Susie Gibb

Pilot study using transcutaneous electrical stimulation (interferential current) to treat chronic treatment-resistant constipation and soiling in children.

Background:  Chronic constipation in children may have organic or behavioral causes. The purpose of the present study was to investigate the effect of treatment with transcutaneous electrical stimulation (using interferential current) in children with chronic treatment‐resistant constipation with proven organic disorders.

Decreased colonic transit time after transcutaneous interferential electrical stimulation in children with slow transit constipation

PURPOSE Idiopathic slow transit constipation (STC) describes a clinical syndrome characterised by intractable constipation. It is diagnosed by demonstrating delayed colonic transit on nuclear transit studies (NTS). A possible new treatment is interferential therapy (IFT), which is a form of electrical stimulation that involves the transcutaneous application of electrical current. This study aimed to ascertain the effect of IFT on colonic transit time. METHODS Children with STC diagnosed by NTS were randomised to receive either 12 real or placebo IFT sessions for a 4-week period. After a 2-month break, they all received 12 real IFT sessions-again for a 4-week period. A NTS was repeated 6 to 8 weeks after cessation of each treatment period where able. Geometric centres (GCs) of activity were calculated for all studies at 6, 24, 30, and 48 hours. Pretreatment and posttreatment GCs were compared by statistical parametric analysis (paired t test). RESULTS Thirty-one pretreatment, 22 postreal IFT, and 8 postplacebo IFT studies were identified in 26 children (mean age, 12.7 years; 16 male). Colonic transit was significantly faster in children given real treatment when compared to their pretreatment NTS at 24 (mean CG, 2.39 vs 3.04; P < or = .0001), 30 (mean GC, 2.79 vs 3.47; P = .0039), and 48 (mean GC, 3.34 vs 4.32; P = .0001) hours. By contrast, those children who received placebo IFT had no significant change in colonic transit. CONCLUSIONS Transcutaneous electrical stimulation with interferential therapy can significantly speed up colonic transit in children with slow transit constipation.

Quality of life in children with slow transit constipation

BACKGROUND Slow transit constipation (STC) causes intractable symptoms not readily responsive to laxatives, diet, or life-style changes. Children with STC have irregular bowel motions associated with colicky abdominal pain and frequent uncontrollable soiling. This study assessed the physical and psychosocial quality of life (QOL) in children with long-standing (> or =2 years) STC vs healthy controls. METHODS Children (aged 8-18) were recruited from gastrointestinal and surgical clinics and a Scout Jamboree. After informed consent was obtained, the questionnaire (Pediatric Quality of Life Inventory) was administered. This consists of parallel child and parent self-report scales encompassing physical functioning, emotional functioning, social functioning, and school functioning. Higher scores indicate better QOL. P value less than .05 was considered statistically significant. RESULTS In 51 children with STC (mean, 11.5 years; male/female, 2:1) and 79 controls (mean, 12.1 years; male/female, 1.9:1), Pediatric Quality of Life Inventory QOL score was significantly lower in the STC group (72.90 vs 85.99; P < .0001). In addition, parents of children with STC reported a significantly lower QOL score than their child compared with the childs own report (64.43 vs 72.90; P = .0034). Parents of controls did not (84.25 vs 85.99; P = .12). CONCLUSIONS Slow transit constipation is a debilitating condition affecting both physical and emotional functioning in children. Parental perception of QOL is significantly worse, highlighting the considerable family impact of constipation and uncontrollable soiling.

Slow transit constipation in children

Abstract: Patients with chronic constipation that fails to respond to treatment remain a challenge for paediatricians and surgeons. Ongoing work in our institution suggests that a number of children with intractable symptoms have slow transit constipation, which has only been described recently in paediatrics. Common features of slow transit are: delayed passage of the first meconium stool beyond 24 h of age, symptoms of severe constipation within a year, or treatment‐resistant ‘encopresis’ at 2–3 years, soft stools despite infrequent bowel actions, and delay in colonic transit on a transit study. A proportion of children with slow transit constipation have an abnormality of intestinal innervation associated with the dysfunctional colonic motility, recognized as intestinal neuronal dysplasia (IND). Intestinal neuronal dysplasia type B, the most common variant of IND, is defined on rectal biopsy by hyperplasia of the submucosal plexus. On laparoscopic colon muscle biopsy, many specimens show reduced numbers of excitatory substance P‐immunoreactive nerve fibres in the circular muscle. Functional markers of the nerves allow new diagnostic criteria to be developed which may also allow a more rational approach to treatment. The aetiology remains obscure and the optimal management poorly defined, although subtotal colectomy, proximal colostomy or appendicostomy (for antegrade enemas) have been tried. Once the anatomy and physiology of the colon in children with slow colonic transit is better understood, we will have defined not only a new form of constipation, but also will be able to consider new therapies.

Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation

BACKGROUND Slow transit constipation (STC) causes intractable symptoms not responsive to medical treatment. Children have irregular bowel motions, colicky abdominal pain, and frequent soiling. Transcutaneous electrical stimulation using interferential current (interferential therapy [IFT]) is a novel treatment of STC. This study assessed quality of life (QOL) in STC children before and after IFT treatment. METHODS Eligible STC children were randomized to receive either real or placebo IFT (12 sessions for 4 weeks). Questionnaires (Pediatric Quality of Life Inventory) were administered before and 6 weeks after treatment, with parallel parent and child self-report scales. Higher scores indicate better QOL. Holschneider and Templeton scores were also obtained. The QOL scores were compared using paired t tests. RESULTS Thirty-three children (21 male), with a mean age of 11.8 years (range, 7.4-16.5 years), were recruited; 16 received real IFT. Child-perceived QOL was improved after real IFT compared with baseline (81.1 vs 72.9, P = .005) but not after placebo IFT (78.1 vs 74.9, P = .120). The Holschneider score improved after real IFT (10 vs 8, P = .015) but not after placebo IFT (9 vs 8, P = .112). Parentally perceived QOL was similar after real IFT (70.1 vs 70.3, P = .927) and placebo IFT (70.2 vs 69.8, P = .899). There were no differences in Templeton scores. CONCLUSION Interferential therapy is a novel therapy for children with STC that improves their self-perceived QOL.

Daily transabdominal electrical stimulation at home increased defecation in children with slow-transit constipation: a pilot study

PURPOSE Transcutaneous electrical stimulation (TES) (3 sessions/wk) over the abdomen stimulated bowel functions in a randomized controlled trial. This pilot study assessed whether daily TES at home with a safe, portable machine would be possible and more efficacious than trial results. METHODS Eleven patients (6 male/5 female; mean age, 14 years; range, 12-18 years) with slow-transit constipation who relapsed or responded poorly in the trial were recruited (11 +/- 5 months later). An EPM-IF-4160 (Fuji Dynamics, Hong Kong) portable machine (sine waveform, 4 kHz carrier frequency, 80-160 Hz beat frequency, intensity <33 mA) delivering interferential current (2 electrodes over epigastrium + 2 over kidneys) was applied 1 hour daily at home. Continence diaries were kept for 1 month before and 2 months during treatment. RESULTS All children completed more than 1 month of treatment after baseline recording. Defecation increased in 9 of 11 children, and soiling decreased in 4 of 11 children. There was a significant increase in total episodes of defecation per week (mean +/- SD, 2.5 +/- 2.1 vs 6.7 +/- 4.4; P = .008) and a nonsignificant decrease in soiling (3.8 +/- 1.6 vs 1.1 +/- 0.5 episodes/wk, P = .1). Daily stimulation does not affect abdominal pain. No adverse events occurred. CONCLUSIONS Daily TES at home is safe and significantly improved bowel function in children who did not respond to 3 times per week of TES. Home TES may be a novel treatment of intractable slow transit constipation, avoiding hospital visits.

Slow-transit constipation in children: our experience

Constipation is a common problem in children, with childhood prevalence estimated at between 1 and 30%. It accounts for a significant percentage of referrals to paediatricians and paediatric gastroenterologists. It commonly runs in families, suggesting either an underlying genetic predisposition or common environmental factors, such as dietary exposure. The peak age for presentation of constipation is shortly after toilet training, when passage of hard stools can cause pain on defecation, which then triggers holding-on behaviour in the child. At the time of the next call to stool the toddler may try to prevent defecation by contraction of the pelvic floor muscles and anal sphincter. Unless the holding-on behaviour is quickly corrected by interventions to soften faeces and prevent further pain, the constipation can very rapidly become severe and chronic. Until recently, this mechanism was thought to be the only significant primary cause of constipation in childhood. In this review, we will summarise recent evidence to suggest that severe chronic constipation in children may also be due to slowed colonic transit.

Connective tissue disorder—a new subgroup of boys with slow transit constipation?

PURPOSE Slow transit constipation (STC) is a form of chronic constipation, with delayed colonic passage of stool. Possible etiologies include reduced neurotransmitter levels, reduced interstitial cells of Cajal density, or a disorder of connective tissue (CT) synthesis. A common CT disorder is generalized joint hypermobility (GJH). This study aimed to investigate whether there was a greater prevalence of GJH among patients with STC than controls. METHODS Children (aged 7-17) diagnosed with STC by radio/nuclear transit study were recruited from outpatient clinics. Controls (no history of constipation) were recruited from outpatient clinics and a scout jamboree. Hypermobility was assessed using the Beighton score (4 or more = hypermobile). This project received ethical approval by the human research ethics committee. RESULTS Thirty-nine STC subjects and 41 controls were measured. Of 39 STC subjects, 15 (38%) were hypermobile, compared to 8 (20%) of 41 controls (P = .06). Analyzed by gender, 10 (38%) of 26 STC males and 1 (4%) of 23 control males were hypermobile (P < .01). CONCLUSIONS These results show that GJH is higher in STC children, particularly males, suggesting that a disorder of CT synthesis plays a role in the etiology of STC. Further research is required to ascertain the nature of any relationship and how this knowledge may aid our understanding and treatment of STC.