FUNCTIONAL CONSTIPATION IN INFANTS:A FOLLOW-UP STUDY
M.M.VAN DEN B ERG,MD,C.H.VAN R OSSUM,MS,F.DE L ORIJN,MD,J.B.R EITSMA,MD,P H D,
C.D I L ORENZO,MD,AND M.A.B ENNINGA,MD,P H D
Our objective of this study was to describe the clinical cour of vere functional constipation in early childhood.Eligible patients were47children(60%boys;median age,3.5months)who had constipation in theirfirst year of life.Follow-up data were obtained through a standardized questionnaire.Success was defined as a period of at least4weeks with$3painless bowel movements per week.Six months after initial evaluation,69%of the children were recovered.After initial success,a relap occurred in15%of the children within3years.A duration of symptoms<3months before referral correlated significantly with better outcome.We conclude that most infants with vere constipation evaluated at a tertiary center are recovered after6months.Early therapeutic intervention may beneficially contribute to the resolution of constipation.(J Pediatr2005; 147:700-4)
E stimates of the prevalence of constipation in children vary from0.3%to8%.1Childhood constipation is often regarded
as a trivial symptom that will gradually disappear.However,the general belief that children‘‘will just grow out of it’’has never been substantiated.In approximately40%of constipated children,symptoms originate during theirfirst year of life.2,3 A rare cau of constipation in the children is Hirschsprung dia.Bad on typical symptoms and exclusion of organic caus, most children are eventually diagnod as having functional constipation.Several mechanisms appear to contribute to the development of childhood functional constipation.4
形容跑步的句子Infants with constipation typically prent with a defecation frequency of<3times per week,accompanied by straining and crying.Some of the infants may have fecal impaction on physical examination.1The Rome II criteria describe infant dyschezia as the most common functional defecation disorder in infants.5This condition is defined as at least10minutes of straining and crying before a successful passage of soft stools in otherwi healthy infants of<6months.5Other Rome II diagnos for functional defecation disorders in children are functional constipation and functional fecal retention and apply to older children.5Previous rearch on children with functional constipation shows a cure rate of approximately30%after6months of intensive medical and behavioral treatment.6Longer follow-up studies show that half of the patients remain constipated after5years,7and in30%of the children,symptoms of constipation persist into young adulthood.6Despite the high
prevalence of constipation in infants,scarce outcome data are available in this group of
patients.The prent study was designed to asss the outcome in children with functional
constipation vere enough to require referral to a specialist to rule out Hirschsprung dia.
梦见藕METHODS
Subjects
Patients referred between1999and2003to the tertiary outpatient gastroenterology clinic of the Academic Medical Center,with a suspicion of having Hirschsprung dia and in whom constipation had started during thefirst year of life(n=99),constituted the subjects of this study.The population reported in this study bestfits the age group of infant dyschezia;however,this entity has not been validated,and the term‘‘infant dyschezia’’is not widely ud or understood.In this study,we will u the more generic term of functional constipation.Hirschsprung dia was excluded by anorectal manom-etry and rectal suction biopsy in73children.To be eligible for this study,patients had to fulfill one of the following criteria for constipation:(1)defecation frequency<3times a week;(2)painful defecation;(3)u of laxatives.Children with other organic caus,such as gastrointestinal malformati
ons,spinal abnormalities,and cerebral palsy,were excluded from the study.Seven children did not meet the criteria for constipation and13had other 700From the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital,and the Department of Clinical Epidemiology and Biostatistics,Academic Medical Center,Amsterdam,The Nether-lands;and the Department of Pediat-ric Gastroenterology and Nutrition, Columbus Children’s Hospital,Colum-bus,Ohio.
Submitted for publication Jan4, 2005;revision received Mar25, 2005;accepted May9,2005. Reprint requests:Maartje M.van den Berg,MD,Columbus Children’s Hospital,Department of Pediatric Gastroenterology and Nutrition,700 Children’s Drive,Columbus,OH 43205.
0022-3476/$-e front matter Copyrightª2005Elvier Inc.All rights rerved.
10.1016/j.jpeds.2005.05.032
dias:2patients had cow’s milk allergy,5had chromosomal defects,4had intestinal malformations,and2children had been previously treated with a colostomy.Only children who were less than3years old at time of the initial referral to the gastroenterology outpatient clinic were considered eligible for this study.This rearch was approved by the medical ethical committee of th
e Academic Medical Center.
Treatment
After the diagnostic evaluation of Hirschsprung dia was completed,parents were given a thorough explanation of childhood constipation,including the abnce of an organic cau,the possible behavioral component,and the different therapeutic options available.We recommended elimination of the fecal impaction,when prent,with enemas(sodium-ducosate sorbitol or sodiumlaurylsulfoacatate)followed by the u of an adequate do of oral laxatives(2mL/kg per day lactulo or0.5g/kg per day polyethylene glycol).Treatment was managed by the primary care physicians according to our recommendations and their own preference.
Follow-up and Data Collection
Follow-up data were obtained by telephone,with the u of a standardized questionnaire.The questionnaire addresd the time offirst passage of meconium,defecation frequency,stool consistency,straining and crying during defecation passage,bloody stools,the existence offissures,age of ont of constipation,u of laxatives,medical and family history,and developmental benchmarks.Parents were asked to recall the clinical status of their child at the age of6months and1,
2,3,and4years.At the different ages,the number of months from prentation to the gastroenterology clinic to follow-up was calculated and categories of follow-up periods were plotted(3,6,9,12,18,24,and36months).In addition to the clinical status at the specified ages,data about relap were obtained within the time intervals.
Definition of Clinical Outcome
To asss clinical outcomes,three categories were defined.‘‘Successful outcome’’was defined as a period of at least4weeks with$3bowel movements per week,without pain during defecation and without the u of oral or rectal laxatives(category1).The cond category of children had ‘‘success while using laxatives’’(category2),whereas the last group did not fulfill the clinical criteria for success(‘‘unsuc-cessful outcome’’),whether with or without the u of laxatives (category3).A relap was defined as a period of at least4 weeks in which bowel movement frequency had decread to <3per week or,becau of increasing symptoms,laxatives had to be reintroduced,after a period of either‘‘successful outcome’’or‘‘success while using laxatives.’’
Statistical Analysis
Nonparametric(Mann-Whitney U)and x2statistics were ud to test differences for baline character
istics between boys and girls.For each of thefixed time points of follow-up,the distribution of patients over the three possible categories of clinical outcome was computed.The frequency and timing of initial success was prented in a Kaplan-Meier curve without adjustment for the discrete nature of the follow-up.A log-rank test was ud to evaluate the prognostic value of predefined factors on time untilfirst success.The following factors were examined:x,age of ont,total period of symptoms before intake,and total duration of treatment before prentation.Binary logistic regression models were ud to examine the relation between predefined baline factors and the probability of a good clinical outcome after 1year of follow-up.The following factors were examined:x, age of ont,total period of symptoms before intake and total period of treatment before intake,defecation frequency at prentation,prematurity at birth,delayed passage of meco-nium,and positive family history.Continuous variables were dichotomized by using the median as the cutoff value.
RESULTS
A total of53children were eligible for the study;6 patients were lost to follow-up(11%),as contact information could not be retrieved.The baline characteristics were compared between patients in the study and tho lost to follow-up;no significant difference between the groups was found.The clinical baline characteristics of the remaining 47patients(60%boys)are prented in the Table.The
median age of ont of constipation was9days,and the median age at prentation to the clinic was3.5months.No significant difference was found between boys and girls concerning clin-ical characteristics at enrollment.
The median duration of follow-up was20months (range,6to52).Different types of laxatives were ud during the treatment period,including lactulo(n=25),polyethyl-ene glycol(n=5),bisacodyl(n=2),and enemas(sodiumdu-cosate sorbitol or sodiumlaurylsulfoacatate)(n=7).At6 months of follow-up,69%of the patients achieved success without using laxatives(category1)and8%met the criteria for success but were still using laxatives(category2)(Figure1).
A relap of constipation after initial clinical success occurred in15%of the children within the3-year follow-up period.Within3months,18%of all patients reached their first successful period without using laxatives(category1) (Figure2).This percentage incread to54%at6months of follow-up.Thereafter,the increa in success rate was con-siderably slower,reaching a cumulative percentage of70% after3years.
Two factors were significant in the analysis of the time needed to achieve‘‘successful outcome’’(category1).Children with constipation for<3months before prentation to the gastroentero
logy clinic achieved earlier initial success;79%of the children were successful without using laxatives at6 months of follow-up,in contrast to32%of the children with more than3months of complaints(P<.002.)(Figure3). Tho children treated less than2months before prenta-tion reachedfirst success without using laxatives earlier
Functional Constipation In Infants:A Follow-Up Study701
than children who were treated with oral or rectal laxatives for more than2months(84%vs36%,P<0.002)at6months of follow-up.Sex and age of ont of constipation were not associated with success.
In regression models examining prognostic factors for success at1year,the same factors described earlier were significantly related to success.After1year of follow-up, successful outcome without using laxatives occurred more often in children with less than3months of symptoms(RR, 2.5;95%CI,1.1to3.7)and children with less than2months of treatment(RR,2.4;95%CI,1.2to4.8).Sex,age of ont of symptoms,defecation frequency,prematurity at birth,delayed passage of meconium,and positive family history were not associated with successful outcome.
No difference was found between the anal resting pressures of patients with successful outcome(category1)or unsuccessful outcome(P=.095).
DISCUSSION
We evaluated the outcome of infants who in theirfirst year of life had ont of constipation vere enough to rai the suspicion of Hirschsprung dia;69%of the children were recovered within6months.This proportion reached77%if we included patients with normal defecation but still using laxatives.
Comparison of our results with previous studies is hampered by the lack of standardized definitions for functional constipation in infants and the difference in age distribution among studies.Patients described in this study are younger than tho in earlier studies,and a high percentage of the children were born premature and had delayed passage of meconium.Passage of meconium later than24hours after birth in term children is an alarm symptom of Hirschsprung dia and an indication for diagnostic evaluation.4The association between delayed passage of meconium and the development of functional constipation in children is unknown.
Table.Characteristics at time of prentation to the gastroenterology clinic of47children with function
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al constipation with ont in theirfirst year of life Characteristics Value
Sex,No.(%)
Male28(60) Female19(40) Age,mo
Median 3.5 Percentiles,25–75 2.0–13.5 Age of ont,mo
Median0.3 Percentiles,25–750.0–1.5 Period of complaints,mo
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Median3 Percentiles,25–75 1.2–9.2 Period of treatment,mo
Median 1.8 Percentiles,25–750.5–5.8 Defecation frequency/wk
Median2 Percentiles,25–750–7 ,3times/wk,No.(%)27(57) Straining during defecation77% Crying during defecation49% Bloody stools11% U of laxatives60% U of rectal stimulans17% Delayed passage of meconium52% Ont caud by change to formula9% Positive family history33% Prematurity23% Rectal anal inhibition reflex90% Anal resting pressure,mm Hg
Median31 Percentiles,25–75
25–40Figure1.Distribution of patients over three defined clinical outcome categories at different times of follow-up.Numbers on top of each bar show the number of subjects available for follow-up at that
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time.
Figure2.Cumulative percentage of children achieving at least one period of successful clinical outcome(category1)during follow-up.
702van den Berg et al The Journal of Pediatrics November2005
It is suggested that most infants with functional con-stipation fit the phenotype of infant dyschezia.It is propod but not empirically demonstrated that this entity occurs when neonates fail to coordinate incread intra-abdominal pressure with relaxation of the pelvic floor.Symptoms are thought to resolve spontaneously within a few months when improved muscle coordination is achieved.Using our criteria of consti-pation in infants,we were unable to rule out infant dyschezia in the study patients.Different definitions for functional constipation may be required to discriminate between the defecation disorders in infants.
A success rate of 59%was found after 1year of follow-up.In previous outcome studies,comparable results were found in older children (1to 8years)with constipation.1,6-8In tho studies,47%to 59%of the patients were considered successfully treated after 1year.6-9Van Ginkel et al 6did not find an association between duration of symptoms and wor outcome but reported the ont of constipatio
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n before the age of 1year as a poor prognostic sign.Our study ems to contradict that obrvation,since all children had symptoms within their first year of life and the clinical outcome was similar to that previously described in older children.In fact,the younger population appeared to have earlier success than older children.In older children,only 31%were recovered after 6months 6compared with 69%in our population.
During the total follow-up period,only 15%of the patients with an initial success had a relap of constipation.A 10-year follow-up study of constipation in children showed a much higher relap rate;50%of the children had at least one relap within the first 5years after initial success.6Possibly,the relap rate in our patients will increa with a
longer period of follow-up.In addition,many children in our population were not yet toilet-trained at the end of follow-up,and it is known that toilet training is a critical period when many children become constipated.10Statistical analysis on prognostic factors for relap was not performed in this study becau the number of patients with a relap was considered too small.
Children with shorter duration of symptoms had a significantly better outcome.The negative association be-tween longer durations of symptoms and good clinical outcome might indicate that th
erapeutic intervention in an early pha of constipation is more likely to be beneficial.Poor prognostic outcome found in children with a period of treatment with laxatives longer than 2months before enroll-ment is probably related to a longer period of symptoms with inadequate treatment.As a conquence of repeated painful defecations and accumulation of feces in the rectum,children may develop stool-withholding behavior.1Long-standing rectal dilation leads to physiologic changes of the anorectum such as reduced rectal nsation and loss of rectal wall elasticity (ie,incread compliance).11,12One can speculate that the rectal abnormalities are responsible for the chronicity of constipation.
A drawback of this study is that the data were collected retrospectively,bad on recalled information provided by the parents.However,an earlier study in children with constipa-tion showed fair agreement between recalled and recorded data regarding the defecation pattern of children.13We have no reliable information about the specific dos of the different types of medication,oral and/or rectal,ud by the parents becau parents had difficulties with recall,and many ud variable dos of the medications,dependent on the defecation patterns of their child.As previously reported,education to parents about childhood constipation also might have played a role in the success of therapy.14The good clinical outcome of children entering our outpatient clinic with a symp
tom history of <3months might also reflect a heightened attention of caretakers toward their children’s constipation.醋泡姜
The data may not be generalized to the general pediatric care tting,where less vere forms of constipation may be encountered.We found that a number of patients remain constipated for a prolonged period of time,requiring continuing treatment and long-term follow-up.Early thera-peutic intervention beneficially contributes to the outcome of constipation in infants.
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