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Medline ® Abstracts for References 10,13

of 'Chronic functional constipation and fecal incontinence in infants and children: Treatment'

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children.
Brazzelli M, Griffiths PV, Cody JD, Tappin D
Cochrane Database Syst Rev. 2011;
BACKGROUND: Faecal incontinence is a common and potentially distressing disorder of childhood.
OBJECTIVES: To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.
SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted authors in the field to identify any additional or unpublished studies.
SELECTION CRITERIA: Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.
DATA COLLECTION AND ANALYSIS: Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.
MAIN RESULTS: Twenty one randomised trials with a total of 1371 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).
AUTHORS' CONCLUSIONS: There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence inchildren with functional faecal incontinence associated with constipation.
Division of Clinical Neurosciences, University of Edinburgh, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh, UK, EH4 2XU.
Treatment of childhood encopresis: a randomized trial comparing three treatment protocols.
Borowitz SM, Cox DJ, Sutphen JL, Kovatchev B
J Pediatr Gastroenterol Nutr. 2002;34(4):378.
OBJECTIVES: To compare short- and long-term effectiveness of three additive treatment protocols in children experiencing chronic encopresis.
METHODS: Children, 6 to 15 years of age, who experienced at least weekly fecal soiling for 6 months or longer were eligible for the study. Children were randomly assigned to a group that received intensive medical therapy (IMT), a group that received intensive medical therapy plus a behavior management program called enhanced toilet training (ETT), or a group that received intensive medical therapy with enhanced toilet training and external anal sphincter electromyographic biofeedback (BF). Data concerning toileting habits were collected for 14 consecutive days before an initial visit, and at 3, 6, and 12 months after initiation of therapy. All data were collected using a computerized voice-mail system that telephoned the families each day. At 12 months, children were classified as significantly improved (reduction in soiling, P<0.001) or cured (<one fecal accident in 2 weeks).
RESULTS: Eighty-seven children participated in the study, 72 boys and 15 girls. Mean age atenrollment was 8.6 +/- 2.0 years, and mean duration of symptoms was 58.2 +/- 38.5 months. At 12 months, the cure rates for the IMM, ETT, and BF groups were 36, 48, and 39, respectively (not significant). The improvement rates for these three groups were 45, 78, and 54, respectively (P<0.05). These results were very stable over time (r>0.90, P<0.001 in each case). Response to treatment during the first 2 weeks of therapy was highly predictive of outcome at 3, 6, and 12 months (P<0.0001). Children in the ETT group used less laxative medication (P<0.04) and required fewer treatment contacts (P = 0.08) than children in the IMM group. All three treatments resulted in significant increases in daily bowel movements passed in the toilet and self-initiated toileting, and resulted in decreases in average daily soiling at 3, 6, and 12 months (P<0.05).
CONCLUSIONS: Enhanced toilet training is somewhat more effective in treating childhood encopresis than either intensive medical therapy or anal sphincter biofeedback therapy. Although similar total cure rates at 1 year can be expected with these three forms of therapy, enhanced toilet training results in statistically significant decreases in the daily frequency of soiling for the greatest number of children.
Department of Pediatrics, University of Virginia, Charlottesville, Virginia 22908, USA. Witz@virginia.edu