Merit M. Tabbers

Currently recommended treatments of childhood constipation are not evidence based. A systematic literature review on the effect of laxative treatment and dietary measures

Introduction: Constipation is a common complaint in children and early intervention with oral laxatives may improve complete resolution of functional constipation. However, most treatment guidelines are based on reviews of the literature that do not incorporate a quality assessment of the studies. Objective: To investigate and summarise the quantity and quality of the current evidence for the effect of laxatives and dietary measures on functional childhood constipation. Methods: The Medline and Embase databases were searched to identify studies evaluating the effect of a medicamentous treatment or dietary intervention on functional constipation. Methodological quality was assessed using a validated list of criteria. Data were statistically pooled, and in case of clinical heterogeneity results were summarised according to a best evidence synthesis. Results: Of the 736 studies found, 28 met the inclusion criteria. In total 10 studies were of high quality. The included studies were clinically and statistically heterogeneous in design. Most laxatives were not compared to placebo. Compared to all other laxatives, polyethylene glycol (PEG) achieved more treatment success (pooled relative risk (RR): 1.47; 95% CI 1.23 to 1.76). Lactulose was less than or equally effective in increasing the defecation frequency compared to all other laxatives investigated. There was no difference in effect on defecation frequency between fibre and placebo (weighted standardised mean difference 0.35 bowel movements per week in favour of fibre, 95% CI −0.04 to 0.74). Conclusion: Insufficient evidence exists supporting that laxative treatment is better than placebo in children with constipation. Compared to all other laxatives, PEG achieved more treatment success, but results on defecation frequency were conflicting. Based on the results of this review, we can give no recommendations to support one laxative over the other for childhood constipation.

The feasibility of wireless capsule endoscopy in detecting small intestinal pathology in children under the age of 8 years – a.Multicentre European Study

Objective: To systematically evaluate the feasibility and methodology to carry out wireless capsule endoscopy (WCE) in children <8 years to define small intestinal pathology. Design: Prospective European multicentre study with negative prior investigation. Patients and interventions: 83 children aged 1.5–7.9 years were recruited. Initially, all were offered “swallowing” (Group 1) for capsule introduction. If this failed endoscopic placement (Group 2) was used and the Roth net, Advance or custom-made introducers were compared. Outcome measures: Primary endpoint: to determine pathology; secondary endpoint: comparison of capsule introduction methods. Results: Capsule introduction: 20 (24%) children aged 4.0–7.9 years (mean, 6.9 years; 14 male) comprising Group 1 were older (p<0.025) than 63 (76%) aged 1.5–7.9 years (mean, 5.25 years; 30 male) forming Group 2. Complications: Roth net mucosal trauma in 50%; no others occurred. The available recording apparatus was inappropriate for those <3 years. Indications: gastrointestinal bleeding: nu200a=u200a30 (16 positive findings: four ulcerative jejunitis, four polyps, two angiodysplasia, two blue rubber blebs, two Meckel’s diverticula, one anastomotic ulcer, one reduplication); suspected Crohn’s disease: nu200a=u200a20 (11 had Crohn’s disease); abdominal pain: nu200a=u200a12 (six positive findings: three Crohn’s disease, two lymphonodular hyperplasia, one blue rubber bleb); protein loss: nu200a=u200a9 (four lymphangectasia); malabsorption: nu200a=u200a12 (seven positive findings: six enteropathy, one ascaris). No abnormalities overall: 45%. Conclusion: WCE is feasible and safe down to the age of 1.5 years. 20 children >4 years swallowed the capsule. The Advance introducer proved superior for endoscopic placement. The pathologies encountered showed age specificity and, unlike in adolescents, obscure gastrointestinal bleeding was the commonest indication.

Catheter-related thrombosis in children with intestinal failure and long-term parenteral nutrition: How to treat and to prevent?

Survival of children with chronic intestinal failure has increased as result of administration of home parenteral nutrition. Crucial for the successful management of home parenteral nutrition is the availability of an adequate central venous access. Venous access can be fraught by episodes of catheter-infection, recurrent replacements of catheters and finally catheter-related thrombosis. Management and prevention of catheter-related thrombosis are of vital importance. For patients with compromised venous access, alternative measures are reported, most of them used as a bridge to bowel transplantation.

Is a multispecies probiotic mixture effective in constipation during pregnancy? 'A pilot study'.

BackgroundConstipation during pregnancy is a common problem. Nowadays only few effective interventions are published preventing or treating constipation during pregnancy. However, their use is limited due to side-effects. This uncontrolled intervention study was performed to determine if a mixture of probiotics in the treatment of constipation during pregnancy is effective.MethodsWomen agedu2009≥u200918 years with functional constipation were included at the Obstetrical outpatient clinic and midwife practices. Patients received during four weeks a daily dose of Ecologic®Relief (Bifidobacterium bifidum W23, Bifidobacterium lactis W52, Bifidobacterium longum W108, Lactobacillus casei W79, Lactobacillus plantarum W62 and Lactobacillus rhamnosus W71 (total 4*109 CFU)). For all analyses, the non-parametric paired Wilcoxon test was used. Primary outcome measure was change in defecation frequency. Secondary outcome measures were stool consistency, sensation of incomplete evacuation, sensation of anorectal obstruction, manual manoeuvres to facilitate defecation, abdominal pain, adverse effects, presence of reflux episodes and intake of Bisacodyl.Results20 women were included. Defecation frequency significantly increased from 3.1 at baseline to 6.7 in week four (pu2009<u20090.01). Compared to baseline, a significant decrease in 1) sensation of anorectal obstruction from 90.0% to 45.0% (pu2009<u20090.01), 2) sensation of incomplete evacuation from 90.0% to 40.0% (pu2009<u20090.01), 3) straining during defecation from 100% to 65% (pu2009=u20090.01), 4) episodes of abdominal pain from 60% to 20% (pu2009=u20090.01) and 5) the presence of reflux episodes from 60% to 20% in week four (pu2009=u20090.01) was found. Other secondary outcomes did not decrease significantly. No side effects were reported.ConclusionsEcologic®Relief is effective in the treatment of constipation during pregnancy. A randomised placebo controlled trial is required to confirm these data.

An unexpected finding in a child with rectal blood loss using video capsule endoscopy

Video capsule endoscopy (VCE) has recently enabled direct visualization of the small bowel mucosa. It is a noninvasive, painless procedure and provides detailed images from areas not accessible utilizing other radiographic or endoscopic methods. Capsule endoscopy has been reported to have a diagnostic yield for small bowel pathology greater than that derived from regular endoscopic and radiographic examinations [1, 3]. The diagnosis of obscure bleeding is currently the most frequent indication for capsule endoscopy in adults [1]. Although VCE is becoming an increasingly popular procedure, welldesigned studies on its clinical implications and application are only just emerging. In this report, we present a boy with rectal blood loss. Despite a negative result from radionuclide imaging, there was still a high clinical suspicion of a Meckel’s diverticulum. Consequently, VCE was performed with the purpose of avoiding unnecessary surgical treatment. Case report

Implementation of an evidence-based guideline on fluid resuscitation: lessons learnt for future guidelines

IntroductionThere is little experience with the nationwide implementation of an evidence-based pediatric guideline on first-choice fluid for resuscitation in hypovolemia.MethodsWe investigated fluid prescribing behavior at (1) guideline development, (2) after guideline development, and (3) after active implementation and identified potential barriers and facilitators for guideline implementation. In order to minimize costs and to optimize implementation effect, we continuously developed and adjusted implementation strategies according to identified barriers. Implementation success was evaluated using questionnaires, pharmaceutical data, and data from medical records.DiscussionThe most remarkable change occurred after guideline development and dissemination: Normal saline use by neonatologists increased from 22–89% to 100% and by pediatric intensivists from 43–71% to 88–100%, and synthetic colloid use by pediatric intensivists declined from 29–43% to 0–13% with a reduction in albumin use by neonatologists from 11–44% to 0%. After active guideline implementation, most of specialist’s management behavior was according to the guideline.ConclusionStakeholders involved in the developmental process are of great importance in disseminating recommendations before active implementation. Therefore, to successfully implement guidelines and reduce costs of active implementation, any guideline development should consider implementation right from the beginning. Implementation strategies should target identified barriers and will therefore always be guideline specific.

HELLP syndrome preceded by intrahepatic cholestasis of pregnancy: one serious itch

We present four women with seven ongoing pregnancies. Five pregnancies were complicated by intrahepatic cholestasis of pregnancy (ICP) and severe haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome with uncommon maternal morbidity. The combination of ICP and HELLP syndrome has not previously been reported. Awareness is warranted to accurately identify this combination of pregnancy-specific diseases with severe maternal morbidity.

The Relation Between Malnutrition and the Exocrine Pancreas: A Systematic Review

Objective: The relation between malnutrition and exocrine pancreatic insufficiency (EPI) has been described previously, but it is unclear if malnutrition leads to EPI or vice versa. We systematically synthesized current evidence evaluating the association between malnutrition and EPI in children. Methods: Pubmed, Embase, and Cochrane databases were searched from inception until February 2017. We included cohort or case-controlled studies in children reporting on prevalence or incidence of EPI and malnutrition. Data generation was performed independently by 2 authors. Quality was assessed by using quality assessment tools from the National Heart, Lung, and Blood Institute. Results: Nineteen studies were divided into 2 groups: 10 studies showing EPI leading to malnutrition, and 9 studies showing malnutrition leading to EPI. Because of heterogeneity in design, definitions, and outcome measures, pooling of results was impossible. Quality was good in 4 of 19 studies. Pancreatic insufficiency was linked to decreased nutritional status in 8 of 10 articles, although this link was not specified properly in most articles. In malnourished children, improvement was seen in pancreatic function in 7 of 9 articles after nutritional rehabilitation. The link between the 2 was not further specified. Heterogeneity exists with respect to definitions, outcome measures, and study design. Conclusions: There is sufficient evidence for an association between EPI and malnutrition. We could not confirm whether there is a correlation or causality between EPI or malnutrition. It was therefore not possible to draw firm conclusions from this systematic review on underlying pathophysiological mechanisms between EPI and malnutrition. More observational clinical trials are crucially needed.

Pharmacological treatments for functional nausea and functional dyspepsia in children: a systematic review

ABSTRACT Introduction: Chronic idiopathic nausea (CIN) and functional dyspepsia (FD) cause considerable strain on many children’s lives and their families. Areas covered: This study aims to systematically assess the evidence on efficacy and safety of pharmacological treatments for CIN or FD in children. CENTRAL, EMBASE, and Medline were searched for Randomized Controlled Trials (RCTs) investigating pharmacological treatments of CIN and FD in children (4–18 years). Cochrane risk of bias tool was used to assess methodological quality of the included articles. Expert commentary: Three RCTs (256 children with FD, 2–16 years) were included. No studies were found for CIN. All studies showed considerable risk of bias, therefore results should be interpreted with caution. Compared with baseline, successful relief of dyspeptic symptoms was found for omeprazole (53.8%), famotidine (44.4%), ranitidine (43.2%) and cimetidine (21.6%) (p = 0.024). Compared with placebo, famotidine showed benefit in global symptom improvement (OR 11.0; 95% CI 1.6–75.5; p = 0.02). Compared with baseline, mosapride versus pantoprazole reduced global symptoms (p = 0.011; p = 0.009). One study reported no occurrence of adverse events. This systematic review found no evidence to support the use of pharmacological drugs to treat CIN or FD in children. More high-quality clinical trials are needed. Abbreviations: AP-FGID: Abdominal Pain Related Functional Gastrointestinal Disorders; BART: Biofeedback-Assisted Relaxation Training; CIN: Chronic Idiopathic Nausea; COS: Core Outcomes Sets; EPS: Epigastric Pain Syndrome; ESPGHAN: European Society for Pediatric Gastroenterology Hepatology and Nutrition; FAP: Functional Abdominal Pain; FD: Functional Dyspepsia; GERD: Gastroesophageal Reflux Disease; GES: Gastric Electrical Stimulation; H2RAs: H2 Receptor Antagonists; IBS: irritable bowel syndrome; NASPGHAN: North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition; PDS: Postprandial Distress Syndrome; PPIs: Proton Pump Inhibitor; PROMs: Patient Reported Outcome Measures; RCTs: Randomized Controlled Trials; SSRIs: selective serotonin reuptake inhibitors; TCAs: tricyclic antidepressants