Marloes E.J. Bongers

Long-Term Prognosis for Childhood Constipation: Clinical Outcomes in Adulthood

OBJECTIVES: This study examines long-term prognoses for children with constipation in adulthood and identifies prognostic factors associated with clinical outcomes. METHODS: In a Dutch tertiary hospital, children (5–18 years of age) who were diagnosed as having functional constipation were eligible for inclusion. After a 6-week treatment protocol, prospective follow-up evaluations were conducted at 6 and 12 months and annually thereafter. Good clinical outcomes were defined as ≥3 bowel movements per week for ≥4 weeks, with ≤2 fecal incontinence episodes per month, irrespective of laxative use. RESULTS: A total of 401 children (260 boys; median age: 8 years [interquartile range: 6–9 years]) were included, with a median follow-up period of 11 years (interquartile range: 9–13 years). The dropout rate during follow-up was 15%. Good clinical outcomes were achieved by 80% of patients at 16 years of age. Thereafter, this proportion remained constant at 75%. Poor clinical outcomes at adult age were associated with: older age at onset (odds ratio [OR]: 1.15 [95% confidence interval [CI]: 1.02–1.30]; P = .04), longer delay between onset and first visit to our outpatient clinic (OR: 1.24 [95% CI: 1.10–1.40]; P = .001), and lower defecation frequency at study entry (OR: 0.92 [95% CI: 0.84–1.00]; P = .03). CONCLUSIONS: One-fourth of children with functional constipation continued to experience symptoms at adult age. Certain risk factors for poor clinical outcomes in adulthood were identified. Referral to a specialized clinic should be considered at an early stage for children who are unresponsive to first-line treatment.

The clinical effect of a new infant formula in term infants with constipation: a double-blind, randomized cross-over trial

BackgroundNutrilon Omneo (new formula; NF) contains high concentration of sn-2 palmitic acid, a mixture of prebiotic oligosaccharides and partially hydrolyzed whey protein. It is hypothesized that NF positively affects stool characteristics in constipated infants.MethodsThirty-eight constipated infants, aged 3–20 weeks, were included and randomized to NF (n = 20) or a standard formula (SF; n = 18) in period 1 and crossed-over after 3 weeks to treatment period 2. Constipation was defined by at least one of the following symptoms: 1) defecation frequency < 3/week; 2) painful defecation; 3) abdominal or rectal palpable mass.ResultsPeriod 1 was completed by 35 infants. A significant increase in defecation frequency (NF: 3.5 pre versus 5.6/week post treatment; SF 3.6 pre versus 4.9/week post treatment) was found in both groups, but was not significantly different between the two formulas (p = 0.36). Improvement of hard stool consistency to soft stool consistency was found more often with NF than SF, but did not reach statistical significance (90% versus 50%; RR, 1.8; 95% CI, 0.9–3.5; p = 0.14). No difference was found in painful defecation or the presence of an abdominal or rectal mass between the two groups. Twenty-four infants completed period 2. Only stool consistency was significantly different between the two formulas (17% had soft stools on NF and hard stools on SF; no infants had soft stools on SF and hard stools on NF, McNemar test p = 0.046).ConclusionThe addition of a high concentration sn-2 palmitic acid, prebiotic oligosaccharides and partially hydrolyzed whey protein resulted in a strong tendency of softer stools in constipated infants, but not in a difference in defecation frequency. Formula transition to NF may be considered as treatment in constipated infants with hard stools.

Rectal Fecal Impaction Treatment in Childhood Constipation: Enemas Versus High Doses Oral PEG

OBJECTIVE: We hypothesized that enemas and polyethylene glycol (PEG) would be equally effective in treating rectal fecal impaction (RFI) but enemas would be less well tolerated and colonic transit time (CTT) would improve during disimpaction. METHODS: Children (4–16 years) with functional constipation and RFI participated. One week before disimpaction, a rectal examination was performed, symptoms of constipation were recorded, and the first CTT measurement was started. If RFI was determined, then patients were assigned randomly to receive enemas once daily or PEG (1.5 g/kg per day) for 6 consecutive days. During this period, the second CTT measurement was started and a childs behavior questionnaire was administered. Successful rectal disimpaction, defecation and fecal incontinence frequencies, occurrence of abdominal pain and watery stools, CTTs (before and after disimpaction), and behavior scores were assessed. RESULTS: Ninety-five patients were eligible, of whom 90 participated (male, n = 60; mean age: 7.5 ± 2.8 years). Forty-six patients received enemas and 44 PEG, with 5 dropouts in each group. Successful disimpaction was achieved with enemas (80%) and PEG (68%; P = .28). Fecal incontinence and watery stools were reported more frequently with PEG (P < .01), but defecation frequency (P = .64), abdominal pain (P = .33), and behavior scores were comparable between groups. CTT normalized equally (P = .85) in the 2 groups. CONCLUSION: Enemas and PEG were equally effective in treating RFI in children. Compared with enemas, PEG caused more fecal incontinence, with comparable behavior scores. The treatments should be considered equally as first-line therapy for RFI.

The role of a probiotics mixture in the treatment of childhood constipation: a pilot study.

BackgroundInconsistent data exist about the efficacy of probiotics in the treatment of constipation. Several studies in adults with constipation showed positive effects of probiotics on constipation. Inconsistent data exist regarding the effect of a single probiotic strain in constipated children. The aim of this pilot study was to determine the effect of a mixture of probiotics containing bifidobacteria and lactobacilli in the treatment of childhood constipation.MethodsChildren aged 4–16 years with constipation as defined by the Rome III criteria were eligible for the study. During a 4 week period, children received a daily mix of 4 × 109 colony forming units of a probiotic mixture (Ecologic®Relief) containing Bifidobacteria (B.) bifidum, B. infantis, B. longum, Lactobacilli (L.) casei, L. plantarum and L. rhamnosus. Primary outcome measures were frequency of bowel movements (BMs) per week and stool consistency. Secondary outcome measures were number of faecal incontinence episodes per week, abdominal pain and side effects.ResultsTwenty children, 50% male, median age 8 (range 4–16) were included.The frequency of BMs per week increased from 2.0 (1.0–5.0) to 4.2 (0.0–16.0) in week 2 (p = 0.10) and 3.8 (2.1–7.0) in week 4 (p = 0.13). In 12 children presenting with <3 BMs/week, BMs per week increased significantly from 1.0 (0.0–2.0) to 3.0 (0.0–7.0) in week 2 (p = 0.01) and 3.0 (0.0–10.0) in week 4 (p = 0.01). The stool consistency was reported as hard in 7 children at baseline, in 4 children at week 2 (p = 0.23) and in 6 children after 4 weeks of treatment (p = 1.00). A significant decrease in number of faecal incontinence episodes per week was found in the entire group: 4.0 (0.0–35.0) to 1.5 (0.0–14.0) in week 2 (p = 0.01) and 0.3 (0.0–7.0) in week 4 (p = 0.001). The presence of abdominal pain decreased significantly from 45% to 25% in week 2 (p = 0.04) and 20% at week 4 (p = 0.006). No side effects were reported.ConclusionThis pilot study shows that a mixture of probiotics, has positive effects on symptoms of constipation. To confirm these findings, a large randomised placebo controlled trial is required.

Functional Constipation in Children: A Systematic Review on Prognosis and Predictive Factors

Background and Aim: Knowledge regarding prognosis and factors influencing the clinical course of functional constipation in children is important to enable general practitioners and paediatricians to give accurate patient information, to compare treatment strategies, and identify children with high risk for unfavourable outcome. The objective of the study was to investigate and summarize the quantity and quality of evidence on prognosis of childhood constipation with and without treatment and its predictive factors. Methods: An extensive literature search in MEDLINE and Embase was performed to identify prospective follow-up studies evaluating the prognosis or prognostic determinants of functional constipation. Methodological quality was assessed using a standardised list. Results on prognosis of constipation were statistically pooled, and the influence of prognostic factors was summarised in a best evidence synthesis. Results: The search strategy resulted in a total of 2882 abstracts. Only 14 publications met our inclusion criteria, of which 21% scored high methodological quality. Included studies showed large heterogeneity in study populations and outcome measures. Without regard to these differences, 49.3% ± 11.8% of all of the children followed for 6 to 12 months were found to recover and taken off laxatives. The percentage of children who were free from complaints, regardless of laxative use, after 6 to 12 months was 60.6% ± 19.2%. There is substantial evidence that defecation frequency and a positive family history are not associated with recovery from constipation. Conclusions: The few studies published on prognosis of childhood functional constipation and predictive factors showed large heterogeneity and poor methodological quality. Overall, 60.6% of children are found to be free from symptoms after 6 to 12 months. Recovery rate showed no relation with defecation frequency or positive family history. Based on the present literature, we are unable to identify a group of children with high risk for poor prognosis.

Health-related quality of life in young adults with symptoms of constipation continuing from childhood into adulthood.

BackgroundChildren with functional constipation report impaired Health-related Quality of Life (HRQoL) in relation to physical complaints and long duration of symptoms. In about one third of children with constipation, symptoms continue into adulthood. Knowledge on HRQoL in adults with constipation persisting from childhood is lacking.ObjectivesTo assess HRQoL in adults with constipation from early childhood in comparison to that of their peers. Furthermore to gain insight into the specific social consequences related to continuing symptoms of constipation and/or fecal incontinence at adult age.MethodsOne HRQoL questionnaire and one self-developed questionnaire focusing on specific consequences of symptoms of constipation continuing into adulthood were administrated to 182 adults with a history of childhood constipation. Successful clinical outcome was defined as a defecation frequency three or more times per week with less than two episodes of fecal incontinence per month, irrespective of laxative use. HRQoL of both adults with unsuccessful and successful clinical outcome were compared to a control group of 361 peers from the general Dutch population.ResultsNo differences in HRQoL were found between the whole study population and healthy peers, nor between adults with successful clinical outcome (n = 139) and the control group. Adults with an unsuccessful clinical outcome (n = 43) reported significantly lower HRQoL compared to the control group with respect to scores on bodily pain (mean ± SD 77.4 ± 19.6 versus 85.7 ± 19.5, p = 0.01) and general health (67.6 ± 18.8 versus 74.0 ± 18.1, p = 0.04). Adults with an unsuccessful clinical outcome reported difficulties with social contact and intimacy (20% and 12.5%, respectively), related to their current symptoms. Current therapy in these adults was more often self-administered treatment (e.g. diet modifications) (60.4%) than laxatives (20.9%).ConclusionOverall, young adults with constipation in childhood report a good quality of life, as HRQoL of adults with successful clinical outcome was comparable to that of their peers. However, when childhood constipation continues into adulthood, it influences HRQoL negatively with social consequences in 20% of these adults.

Behavioral Therapy for Childhood Constipation: A Randomized, Controlled Trial

OBJECTIVE. It has been suggested that the addition of behavioral interventions to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. Our aim was to evaluate the clinical effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood. PATIENTS AND METHODS. In this randomized, controlled trial conducted in a tertiary hospital in the Netherlands, 134 children aged 4 to 18 years with functional constipation were randomly assigned to 22 weeks (12 visits) of either behavioral therapy or conventional treatment. Primary outcomes were defecation frequency, fecal incontinence frequency, and success rate. Success was defined as defecation frequency of ≥3 times per week and fecal incontinence frequency of ≤1 times per 2 weeks irrespective of laxative use. Secondary outcomes were stool-withholding behavior and behavior problems. Outcomes were evaluated at the end of treatment and at 6-months follow-up. All of the analyses were done by intention to treat. RESULTS. Defecation frequency was significantly higher for conventional treatment. Fecal incontinence frequency showed no difference between treatments. After 22 weeks, success rates did not differ between conventional treatment and behavioral therapy (respectively, 62.3% and 51.5%), nor did it differ at 6 months of follow-up (respectively, 57.3% and 42.3%). The proportion of children withholding stools was not different between interventions. At follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7% vs 29.2%). CONCLUSION. Behavioral therapy with laxatives has no advantage over conventional treatment in treating childhood constipation. However, when behavior problems are present, behavioral therapy or referral to mental health services should be considered.

Health Related Quality of Life in Children with Constipation-Associated Fecal Incontinence

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.

No Change in Rectal Sensitivity After Gut-Directed Hypnotherapy in Children With Functional Abdominal Pain or Irritable Bowel Syndrome

OBJECTIVES:Gut-directed hypnotherapy (HT) has recently been shown to be highly effective in treating children with functional abdominal pain (FAP) and irritable bowel syndrome (IBS). This study was conducted to determine the extent to which this treatment success is because of an improvement in rectal sensitivity.METHODS:A total of 46 patients (aged 8–18 years) with FAP (n=28) or IBS (n=18) were randomized to either 12 weeks of standard medical therapy (SMT) or HT. To assess rectal sensitivity, a pressure-controlled intermittent distension protocol (barostat) was performed before and after the therapy.RESULTS:Rectal sensitivity scores changed in SMT patients from 15.1±7.3 mm Hg at baseline to 18.6±8.5 mm Hg after 12 weeks of treatment (P=0.09) and in HT patients from 17.0±9.2 mm Hg to 22.5±10.1 mm Hg (P=0.09). The number of patients with rectal hypersensitivity decreased from 6 of 18 to 0 of 18 in the HT group (P=0.04) vs. 6 of 20 to 4 of 20 in the SMT group (P=0.67). No relationship was established between treatment success and rectal pain thresholds. Rectal sensitivity scores at baseline were not correlated with intensity, frequency, or duration of abdominal pain.CONCLUSIONS:Clinical success achieved with HT cannot be explained by improvement in rectal sensitivity. Furthermore, no association could be found between rectal barostat findings and clinical symptoms in children with FAP or IBS. Further studies are necessary to shed more light on both the role of rectal sensitivity in pediatric FAP and IBS and the mechanisms by which hypnotherapy results in improvement of clinical symptoms.

A Randomized Controlled Trial of Enemas in Combination With Oral Laxative Therapy for Children With Chronic Constipation

BACKGROUND & AIMS After 5 years of intensive oral laxative use, up to 30% of constipated children still have an unsuccessful outcome. Children refractory to oral laxatives might benefit from regular rectal evacuation by enemas. This randomized controlled trial compared the effects of additional treatment with rectal enemas (intervention) with conventional treatment alone (oral laxatives, control) in severely constipated children. METHODS In a tertiary hospital in the Netherlands, 100 children, aged 8-18 years, with functional constipation for at least 2 years were randomly assigned to intervention or control groups. The control group received education, behavioral strategies, and oral laxatives. The intervention group was also given 3 rectal enemas/week, reduced by 1 enema/week every 3 months. Outcome measures were defecation and fecal incontinence frequency and overall success at 12, 26, 39, and 52 weeks. Overall success was defined as 3 or more defecations/week and less than 1 fecal incontinence episode/week, irrespective of laxative use. RESULTS Defecation frequency normalized in both groups but was significantly higher in the intervention group compared with controls at 26 and 52 weeks (5.6 vs 3.9/week, P = .02, and 5.3 vs 3.9/week, P = .02, respectively). There were no significant differences between groups in reduction of fecal incontinence episodes (P = .49) and overall success rates (P = .67). After 1 year of treatment, the overall success rate was 47.1% in the intervention group versus 36.1% in the control group. CONCLUSIONS There is no additional effect of enemas compared with oral laxatives alone as maintenance therapy for severely constipated children.