Magdalena Reich, Barbara Iwańczak
Symptoms Associated with Functional Constipations
in Children and Adolescents
Objawy towarzyszące zaparciom czynnościowym u dzieci i młodzieży
2nd Department of Pediatrics, Gastroenterology and Nutrition, Wroclaw Medical University, PolandAbstract
Background. Chronic constipations present an important problem in children. They cause a significant distress
and decrease the quality of life of patients and their families.
Objectives. The aim of this study was to assess the major clinical and demographic parameters influencing the
manifestation of functional constipations in children.
Material and Methods. A total of 126 children (67 boys and 59 girls) suffering from functional constipations were
included into the study. A specially designed questionnaire containing demographic and clinical data was com-pleted based on anamnesis and physical examinations. All subjects were divided into subgroups according to their age, gender, age at disease onset, disease duration, family history of chronic constipations, coexistence of allergic disorders, coexistence of urinary tract infection, presence of emotional problems, the previous treatment, and Body Mass Index (BMI).
Results. The most frequently observed symptoms of functional constipations were abdominal pain (60.3% of
children), followed by rectal tenesmus (58.7%) and pain during defecation (52.4%). Analysis of various clinical parameters revealed that patients’ age, gender, age at disease onset, disease duration, positive family history of con-stipation, food allergy and urinary tract infection may have an influence on the clinical presentation of functional constipations in children.
Conclusions. Clinical manifestation of functional constipations in children may significantly vary between patients.
While studying the symptoms of chronic constipations in children it is of great importance to identify parameters that influence the clinical presentation of this disorder (Adv Clin Exp Med 2010, 19, 4, 519–530).
Key words: chronic constipations, soiling, children, adolescents.
Streszczenie
Wprowadzenie. Przewlekłe zaparcia są poważnym problemem u dzieci. Zaparcia powodują niepokój rodziców,
którzy niejednokrotnie uważają, że obserwowane dolegliwości są objawem ciężkiej choroby.
Cel pracy. Ocena najczęściej występujących objawów klinicznych zaparć czynnościowych u dzieci.
Materiał i metody. Do badania włączono 126 dzieci (67 chłopców i 59 dziewczynek) cierpiących z powodu zaparć
czynnościowych. Każdy pacjent został poddany szczegółowemu badaniu podmiotowemu i fizykalnemu. Na pod-stawie uzyskanych informacji wypełniano specjalnie w tym celu przygotowaną ankietę. Wszystkich pacjentów podzielono na podgrupy pod względem wieku, płci, leczenia zaparć w przeszłości, wieku w chwili zachorowania, długości trwania schorzenia, współistnienia schorzeń alergicznych, występowania zaburzeń emocjonalnych, dodat-niego wywiadu rodzinnego w kierunku występowania zaparć, wartości wskaźnika Body Mass Index, współistnienia zakażenia układu moczowego.
Wyniki. Najczęstszym objawem towarzyszącym zaparciom czynnościowym były bóle brzucha (60,3% dzieci),
uczucie nasilonego parcia na stolec (58,7% dzieci) oraz ból towarzyszący defekacji (52,4% dzieci). Analizując obraz chorobowy zaparć w wyszczególnionych podgrupach chorych wykazano, że na częstość występowania poszczegól-nych objawów kliniczposzczegól-nych zaparć czynnościowych istotny wpływ mają wiek i płeć pacjentów, a także wiek wystą-pienia choroby, długość jej trwania, występowanie zaparć wśród innych członków rodziny oraz współistnienie alergii pokarmowej lub zakażenia układu moczowego.
Wnioski. Kliniczne objawy zaparć czynnościowych mogą znacznie różnić się u poszczególnych pacjentów. Analiza
objawów zaparć przewlekłych ma istotne znaczenie w ustaleniu czynników wpływających na kliniczną manifestację schorzenia (Adv Clin Exp Med 2010, 19, 4, 519–530).
Słowa kluczowe: zaparcia czynnościowe, brudzenie bielizny, dzieci, młodzież.
Adv Clin Exp Med 2010, 19, 4, 519–530 ISSN 1230-025X
ORIGINAl PAPERS
M. Reich, B. Iwańczak
Constipations are defined as defecations oc-curring less than 3 times a week or at intervals longer than three days or any defecation with dif-ficulties requiring increased effort during stool passage [1, 2]. However, healthy children may sometimes defecate with soft stool every 2–3 days and in such situations constipations should not be diagnosed unless the defecations are connected with increased effort or pain. Similar situation is occurring among breastfed infants that may also defecate on rare occasions, however, with normal stool consistency [2]. Constipations in children are characterized by low frequency of defecations, concomitant soiling, passage of a large amount of stool, retaining position and commonly difficult, painful defecation [3]. Functional constipations are the most common type of chronic constipations in children, however, about 10–15% of pediatric patients may require additional diagnostic proce-dures to exclude other causes, as constipations in children may also be related to anatomical abnor-malities, genetic disorders, wrong diet as well as to some medicines or chemical substances [2, 4].
little is known about the prevalence of chronic constipations in children. It was observed that chil-dren with constipations constituted about 3–5% of all visits in pediatric outpatient clinics [5, 6], and about 25% of all children referred to gastroenter-ologists demonstrated problems with defecation [7–9]. According to Felt et al. [10], about 3% of pre-school children and about 1–2% of children attending school have problems with constipations with or without soiling.
Clinical symptoms of chronic constipations may vary markedly in relation to the patient’s age and duration of the disease [2]. Usually, most pa-tients experience increased rectal tenesmus, abun-dant stools, painful defecations, feeling of not complete emptying and long intervals between defecations [2]. Sometimes there is blood present in the stool and about 1/3 of patients suffer from soiling [2, 4]. In addition, the majority of children with constipations had recurrent abdominal pains, that lead to frequent school absences and some-times avoidance of contacts with other children limiting the normal social activity of sufferers [4]. Therefore, functional constipations constitute an important medical problem, as they cause signifi-cant distress, both for children and their parents, as well as may alter the proper psychosocial de-velopment of children and adolescents. For this reason the authors performed a study to assess the frequency of various clinical and radiological abnormalities in children and adolescents with functional constipations in relation to a number of sociodemographic and clinical parameters.
Material and Methods
Patients
Patients were consecutively recruited between January 2006 and December 2008 from children admitted to the 2nd Department of Pediatrics, Gas-troenterology and Nutrition of Wroclaw Medical University (Poland) to diagnose and treat chronic constipations. Among 137 pre-identified individu-als with chronic constipations, 126 (92%) were found to suffer from functional constipations based on the Rome III criteria [11] and these subjects were enrolled for final analysis. Their age ranged between 1.5 and 220 months (mean ± SD: 89.8 ± ± 55.7 months, median: 79 months), the time of disease onset ranged between 0 and 198th month of patients age (mean ± SD: 50.2 ± 49.1 month, me-dian: 34 months) and the duration of chronic con-stipations was between 1 and 187 months (mean ± ± SD: 37.9 ± 40.8 months, median: 24 months). All subjects were divided into subgroups based on their age, gender, age at disease onset, disease dura-tion, family history of chronic constipations, coex-istence of allergic disorders, coexcoex-istence of urinary tract infection, presence of emotional problems, the fact of previously performed treatment of con-stipations, as well as the value of Body Mass Index (BMI). A detailed characteristics of included pa-tients is shown in Table 1.
Study Description
The study was approved by local Ethic Com-mittee of Wroclaw Medical University (KB– –3/2005). The study was performed according to the guidelines of Helsinki Declaration. All parents or legal guardians agreed to include their children into the study.
Every patient underwent careful examination. A specially designed questionnaire was completed based on anamnesis and physical examination. The BMI was calculated according to the follow-ing formula:
BMI = weight [kg] / (height [m])2
The BMI values below the 10th percentile for children in Poland [12] were considered as un-derweight, between the 10th and 90th percentile as normal weight, and over the 90th percentile as overweight.
Functional Constipation in Children
Statistical Analysis
All results were analysed statistically using Statis-tica® 7.0 Pl (Statsoft, Kraków, Poland). Means,
stan-dard deviations, medians, minimums, maximums and frequencies were calculated. Student t test, Mann- -Whitney U test, analysis of variance (ANOVA) or χ2 test were applied where appropriate. P-values less than 0.05 were considered significant.
Results
Clinical Symptoms
Age
Abdominal pain seemed to be infrequent in very young children (< 3 years of age) (15.4%) compared to children in the age between 3 and 7 years old (71.8%) and over 7 years old (72.1%) (p < 0.001) (Table 2). Soiling also was rarer in the youngest group than in the two other groups (p < < 0.001) (Table 2), however, this finding might be related to the difficulty in differentiating between a physiological unconscious defecation and soil-ing in very young children. On the other hand, the youngest group was found as suffering more fre-quently from loss of appetite (p = 0.02). Further-more, provoked defecations predominated over spontaneous ones (p < 0.001) as well as retention of stool masses was less frequently observed dur-ing physical examination compared to the remain-ing patients (p < 0.001). In contrast, children over 7 years old significantly more commonly experi-enced the feeling of not complete bowel emptying (p < 0.001). The remaining symptoms related to constipations occurred at a similar frequency in each age group (Table 2).
Gender
Boys were significantly younger than girls (mean ± SD 78.1 ± 46.6 months, median 72 months, range: 1.5–185 months compared to mean ± SD 103.2 ± 62.3 months, median 105 months, range 2–220 months, respectively, p < 0.05). Regarding the symptoms of constipations it was observed that soiling was more frequent in males (55.2%) than in females (30.5%, p < 0.01). In contrast, girls signifi-cantly more commonly suffered from abdominal-gia (71.2%) compared to boys (50.7%, p = 0.03), however, the characteristic and localization of ab-dominal pain was in both groups similar. Further-more, pathologic components of stool were more frequent in girls (37.3%) than in boys (14.9%, p < < 0.01). No other significant differences were
ob-served between males and females in respect of symptoms, result of physical examination and ra-diological findings (Table 2).
Table 1. Patient characteristics
Tabela 1. Charakterystyka pacjentów
Description (Opis) N (%) Age (Wiek):
< 3 years ≥ 3 and < 7 years ≥ 7 years
26 (20.6) 39 (31.0) 61 (48.4) Gender (Płeć):
boys
girls 67 (53.2)59 (46.8) Age at disease onset
(Wiek wystąpienia choroby): < 12 months of age ≥ 12 < 36 months of age ≥ 36 months of age
39 (32.5) 23 (19.2) 58 (48.3) Disease duration
(Czas trwania choroby): < 6 months ≥ 6 < 12 months ≥ 12 months
29 (24.2) 16 (13.3) 75 (62.5) Allergic diseases (Alergia):
food allergy
other allergic diseases none
34 (27.0) 13 (10.3) 79 (62.7)
Family history of chronic constipa-tions (Wywiad rodzinny w kierunku występowania zaparć):
yes
no 11 (8.7)115 (91.3) Urinary tract infection
(Zakażenie układu moczowego)**: yes
no 11 (11.3)86 (88.7) Emotional problems
(Zaburzenia emocjonalne): present
absent 45 (35.7)81 (64.3) Therapy (leczenie):
previously untreated patients
previously treated patients 70 (55.6)56 (44.4) Body Mass Index:
< 10 percentile 10–90 percentile > 90 percentile
16 (12.7) 97 (77) 13 (10.3)
* In 6 patients it was not possible to determine the disease onset.
** The urine culture was done in 97 patients. *** Barium enema was performed in 96 patients.
* U 6 pacjentów ustalenie wieku wystąpienia choroby było niemożliwe.
** Badanie bakteriologiczne moczu zrobiono u 97 pacjentów.
M. Reich, B. Iwańczak Table 2. Clinical symptoms of functional constipations according to age, gender, disease onset and disease duration Tabela 2. Objawy kliniczne zaparć czynnościowych w stosunku do wieku, płci, czasu wystąpienia i czasu trwania choroby Symptoms (Objawy) Age – years (Wiek – lata) Gender (Płeć) Age at disease onset (Czas wystąpienia choroby) Disease duration (Czas trwania choroby) ≤ 3 N (%) > 3 ≤ 7 N (%) > 7 N (%) P
boys N (%) girls N (%)
P
≤
12
months N (%)
>
12
≤3
6
months N (%)
>
36
months N (%)
P
≤
6
months N (%)
>
6
≤
12
months N (%)
>
12
months N (%)
P Abdominal pain 4 (15.4) 28 (71.8) 44 (72.1) < 0.001 34 (50.7) 42 (71.2) 0.03 15 (38.5) 14 (60.9) 43 (74.1) < 0.01 13 (44.8) 9 (56.2) 50 (66.7) 0.12 Frequency of abdominal pain* sporadic, not related to defecation sporadic, in relation to defecation frequent, not related to defecation frequent, in relation to defecation 0 (0) 0 (0) 0 (0) 4 (100) 3 (10.7) 7 (25) 3 (10.7) 15 (53.6) 1 (2.3) 11 (25) 6 (13.6) 26 (59.1) 0.49 0 (0) 7 (20.6) 3 (8.8) 24 (70.6) 4 (9.5) 11 (26.2) 6 (14.3) 21 (50) 0.15 2 (13.3) 0 (0) 3 (20) 10 (66.7) 0 (0) 6 (42.9) 0 (0) 8 (57.1) 2 (4.6) 10 (23.3) 6 (14) 25 (58.1) 0.08 1 (7.7) 1 (7.7) 2 (15.4) 9 (69.2) 0 (0) 4 (44.4) 1 (11.1) 4 (44.4) 3 (6) 11 (22) 6 (12) 30 (60) 0.61 localisation of abdominal pain* epigastrium the middle part of abdomen underbelly epigastrium and the middle part of abdomen epigastrium and underbelly the middle part of abdomen and underbelly the whole abdomen no data 0 (0) 0 (0) 1 (25) 0 (0) 0 (0) 0 (0)
0 (0) 3 (75)
0 (0) 9 (32.1) 12 (42.9) 0 (0) 0 (0) 2 (7.1) 0 (0) 5 (17.9) 5 (11.4) 8 (18.2) 19 (43.2) 2 (4.6) 1 (2.3) 4 (9.1) 1 (2.3) 4 (9.1) 0.13 2 (5.9) 9 (26.5) 14 (41.2) 0 (0) 0 (0) 2 (5.9) 1 (2.9) 6 (17.6) 3 (7.1) 8 (19) 18 (42.9) 2 (4.8) 1 (2.4) 4 (9.5) 0 (0) 6 (14.3) 0.7 0 (0) 6 (40) 6 (40) 0 (0)
0 (0) 0 (0) 0 (0) 3 (20)
0 (0) 2 (14.3) 6 (42.9) 0 (0)
0 (0) 1 (7.1) 1 (7.1) 4 (28.6)
Functional Constipation in Children Table 2. Clinical symptoms of functional constipations according to age, gender, disease onset and disease duration – cont. Tabela 2. Objawy kliniczne zaparć czynnościowych w stosunku do wieku, płci, czasu wystąpienia i czasu trwania choroby – cd. Symptoms (Objawy) Age – years (Wiek – lata) Gender (Płeć) Age at disease onset (Czas wystąpienia choroby) Disease duration (Czas trwania choroby) ≤ 3 N (%) > 3 ≤ 7 N (%) > 7 N (%) P
boys N (%) girls N (%)
P
≤
12
months N (%)
>
12
≤3
6
months N (%)
>
36
months N (%)
P
≤
6
months N (%)
>
6
≤
12
months N (%)
>
12
months N (%)
P Frequency of defecation regularly, but with the feeling of no complete bowel emptying 1–2 times a week less than once a week no data 3 (11.6) 22 (84.6) 0 (0) 1 (3.8) 6 (15.4) 27 (69.2) 5 (12.8) 1 (2.6) 6 (9.8) 45 (73.8) 3 (4.9) 7 (11.5) 0.28 11 (16.4) 45 (67.1) 5 (7.5) 6 (9) 4 (6.8) 49 (83) 3 (5.1) 3 (5.1) 0.15 5 (12.8) 29 (74.4) 3 (7.7) 2 (5.1) 4 (17.4) 17 (74) 1 (4.3) 1 (4.3) 6 (10.3) 43 (74.2) 4 (6.9) 5 (8.6) 0.93 3 (10.3) 22 (75.9) 1 (3.5) 3 (10.3) 1 (6.2) 14 (87.5) 0 (0) 1 (6.2) 11 (14.7) 53 (70.7) 7 (9.3) 4 (5.3) 0.45
Defecation spontaneous after
M. Reich, B. Iwańczak
Age at Disease Onset
Patients who were younger than 1 year at the disease onset complained less commonly of ab-dominal pain (38.5%) when compared to the other groups (60.9% and 74.1%, respectively, p < 0.01). They also significantly more frequently defecat-ed after provocation (19/36) than the remaining subjects (6/17 and 11/46, respectively, p = 0.03). Interestingly, pain during defecation was more common in subjects with disease onset between 12th and 36th months of age (82.6% vs. 48.2% and 44.8% respectively, p < 0.01). Furthermore, soiling was the most frequent symptom in children with functional constipations that started after the 3rd year of their life (p < 0.01). Other pathologic find-ings occurred with similar frequency in all ana-lyzed subgroups (Table 2).
Disease Duration
It was observed that the duration of functional constipations significantly influenced the frequen-cy of soiling and refraining from defecation. Chil-dren suffering from functional constipations less than 6 months significantly rarer had soiling (p < < 0.001) and refrained from defecation (p = 0.03). Moreover, these patients were also less frequently found to have retention of stool masses during physical examination (p = 0.01). The remaining symptoms occurred irrespectively of disease dura-tion (Table 2).
Allergy
Based on anamnesis and results of prick-tests with food allergens, 34 (27%) patients with func-tional constipations were found to suffer from food allergy. Food allergy was accompanied by other allergic diseases in 10 (7.9%) children, including pollinosis in 6 (4.8%), atopic eczema in 3 (2.3%) and asthma in 1 (0.8%) subject. In addition, further 13 (10.3%) individuals with functional constipations had other allergic disorders like pollinosis (n = 6), atopic eczema (n = 2), pollinosis and atopic eczema (n = 2), asthma (n = 1) or asthma and pollinosis (n = 2). The most frequent food allergens in ana-lyzed patients were cow milk (n = 16), beef (n = 6), soy bean (n = 5), peanuts (n = 4) and citrus fruits (n = 4); less commonly wheat flour (n = 3), sesa-me (n = 3), egg white (n = 2), banana (n = 2), fish (n = 1), cacao (n = 1), strawberries (n = 1), chicken meat (n = 1), pork (n = 1) and egg yolk (n = 1) were observed. Patients with food allergy accompany-ing functional constipations were younger (mean age ± SD 70.7 ± 55.7 months, median 55 months, range 2–220 months) than subjects with other
aller-gic diseases (mean age ± SD: 122.0 ± 46.4 months, median 126 months, range 38–185 months) and patients without any symptoms of allergy (mean age ± SD 92.8 ± 54.7 months, median 79 months, range 1.5–208 months) (p = 0.01). Furthermore, the onset of chronic constipations in children with food allergy occurred significantly earlier (mean ± SD 37.5 ± 41.7 months of age, median 24th month, range 1st–142nd month) compared to patients with other allergic diseases (mean ± SD 87.7 ± 56.0 months of age, median 94 months, range 2nd– 181st month) or without any allergy (mean ± SD 49.1 ± 48.2 months of age, median 37th month, range 0–199th month) (p < 0.01).
Regarding the gastrointestinal symptoms, abdominal pain occurred more commonly in pa-tients with allergic diseases compared to subjects without any allergy (p = 0.02), although the pain character and localization was in all groups simi-lar. In addition, pathologic components were more frequently observed in the stools of subjects with food allergy (38.2%) than in patients with other al-lergic diseases (30.8%) or without allergy (29.1%) (p = 0.04). The prevalence of other symptoms did not differ significantly between the analyzed sub-groups (Table 3).
Family History of Chronic
Constipations
Patients with positive family history of func-tional constipations became ill significantly earlier (mean ± SD 26.3 ± 42.3 month, median 10 months range 1st week – 140th month) than the rest of pa-tients (mean ± SD 52.3 ± 49.3 months, median 38th month, range 0–199th month) (p < 0.05). Concern-ing the clinical symptoms, only the frequency of soiling was significantly influenced by the fam-ily history of constipation, being more commonly stated in subjects with negative family history of chronic constipations (47% vs. 9.1%, p = 0.02) (Table 3).
Urinary Tract Infection
Functional Constipation in Children Table 3. Clinical symptoms of functional constipations in relation to concomitant allergic disorders, family history of chronic constipations, presence of urinary tract infection and emotional problems Tabela 3. Objawy zaparć czynnościowych w zależności od współistnienia chorób alergicznych, wywiadu rodzinnego, obecności zakażenia układu moczowego i problemów emocjonalnych Symptoms (Objawy) Allergy (Alergia) Family history of chronic constipations (Czas trwania choroby) Unomary tract infection** (Zakażenie układu moczowego) Emotional problems (Zaburzenia emocjonalne) food allergy N (%) other allergic
diseases N (%)
no
allergy
N
(%)
P
positive N (%) negative N (%)
P
yes N (%) no N (%)
P
present N (%) absent N (%)
P Abdominal pain 22 (64.7) 12 (92.3) 42 (53.2) 0.02 6 (54.6) 70 (60.9) 0.68 4 (36.4) 54 (62.8) 0.09 28 (62.2) 48 (59.3) 0.89 Frequency of abdominal pain* sporadic, not related to defecation sporadic, in relation to defecation frequent, not related to defecation frequent, in relation to defecation 1 (4.5) 4 (18.2) 2 (9.1) 15 (68.2) 0 (0) 3 (25) 3 (25) 6 (50) 3 (7.1) 11 (26.2) 4 (9.5) 24 (57.1) 0.69 0 (0) 1 (16.7) 0 (0) 5 (83.3) 4 (5.7) 17 (24.3) 9 (12.9) 40 (57.1) 0.6 0 (0) 0 (0) 0 (0) 4 (100) 1 (1.9) 14 (25.9) 8 (14.8) 31 (57.4) 0.42 2 (7.1) 7 (25) 2 (7.1) 17 (60.8) 2 (4.2) 11 (22.9) 7 (14.6) 28 (58.3) 0.76 localisation of abdominal pain* epigastrium the middle part of abdomen underbelly epigastrium and the middle part of abdomen epigastrium and underbelly the middle part of abdomen and underbelly the whole abdomen no data 1 (4.5) 5 (22.7) 9 (40.9) 0 (0) 1 (4.5) 3 (13.6) 0 (0) 3 (13.6) 1 (8.3) 3 (25) 4 (33.3) 1 (8.3) 0 (0) 1 (8.3) 0 (0) 2 (16.7) 3 (7.1) 9 (21.4) 19 (45.2) 1 (2.4) 0 (2.3) 2 (4.8) 1 (2.4) 7 (16.7) 0.92 0 (0) 2 (33.3) 2 (33.3) 0 (0) 0 (0) 0 (0) 0 (0) 2 (33.3) 5 (7.1) 15 (21.4) 30 (42.9) 2 (2.9) 1 (1.4) 6 (8.6) 1 (1.4) 10 (14.3) 0.88 0 (0) 0 (0) 2 (50) 0 (0) 0 (0) 0 (0)
– 2 (50)
5 (9.3) 12 (22.2) 22 (40.7) 1 (1.9) 1 (1.9) 6 (11.1)
– 7 (12.9)
M. Reich, B. Iwańczak Table 3. Clinical symptoms of functional constipations in relation to concomitant allergic disorders, family history of chronic constipations, presence of urinary tract infection and emotional problems – cont. Tabela 3. Objawy zaparć czynnościowych w zależności od współistnienia chorób alergicznych, wywiadu rodzinnego, obecności zakażenia układu moczowego i problemów emocjonalnych – cd. Symptoms (Objawy) Allergy (Alergia) Family history of chronic constipations (Czas trwania choroby) Unomary tract infection** (Zakażenie układu moczowego) Emotional problems (Zaburzenia emocjonalne) food allergy N (%) other allergic
diseases N (%)
no
allergy
N
(%)
P
positive N (%) negative N (%)
P
yes N (%) no N (%)
P
present N (%) absent N (%)
P Frequency of defecation regularly, but with the feeling of no complete bowel emptying 1–2 times a week less than once a week no data 2 (5.9) 27 (79.4) 3 (8.8) 2 (5.9) 1 (7.7) 9 (69.2) 0 (0) 3 (23.1) 12 (15.2) 58 (73.4) 5 (6.3) 4 (5.1) 0.56 1 (9.1) 10 (90.9) 0 (0) 0 (0) 14 (12.2) 84 (73) 8 (7) 9 (7.8) 0.57 4
(36.4) 7 (63.6) 0 (0) 0 (0)
6 (7) 67 (77.9) 6 (7) 7 (8.1) 0.01 3 (6.7) 34 (75.5) 3 (6.7) 5 (11.1) 12 (14.8) 60 (74.1) 5 (6.2) 4 (4.9) 0.46
Defecation spontaneous after
provocation no data 18 (52.9) 12 (35.3) 4 (11.8) 5 (38.5) 2 (15.4) 6 (46.1) 43 (54.4) 22 (27.9) 14 (17.7) 0.78 5 (45.4) 4 (36.4) 2 (18.2) 61 (53) 32 (27.8) 22 (19.1) 0.72 4
(36.4) 6 (54.5) 1 (9.1)
47 (54.7) 23 (26.7) 16 (18.6) 0.09 22 (48.9) 13 (28.9) 10 (22.2) 44 (54.3) 23 (28.4) 14 (17.3) 0.95 Stool characteristic normal tight plentiful/big bean-like tight and plentiful/big tight and bean-like plentiful/big and bean-like no data 2 (5.9) 12 (35.3) 5 (14.7) 5 (14.7) 1 (2.9) 2 (5.9) 2 (5.9) 5 (14.7) 1 (7.7) 4 (30.8) 1 (7.7) 1 (7.7) 0 (0) 1 (7.7) 0 (0) 5 (38.5) 5 (6.3) 23 (29.1) 9 (11.4) 10 (12.7) 14 (17.7) 4 (5.1) 3 (3.8) 11 (13.9) 0.58 0 (0) 2 (18.2) 2 (18.2) 1 (9.1) 2 (18.2) 1 (9.1) 1 (9.1) 2 (18.2) 8 (7) 37 (32.2) 13 (11.3) 15 (13) 13 (11.3) 6 (5.2) 4 (3.5) 19 (16.5) 0.75 1
(9.1) 5 (45.4) 0 (0) 2 (18.2) 1 (9.1) 0 (0) 1 (9.1) 1 (9.1)
2 (2.3) 28 (32.6) 11 (12.8) 12 (14) 10 (11.6) 3 (3.5) 3 (3.5) 17 (19.8) 0.63 0 (0) 17 (37.8) 4 (8.9) 6 (13.3) 6 (13.3) 3 (6.7) 0 (0) 9 (20) 8 (9.9) 22 (27.2) 11 (13.6) 10 (12.3) 9 (11.1) 4 (4.9) 5 (6.2) 12 (14.8) 0.16 Stool retention on palpation yes no no data 24 (70.6) 9 (26.5) 1 (2.9) 5 (38.5) 4 (30.8) 4 (30.8) 60 (76) 17 (21.5) 2 (2.5) 0.33 5 (45.4) 5 (45.4) 1 (9.1) 84 (73.1) 25 (21.7) 5 (5.2) 0.12 8
(72.7) 3 (27.3) 0 (0)
Functional Constipation in Children
median 36 months, range 0–199 months, p = 0.03). Regarding the clinical symptoms of chronic con-stipations it was observed that only the frequency of defecations differed significantly between these two groups of patients: in subjects with urinary tract infections defecations were more regular, al-though incomplete (p = 0.01) (Table 3).
Emotional Problems
Based on the psychological examination signif-icant emotional problems were found in 45 (35.7%) children with functional constipations. However, the presence of emotional problems did not influ-ence significantly the symptoms of chronic consti-pations in analyzed group of patients (Table 3).
Previous Therapy Against
Constipations
By comparison of previously untreated patients with those who received therapy against constipa-tions before the admission to the department it was observed that the only important difference between these two groups of patients regarding the clinical symptoms was slightly higher prevalence of abdom-inal pain in previously untreated subjects (n = 48, 68.6%) than in the remaining patients (n = 28, 50%) (p = 0.05). The frequency of other symptoms were similar in both groups (data not shown).
Body Mass Index (BMI)
Analyzing the influence of the patient’s weight on the symptoms of chronic constipations it was observed that patients with underweight (BMI < < 10th percentile) significantly more commonly demonstrated lack of appetite (11/16) that children with normal weight (17/97) and children with over-weight (1/13) (p < 0.001). The frequency of other symptoms did not differ between the subgroups discriminated based on BMI (data not shown).
Radiological Findings
As mentioned in Material and Methods, barium enema was performed in 96 (76.2%) sub-jects. Normal morphology of large intestine was found only in 18 (18.7%) subjects. The most com-mon abnormalities were dolichocolon and/or dolichosigma (n = 56, 58.3%), followed by spas-tic lesions (n = 30, 31.2%) and retention of stool masses (n = 23, 24%) (Table 4). The presence of dolichocolon and/or dolichosigma did not influ-enced markedly the symptoms of chronic consti-pations (data not shown). Interestingly, all sub-jects with urinary tract infection that underwent barium enema presented with dolichocolon and/ or dolichosigma (n = 9) compared to 40 (63.5%) children without urinary tract infection (p < 0.05). No other significant relationships were found be-tween radiological findings and clinical symptoms of functional constipations or studied parameters (data not shown).
Discussion
Chronic functional constipations represent an important problem among children [9, 13–15]. They cause a significant distress and reduce the patient’s quality of life which is strictly related to their severity [16, 17]. It was also shown that long- -lasting constipations in pediatric patients may predispose to the development of other diseases including urine incontinence and irritable bowel syndrome [18, 19]. Based on the observation, that in own studied population boys were significantly younger than girls, one could suggest that regard-ing small children functional constipations are more prevalent in boys, while girls are more com-monly affected by functional constipations during adolescence. Similar relationship was also found by Youseff et al. [20], who supposed that higher prevalence of chronic constipations in teenage girls may be related to female sex hormones, as it was shown that progesterone may alter the time of colonic transit [21].
In own study the clinical manifestation of chronic constipations in children were strictly dependent on their age. These differences can be explained by different physiology and psycho-social development of children with various age. In infants constipations commonly appear while stopping breastfeeding or during introduction of new foods into the diet. Remarkably, in these group of patients the subjective symptoms of con-stipations, like e.g. abdominal pain, can only be deducted based on the child’s behavior. On the other hand, parents are usually more
concentrat-Table 4. Results of barium enema of large intestine
Tabela 4. Wyniki wlewu kontrasowego jelita grubego Findings (Wyniki) N % Normal morphology
Dolichocolon and/or dolichosigma Spastic lesions
Retention of stool masses Contraction close to anus Vanishing of colonic haustration Megarectum
Polyps
18 56 30 23 2 2 4 1
M. Reich, B. Iwańczak
ed on small children. Therefore, any decrease in defecation frequency in these patients may induce a “therapeutic” activity of care givers resulting in the observed high prevalence of provoked defeca-tions in the youngest group of studied subjects. In toddlers functional constipations may be related to the learning of independent toilet using, while in school children they are frequently connected with stress at school or with the necessity of common toilet usage [14, 22]. In children older than 3 years the most common symptom of constipations was abdominal pain. This is of importance, as consti-pations were found to be the most common cause of acute abdominal pain in nearly 1000 children visiting the primary care clinics, while a surgical reason constituted only 2% of cases [23].
Symptoms of chronic constipations also de-pended on the time of disease onset and duration of functional constipations. Importantly, patients who suffered from that problem longer than six months frequently refrained from defecation. This phenomenon can be explained by the fact that pas-sage of a big and hard stool, that is commonly ob-served in constipated patients, is usually connected with much pain. Thus, a vicious circle can be easily identified: problems with bowel movement lead to stool accumulation that become very hard; pas-sage of such stool is painful and children start to refrain from defecation to prevent a pain. Finally, this behavior leads to intensification of constipa-tions. Retention of stool may result in megarectum and fecal soiling [2]. Therefore, at the beginning any treatment of chronic constipations in children should be directed to the softening of the stool and, if necessary, to the removal of stool masses from rectum to overcome the fear of painful defecation. It is still not clear whether food allergy can contribute to functional constipations in children or not. However, painful defecation may theoreti-cally explain such a relationship. It seems that at least cow milk allergy can be an important factor contributing to problems with defecation. It was observed that ceasing of cow milk supplementa-tion resulted in receding of chronic constipasupplementa-tions in a portion of children younger than 6 years, while re-exposure to this allergen led to the recurrence of constipations [24–29]. Interestingly, in own popu-lation the subjects with food allergy were signifi-cantly younger as well as the onset of functional constipations appeared at younger age than in re-maining patients. This finding may be explained by the fact that the cow milk allergy is more preva-lent in smaller children, however, it could also be suggested that food allergy may promote consti-pations mainly in younger patients, while in older ones this factor seems to be less important. Iacono et al. [27] supposed that cow milk allergens may
induce inflammation of large intestine, damage of rectal mucous membrane and pain during bowel movement. As a consequence, inhibition of def-ecation may occur. Indeed, it was observed that food allergy may decrease the colonic transit time in children [30, 31] as well as may induce proctitis with eosinophils infiltrating mucous membrane of rectum [25]. On the other hand, Caffarelli et al. [17] did not find any significant differences re-garding the prevalence of constipations between children with and without food allergy [32].
Regarding other studied parameters the authors were unable to prove their concept that emotional problems, obesity or urinary tract infection may be relevant for the clinical presentation of functional constipations. Based on own results it seems that these factors have rather limited, if any, influence on the symptoms of chronic constipations.
Emotional problems were frequently identified in own patients, however, subjects with and with-out psychological troubles did not differ between themselves significantly regarding the manifesta-tion of constipamanifesta-tions. Importantly, it is sometimes difficult to distinguish whether emotional problems are a reason or a consequence of constipations, lim-iting the value of such analysis. Usually, chronic constipations are believed to produce anxiety and depressive symptoms among sufferers [33, 34]. On the other hand, some authors underlined the possi-bility of causative role of emotions in children with defecation problems, suggesting the necessity of psychiatric treatment in these subjects [35–37].
Several researchers suggested that obesity can be an important co-morbidity of chronic constipa-tions [38–40]. Pashnakar and loening-Baucke [40] found that more than 20% of children with consti-pations suffered from obesity comparing to about 10% in control population, with higher prevalence of overweight in constipated boys than in girls. In addition, constipations were observed 22.5–43.6% of obese children [38, 39]. In contrast to these find-ings, only 10.3% of own patients had BMI over 90 percentile, suggesting that maybe overweight plays a minor role as a reason of chronic constipations in Polish children. Moreover, similarly to other au-thors [39, 40] the auau-thors did not observe signifi-cant influence of the overweight on the symptoms of constipations.
Functional Constipation in Children
loening-Baucke [43], who observed enuresis in 21.8% children with constipations in comparison to 7.3% of otherwise healthy children. Besides en-uresis, chronic constipations may also predispose to urinary tract infections [13]. Although in stud-ied group of patients infections of urinary tract were not very common, it is worth to underline that they occurred mainly in younger children and those subjects who experienced an earlier onset of functional constipations. Interestingly, there was also a tendency to higher prevalence of urinary tract infections in boys.
Regarding radiological findings in patients with constipations, dolichocolon and/or dolicho-sigma was the most frequently noted abnormality. This observation has been already mentioned in the literature [9, 44]. However, it is essential to under-line, that in contrast to previous suggestions [44], the presence of this finding had no influence on the clinical manifestation of functional constipa-tions. It seems that dolichocolon and/or dolicho-sigma has rather limited importance regarding
functional constipations and that they could be a result of a frequent retention of stool masses in constipated children rather than a true anatomi-cal alteration. It is also important to mention, that it was demonstrated that the radiological assess-ment in constipations is very subjective showing high inter- and intrapersonal variability and have little relationship with colonic transit time [45]. Therefore, the authors do believe that the presence of dolichocolon and/or dolichosigma in patients with functional constipations should not be an in-dication to any surgical procedures and that these subjects required the same therapy as remaining children with constipations.
In conclusions, clinical manifestation of func-tional constipations in children may significantly vary between patients. Therefore, it is of great im-portance to identify parameters that influence the clinical presentation of chronic constipations, while examining children with this problem. The authors hope that own study will be of interest for clinicians dealing with patients suffering from constipations.
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Address for correspondence:
Magdalena Reich2nd Department of Pediatrics, Gastroenterology and Nutrition Wroclaw Medical University
M. Curie-Skłodowskiej 50/52 50-369 Wrocław
Poland
Tel.: +48 71 770 30 45 E-mail: [email protected]
Conflict of interest: None declared
