Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN

Posted on January 4, 2024January 5, 2024 by chayahlichtig

M M Tabbers, C DiLorenzo, M Y Berger, C Faure, M W Langendam, S Nurko, A Staiano, Y Vandenplas, M A Benninga

Abstract

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:

https://pubmed.ncbi.nlm.nih.gov/24345831/

Health related quality of life in children with constipation-associated fecal incontinence

Posted on January 4, 2024 by chayahlichtig

Marloes E J Bongers, Marieke van Dijk Marc A Benninga, Martha A Grootenhuis

Abstract

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/

Conventional treatment of functional constipation has a positive impact on the behavioural difficulties in children with and without faecal incontinence

Posted on January 4, 2024 by chayahlichtig

Line Modin, Ida Skytte Jakobsen, Marianne Skytte Jakobsen

Abstract

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.

Click the link for access to full text article:

https://pubmed.ncbi.nlm.nih.gov/26913469/

Parental child-rearing attitudes are associated with functional constipation in childhood

Posted on January 4, 2024 by chayahlichtig

Marieke van Dijk, Giel-Jan de Vries, Bob F Last, Marc A Benninga, Martha A Grootenhuis

Abstract

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.

Click on the link for access to full text:

https://pubmed.ncbi.nlm.nih.gov/25359759/

For social-behavioral resources related to toileting, see our “Behavior and Positive Reinforcement” category of resources.

The Uniformed Services Constipation Action Plan: An Effective Tool for the Management of Children with Functional Constipation

Posted on January 4, 2024January 4, 2024 by chayahlichtig

Patrick T. Reeves, et al.

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

Paediatrics: how to manage functional constipation

Posted on January 4, 2024January 4, 2024 by chayahlichtig

Alexander KC Leung, corresponding author and Kam Lun Hon

Abstract

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.

Click link to access full text:

https://pubmed.ncbi.nlm.nih.gov/33828605/

Parents’ Experiences and Information Needs While Caring for a Child With Functional Constipation: A Systematic Review

Posted on January 4, 2024January 4, 2024 by chayahlichtig

Alison P, Thompson, Eytan Wine, Shannon E MacDonald, Alyson Campbell, Shannon D. Scott

Abstract

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.

Click Link for full text access:

https://pubmed.ncbi.nlm.nih.gov/33026251/

Survey: Improve Continence Care for VT’s Children

Posted on November 15, 2022November 16, 2022 by chayahlichtig

Do you support children with continence challenges, or have a child with a continence challenge?

We want to hear about your experience, and what would help you.

We want to hear from any Vermonter who has worked with children and youth who have incontinence or toileting-related challenges. We want feedback from from parents and guardians, educators, paraprofessionals, physicians, allied health professionals, nurses, mental health professionals, and more. We would also like to hear from any Vermonter who had a toileting or continence challenge in their youth.

The survey will take about five minutes to complete. Your answers will help us to plan the next several years of work for our project. You can win a $100 Amazon gift card when you complete the survey.

To respond to the survey: go.uvm.edu/continence-survey

Do you work somewhere that parents will see our message?

Please print out this poster encouraging parents to respond, and share this .jpeg version on your social media channels.

GUIDE: Best Practices in School-Based Toilet-Learning & Continence

Posted on August 8, 2022 by chayahlichtig

Most children and youth spend many hours a day at school, but school teams aren’t sure of the best ways to support their students’ incontinence. This evidence-based guide includes recommendations on this topic, as well as several appendices covering goals, documentation, accommodations, and a planning template.

VT Continence Project School Based Best Practice

Appendix A_ Accommodations

Appendix B_ Goals

Appendix C_ Documenting a Student’s Toilet Learning Plan

Appendix D_ School Toilet Plan Template

GUIDE: Approaching Encopresis with Sensitivity

Posted on August 8, 2022 by chayahlichtig

The Vermont Continence Project supports many children and young adults with encopresis, also known as fecal incontinence. The impact of long-term fecal incontinence on a young person can be significant and traumatic. We created this guide to help teams plan the best care and support possible for this condition

Approaching Encopresis with Sensitivity