Medline ® Abstracts for References 2,87-91
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.
Cutoff volume of dietary fiber to ameliorate constipation in children.
Chao HC, Lai MW, Kong MS, Chen SY, Chen CC, Chiu CH
J Pediatr. 2008;153(1):45. Epub 2008 Feb 11.
OBJECTIVE: To evaluate the proper ingested volume of dietary fiber for relieving constipation in children.
STUDY DESIGN: During a 3-year period, we prospectively evaluated the correlation of intake volume of dietary fiber with improvement of constipation in children. Patients were categorized into younger (3-7 years) and older (8-14 years) children. The evaluation period lasted 12 weeks. A good improvement was defined as the child exhibiting at least 60% relief of the constipation symptoms during the observation period. Freedom from constipation was observed during the last 4 weeks.
RESULTS: The study population consisted of 422 patients (213 younger, 209 older), with a mean age of 7.89 +/- 4.71 years. Baseline daily dietary fiber intake of the younger and older groups was 5.97 +/- 2.35 g and 9.83 +/- 3.51 g, respectively. 227 cases (53.8 %) showed improvement of constipation, and 49.1 % of the patients had relief of constipation. Greater intake of dietary fiber was positively associated with good improvement of constipation in both groups (P = .002, and P<.001). Cutoff volumes of daily dietary fiber intake in the relief of constipation were 10 g in the younger group and 14.5 g in the older group.
CONCLUSION: The cutoff of dietary fiber intake needed to relieve constipation increased with age, achievable in a 12-week intervention.
Division of Gastroenterology, Department of Pediatrics, Chang Gung Children's Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
Nonpharmacologic treatments for childhood constipation: systematic review.
Tabbers MM, Boluyt N, Berger MY, Benninga MA
OBJECTIVE: To summarize the evidence and assess the reported quality of studies concerning nonpharmacologic treatments for childhood constipation, including fiber, fluid, physical movement, prebiotics, probiotics, behavioral therapy, multidisciplinary treatment, and forms of alternative medicine.
METHODS: We systematically searched 3 major electronic databases and reference lists of existing reviews. We included systematic reviews and randomized controlled trials (RCTs) that reported on nonpharmacologic treatments. Two reviewers rated the methodologic quality independently.
RESULTS: We included 9 studies with 640 children. Considerable heterogeneity across studies precluded meta-analysis. We found no RCTs for physical movement, multidisciplinary treatment, or alternative medicine. Some evidence shows that fiber may be more effective than placebo in improving both the frequency and consistency of stools and in reducing abdominal pain. Compared with normal fluid intake, we found no evidence that water intake increases or that hyperosmolar fluid treatment is more effective in increasing stool frequency or decreasing difficulty in passing stools. We found no evidence to recommend the use of prebiotics or probiotics. Behavioral therapy with laxatives is not more effective than laxatives alone.
CONCLUSIONS: There is some evidence that fiber supplements are more effective than placebo. No evidence for any effect was found for fluid supplements, prebiotics, probiotics, or behavioral intervention. There is a lack of well-designed RCTs of high quality concerning nonpharmacologic treatments for children with functional constipation.
Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Centre, H7-250, PO Box 22700, 1100 DD Amsterdam, Netherlands. email@example.com
Fiber (glucomannan) is beneficial in the treatment of childhood constipation.
Loening-Baucke V, Miele E, Staiano A
Pediatrics. 2004;113(3 Pt 1):e259.
OBJECTIVE: Constipation and encopresis are common problems in children. Still today, the role of fiber in the treatment of chronic constipation in childhood is controversial. The aim of our study was to evaluate whether fiber supplementation is beneficial in the treatment of children with functional constipation with or without encopresis. We used glucomannan as the fiber supplement.
METHODS: We evaluated the effect of fiber (glucomannan, a fiber gel polysaccharide from the tubers of the Japanese Konjac plant) and placebo in children with chronic functional constipation with and without encopresis in a double-blind, randomized, crossover study. After the initial evaluation, the patients were disimpacted with 1 or 2 phosphate enemas if a rectal impaction was felt during rectal examination. Patients continued with their preevaluation laxative. No enemas were given during each treatment period. Fiber and placebo were given as 100 mg/kg body weight daily (maximal 5 g/day) with 50 mL fluid/500 mg for 4 weeks each. Parents were asked to have children sit on the toilet 4 times daily after meals and to keep a stool diary. Age, frequency of bowel movements into the toilet and into the undergarment, presence of abdominal pain, dietary fiber intake, medications, and the presence of an abdominal and/or a rectal fecal mass were recorded on a structured form at the time of recruitment and 4 weeks and 8 weeks later. Children were rated by the physician as successfully treated when they had>or =3 bowel movements/wk and<or =1 soiling/3 weeks with no abdominal pain in the last 3 weeks of each 4-week treatment period. Parents made a global assessments to whether they believed that the child was better during the first or second treatment period.
RESULTS: Forty-six chronically constipated children were recruited into the study, but only 31 children completed the study. These 31 children (16 boys and 15 girls) were 4.5 to 11.7 years of age (mean: 7 +/- 2 years). All children had functional constipation; in addition, 18 had encopresis when recruited for the study. No significant side effects were reported during each 4-week treatment period. Significantly fewer children complained of abdominal pain and more children were successfully treated while on fiber (45%) as compared with placebo treatment (13%). Parents rated significantly more children (68%) as being better on fiber versus 13% as being better on placebo. The initial fiber intake was low in 22 (71%) children. There was no difference in the percentage of children with low fiber intake living in the United States (70%) and Italy (71%). Successful treatment (physician rating) and improvement (parent rating) were independent of low or acceptable initial fiber intake. The duration of chronic constipation ranged from 0.6 to 10 years (mean: 4.0 +/- 2.5 years). Duration of constipation did not predict response to fiber treatment. Children with constipation only were significantly more likely to be treated successfully with fiber (69%) than those with constipation and encopresis (28%).
CONCLUSION: We found glucomannan to be beneficial in the treatment of constipation with and without encopresis in children. Symptomatic children who were already on laxatives still benefited from the addition of fiber. Therefore, we suggest that we continue with the recommendation to increase the fiber in the diet of constipated children with and without encopresis.
University of Iowa, Iowa City, Iowa, USA. firstname.lastname@example.org
A controlled, randomized, double-blind trial to evaluate the effect of a supplement of cocoa husk that is rich in dietary fiber on colonic transit in constipated pediatric patients.
Castillejo G, BullóM, Anguera A, Escribano J, Salas-SalvadóJ
Pediatrics. 2006 Sep;118(3):e641-8.
OBJECTIVE: Although a diet that is rich in fiber is widely recommended for preventing and treating constipation, the efficacy of fiber supplements have not been tested sufficiently in children. Our aim with this pilot study was to evaluate if fiber supplementation is beneficial for the treatment of children with idiopathic chronic constipation.
METHODS: Using a parallel, randomized, double-blind, controlled trial, we conducted an interventional study to evaluate the efficacy of a supplement of cocoa husk rich in dietary fiber on intestinal transit time and other indices of constipation in children with constipation. After screening, the patients were randomly allocated to receive, for a period of 4 weeks, either a cocoa husk supplement or placebo plus standardized toilet training procedures. Before and after 4 weeks of treatment, we (1) performed anthropometry, a physical examination, and routine laboratory measurements, (2) determined total and segmental colonic transit time, (3) evaluated bowel movement habits and stool consistency using a diary, and (4) received a subjective evaluation from the parents regarding the efficacy of the treatment. The main variable for verifying the efficacy of the treatment was the total colonic transit time.
RESULTS: Fifty-six chronically constipated children were randomly assigned into the study, but only 48 children completed it. These children, who were aged between 3 and 10 years, had a diagnosis of chronic idiopathic constipation. With respect to total, partial colon, and rectum transit time, there seemed to be a trend, although statistically nonsignificant, toward faster transit times in the cocoa husk group than in the placebo group. When we analyzed the evolution of the intestinal transit time throughout the study of children whose total basal intestinal transit time was>50th percentile, significant differences were observed between the groups. The total transit time decreased by 45.4 +/- 38.4 hours in the cocoa husk group and by 8.7 +/- 28.9 hours in the placebo group (-38.1 hours). In the case of the right colon, changes in transit time also were significant between groups. Mean changes tended toward faster transit times in the left colon and the rectum, although the differences were not statistically significant. The children who received cocoa husk supplements tended to increase the number of bowel movements by more than that of the children of the placebo group. We also observed a reduction in the percentage of patients who reported hard stools (hard scybalous or pebble-like stools), although this reduction was significantly greater in the cocoa husk group. At the end of the intervention, 41.7% and 75.0% of the patients who received cocoa husk supplementation or placebo, respectively, reported having hard stools. Moreover, a significantly higher number of children (or their parents) reported a subjective improvement in stool consistency. No significant adverse effects were reported during the study.
CONCLUSIONS: This study confirms the beneficial effect of a supplement of cocoa husk that is rich in dietary fiber on chronic idiopathic constipation in children. These benefits seem to be more evident in pediatric constipated patients with slow colonic transit time.
Human Nutrition Unit, Hospital Universitari de Sant Joan de Reus, Departament de Bioquímica i Biotecnologia, Universitat Rovira i Virgili, Reus, Spain.
Glucomannan is not effective for the treatment of functional constipation in children: a double-blind, placebo-controlled, randomized trial.
Chmielewska A, Horvath A, Dziechciarz P, Szajewska H
Clin Nutr. 2011 Aug;30(4):462-8. Epub 2011 Feb 12.
BACKGROUND&AIMS: Treatment measures for constipation in children are often not satisfactory. The aim was to assess the efficacy of glucomannan (GNN) as a sole treatment for functional constipation.
METHODS: Children aged 3-16 years with functional constipation according to Rome III criteria were randomly assigned to receive GNN (2.52 g/d) or placebo for 4 weeks.
RESULTS: Of the 80 children, 72 (90%) completed the study. The primary outcome, treatment success (≥3 stools per week with no soiling), was similar in the GNN (n = 36) and placebo (n = 36) groups (relative risk 0.95, 95% CI 0.6 to 1.4). In the GNN group, the stool consistency score was higher at week 1 (P < 0.0001), lower at week 3 (P = 0.008), and similar at weeks 2 and 4. Stool frequency was higher only at week 3 (P = 0.007). Abdominal pain episodes were more frequent in the GNN group at week 1 (P = 0.04) and week 4 (P < 0.0001) but were similar between groups at weeks 2 and 3. No difference was observed in the frequency of any other secondary outcome or adverse event.
CONCLUSIONS: In our setting, GNN, as dosed in this study, was not more effective than placebo in achieving therapeutic success in constipated children. The trial was registered at ClinicalTrials.gov (http://clinicaltrials.gov), number NCT01151878.
Department of Paediatrics, The Medical University of Warsaw, Dzialdowska 1, 01-183 Warsaw, Poland. email@example.com