Functional Constipation in Children: Does It Return?
Functional Constipation in Children: Does It Return?
Bongers MEJ, van Wijk MP, Reitsma JB, Benninga MA
Pediatrics. 2010;126:e156-e162
Bongers and associates note that approximately 3% of ambulatory pediatric visits are for functional constipation, and the percentage of visits to pediatric gastroenterologists for this reason is even higher. Some previous data have suggested that functional constipation was not as self-limited as believed, but this study aimed to evaluate the persistence of constipation into adulthood, data which were previously lacking.
The investigators also sought to determine which variables, as measured at the time of referral, would predict later persistence of symptoms. All children were enrolled in clinical studies of constipation conducted at the referral center from 1991-1999 and met the following uniform definition of functional constipation by having at least 2 of following 4 criteria: < 3 stools per week; at least 2 episodes of stool incontinence per week; large stool at least once every 7-30 days; or palpable rectal or abdominal mass on physical examination. The children were 5-18 years of age at enrollment.
In the clinical treatment phase, the children all underwent an aggressive 6- to 8-week protocol followed by visits approximately every 6 months. The final follow-up for this study was conducted between 2005 and 2007, and data were collected either during a clinic visit or by telephone. During each follow-up, the investigators collected a standardized set of clinical information to assess the status of patient symptoms. They defined good clinical outcome as defecation at least 3 times per week for at least 4 weeks; < 2 episodes of incontinence per month; and no requirement for laxatives in the previous 4 weeks. The investigators also identified children who had good clinical outcomes with laxative use, and 2 groups of children with poor clinical outcomes (with or without laxative use). Relapse was defined as reduction in stool frequency to < 3 times per week or an increase in incontinence episodes.
This report included outcomes of 401 children, 65% of whom were boys; median 8 years of age at enrollment; and with a median follow-up period of 11 years. The median age of onset of constipation was 3 years. At enrollment, 68% reported large stools, 54% had abdominal pain, and 47% reported painful defecation. Rectal masses were noted in 30%. In the first year after enrollment, 50% of the children had good clinical outcomes. The 10-year success rate was approximately 80%, and the success rates of those who had reached adulthood was 75%. Children generally improved with advancing age/time in follow-up. To determine predictors of success in adulthood, Bongers and associates used a cutoff age of 16 years and analyzed 302 of those children. Three factors were found to predict persistent constipation: delay in referral; older age at referral; and defecation frequency ≤ 1 time per week at enrollment. Cumulative relapse rates were high, at 40% of women and 20% of men who had 7 years of follow-up. The investigators concluded that 25% of children with functional constipation will have symptoms that persist into adulthood.
It is important to remember that this is a referral population, so these outcomes should not be expected for all children who a primary care provider (PCP) might treat for constipation. However, PCPs can take away several important points from this study. First, the findings suggest that early referral is important. In this study, the investigators give the example that if children were referred with a 1-year delay between onset and referral, their chances of having persistent symptoms in adulthood were 7%. However, referral after 9-years delay was associated with a 31% chance of having symptoms as adults. Second, the data show that relapses are common, but perhaps not common in any single year. Therefore, once treated for constipation, a patient seems to remain at risk for relapse, necessitating rescreening for symptoms in subsequent years. The study can't directly answer this, but the finding that individuals who present with constipation at older ages represent a higher-risk group raises the question of whether older children should be referred at a lower threshold. Their natural history certainly appears to differ from that of children who present at younger ages.
Abstract
Long-term Prognosis for Childhood Constipation: Clinical Outcomes in Adulthood
Bongers MEJ, van Wijk MP, Reitsma JB, Benninga MA
Pediatrics. 2010;126:e156-e162
Study Summary
Bongers and associates note that approximately 3% of ambulatory pediatric visits are for functional constipation, and the percentage of visits to pediatric gastroenterologists for this reason is even higher. Some previous data have suggested that functional constipation was not as self-limited as believed, but this study aimed to evaluate the persistence of constipation into adulthood, data which were previously lacking.
The investigators also sought to determine which variables, as measured at the time of referral, would predict later persistence of symptoms. All children were enrolled in clinical studies of constipation conducted at the referral center from 1991-1999 and met the following uniform definition of functional constipation by having at least 2 of following 4 criteria: < 3 stools per week; at least 2 episodes of stool incontinence per week; large stool at least once every 7-30 days; or palpable rectal or abdominal mass on physical examination. The children were 5-18 years of age at enrollment.
In the clinical treatment phase, the children all underwent an aggressive 6- to 8-week protocol followed by visits approximately every 6 months. The final follow-up for this study was conducted between 2005 and 2007, and data were collected either during a clinic visit or by telephone. During each follow-up, the investigators collected a standardized set of clinical information to assess the status of patient symptoms. They defined good clinical outcome as defecation at least 3 times per week for at least 4 weeks; < 2 episodes of incontinence per month; and no requirement for laxatives in the previous 4 weeks. The investigators also identified children who had good clinical outcomes with laxative use, and 2 groups of children with poor clinical outcomes (with or without laxative use). Relapse was defined as reduction in stool frequency to < 3 times per week or an increase in incontinence episodes.
This report included outcomes of 401 children, 65% of whom were boys; median 8 years of age at enrollment; and with a median follow-up period of 11 years. The median age of onset of constipation was 3 years. At enrollment, 68% reported large stools, 54% had abdominal pain, and 47% reported painful defecation. Rectal masses were noted in 30%. In the first year after enrollment, 50% of the children had good clinical outcomes. The 10-year success rate was approximately 80%, and the success rates of those who had reached adulthood was 75%. Children generally improved with advancing age/time in follow-up. To determine predictors of success in adulthood, Bongers and associates used a cutoff age of 16 years and analyzed 302 of those children. Three factors were found to predict persistent constipation: delay in referral; older age at referral; and defecation frequency ≤ 1 time per week at enrollment. Cumulative relapse rates were high, at 40% of women and 20% of men who had 7 years of follow-up. The investigators concluded that 25% of children with functional constipation will have symptoms that persist into adulthood.
Viewpoint
It is important to remember that this is a referral population, so these outcomes should not be expected for all children who a primary care provider (PCP) might treat for constipation. However, PCPs can take away several important points from this study. First, the findings suggest that early referral is important. In this study, the investigators give the example that if children were referred with a 1-year delay between onset and referral, their chances of having persistent symptoms in adulthood were 7%. However, referral after 9-years delay was associated with a 31% chance of having symptoms as adults. Second, the data show that relapses are common, but perhaps not common in any single year. Therefore, once treated for constipation, a patient seems to remain at risk for relapse, necessitating rescreening for symptoms in subsequent years. The study can't directly answer this, but the finding that individuals who present with constipation at older ages represent a higher-risk group raises the question of whether older children should be referred at a lower threshold. Their natural history certainly appears to differ from that of children who present at younger ages.
Abstract
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