Medline ® Abstracts for References 2,27
of 'Chronic functional constipation and fecal incontinence in infants and children: Treatment'
Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN.
Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA
J Pediatr Gastroenterol Nutr. 2014;58(2):258.
BACKGROUND: Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines.
METHODS: Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to theclassification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.
RESULTS: This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants<6 months of age and the other for older infants and children.
CONCLUSIONS: This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.
Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands.
Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome.
Borowitz SM, Cox DJ, Kovatchev B, Ritterband LM, Sheen J, Sutphen J
OBJECTIVE: Childhood constipation accounts for 3% of visits to general pediatric clinics and as many as 30% of visits to pediatric gastroenterologists. The majority of children who experience constipation and whose caregivers seek medical care are seen by primary care physicians such as pediatricians or family physicians. Little is known about how primary care physicians treat childhood constipation or the success of their treatments. With this study, we prospectively examined which treatments primary care physicians prescribe to children who present for the first time with constipation and how effective those treatments are.
METHODS: A total of 119 children who were between 2 and 7 years of age (mean: 44.1 +/- 13.6 months) and presented to 26 different primary care physicians (15 pediatricians and 11 family physicians) for the treatment of constipation for the first time participated in this study. Parents completed daily diaries of their child's bowel habits for 2 weeks before starting treatment recommended by their primary care physician and again 2 months after treatment. The prescribed treatment was identified by reviewing office records of the treating physicians.
RESULTS: After 2 months of treatment, 44 (37%) of 119 children remained constipated. In the majority (87%) of cases, physicians prescribed some form of laxative or stool softener. The most commonly prescribed laxatives were magnesium hydroxide (77%), senna syrup (23%), mineral oil (8%), and lactulose (8%). In nearly all cases, a specific fixed dose of laxative was recommended; in only 5% of cases were parents instructed clearly to adjust the dose of laxative up or down to get the desired effect. In approximately half of the cases, physicians recommended some sort of dietary intervention. Some form of behavioral intervention was mentioned in the office records of approximately one third of cases; however, in most cases, little detail was provided. In 45% of cases, physicians prescribed disimpaction using oral cathartics, enemas, or suppositories followed by daily laxatives. In 35% of cases, physicians prescribed daily laxatives without any disimpaction procedure. In the remainder, physicians prescribed only dietary changes (5%), the use of intermittent laxatives (9%), or no therapy (7%). Treatment success corresponded to how aggressively the child was treated. Specifically, children who underwent some form of colonic evacuation followed by daily laxative therapy were more likely to have responded to treatment than were those who were treated less aggressively.
CONCLUSION: Primary care physicians tend to undertreat childhood constipation. After 2 months of treatment, nearly 40% of constipated children remain symptomatic.
Department of Pediatrics, University of Virginia, Charlottesville, Virginia 22908, USA. firstname.lastname@example.org