time, a muscle at the bottom of the bladder, the urethral sphincter is contracting to hold the bladder shut.
00:00:55:15 – 00:01:19:05
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When the bladder gets a certain amount of stretch. It sends a message to the brain that says the bladder is full. The muscles then reverse their actions. The muscles at the bottom of the bladder. Relax, allowing the urine to flow out while the walls of the bladder contract or squeezed in to make sure that all the urine comes out.
00:01:19:08 – 00:01:53:23
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This is similar to releasing the neck of a water balloon and giving the widest part a squeeze to clear it out. While our body controls that sphincter muscle that holds the urine in. It doesn’t voluntarily control the muscle on the inside that squeezes the bladder, an indication that this process is working well is that a person can urinate very soon after sitting on the toilet and that their urine stream has a steady sound which gets sore, start soft, gets loud and then soft again.
00:01:53:25 – 00:02:21:12
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Holding urine between large urination is also a sign that things are working well. While it’s too complicated to explain why problems occur here. There are some important signs to look for that your child may have a problem or concern with bladder function. If your child urinates very frequently, like more than once an hour, that’s something that we’d want our health care provider to be aware of.
00:02:21:14 – 00:02:50:05
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If your child regularly goes 4 to 6 hours or more between voids, that’s also something that you’d want your health care provider to be aware of. Parents also see this sometimes when their child wakes up dry, but then doesn’t urinate immediately. Some other signs that you may be on to be aware of are that your child’s urine flow is choppy or weak, which you probably would only know if your child is urinating in the toilet.
00:02:50:07 – 00:03:14:28
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Your child has trouble making urine come out even when they say they need to go or they appear to need to go. This can also look like a child pushing while trying to pee. If you remember, the act of urinating is not a pushing maneuver. It’s the act of releasing a muscle, and the pushing should be completely done by your body’s own processes.
00:03:15:00 – 00:03:42:08
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If your child has frequent UTIs, it can be a sign of constipation. Since fecal bacteria coming from the anus can get into the urethra, especially for girls. But it can also be a sign of withheld urine, meaning that the bladder isn’t emptying completely, leading to urine that is staying in the bladder too long and becoming too concentrated. So what to do?
00:03:42:10 – 00:04:21:17
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A common saying in the world of pelvic health is that the bowel drives the bladder and this means that most bladder symptoms for most people may be tied to something happening in the bowel. We frequently tell parents that most of their child’s bladder symptoms may get better when you treat their constipation. If you’ve treated your child’s constipation comprehensively and consistently for 2 to 3 months or more and you see no improvement in your child’s bladder, that’s when another referral may be appropriate.
00:04:21:20 – 00:04:53:25
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We’d suggest discussing your treatment options with your child’s provider for some of the available options. Include a consultation with a pediatric urologist or working with a pelvic floor, physical therapist or occupational therapist with expertise in working with children. If you have a child with any of these symptoms, it’s essential to address them before any kind of sitting program.
00:04:53:28 – 00:05:23:05
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Many of these issues can come from a history of withholding, and a structured program will probably make that worse for your child. If your child already sits on the toilet willingly, it’s really important to use all of the postural supports that we discuss in other videos, such as a footstool and a seat reducer. Thank you for taking the time to watch this.
00:05:23:07 – 00:05:40:01
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The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider.
Many providers suggest that children sit on a regular schedule, but not every body needs the same schedule! This video explains how to know how often, and when, your child needs scheduled sits.