Medline ® Abstracts for References 12-14
of 'Chronic functional constipation and fecal incontinence in infants and children: Treatment'
Randomised trial of laxatives in treatment of childhood encopresis.
Nolan T, Debelle G, Oberklaid F, Coffey C
Primary faecal incontinence (encopresis) in children is usually treated with laxative medication and a behaviour modification programme aimed at promoting regular toileting, but the effectiveness of laxatives has never been adequately investigated. 169 children with encopresis and evidence of stool on plain abdominal radiograph were randomly allocated to receive multimodal (MM) therapy (laxatives plus behaviour modification; n = 83) or behaviour modification alone (BM; n = 86). Mean (SD) follow-up was 55.1 (27.0) weeks and 56.7 (32.0) weeks, respectively. By 12 months' follow-up 42 (51%) of the MM group and 31 (36%) of the BM group (p = 0.079) had achieved remission (at least one 4 week period with no soiling episodes) and 52 (63%) vs 37 (43%) (p = 0.016) had achieved at least partial remission (soiling no more than once a week). MM subjects achieved remission significantly sooner than BM subjects, and the difference in the Kaplan-Meier remission curves was most striking in the first 30 weeks of follow-up (p = 0.012). The patterns of compliance with toileting in the treatment groups were almost identical, although about 1 in 8 children overall did not comply with the sitting programme. After exclusion of the 24 poor compliers, there was no significant difference between BM and MM groups. This study shows a clear advantage overall for the use of laxative medication, although the benefit may not be as great for children who are able to maintain regular toileting.
University of Melbourne Department of Paediatrics, Australia.
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
A controlled trial of 'Senokot' in faecal soiling treated by behavioural methods.
Berg I, Forsythe I, Holt P, Watts J
J Child Psychol Psychiatry. 1983;24(4):543.
A double-blind randomly controlled trial of one particular laxative, Senokot, used in moderate dosage, was carried out on a group of 40 children with severe and persistent soiling and often with a history of faecal retention. Significant improvement occurred following three months of outpatient treatment using a behavioural approach and either Senokot, placebo or no medication. However, there was no evidence either during the trial or subsequently when Senokot was employed to supplement behavioural treatment in every child who continued with therapy that this laxative contributed in any way to relieving the problem in this group of cases.