original papers Adv Clin Exp Med 2010, 19, 4, 519–530 ISSN 1230-025X

© Copyright by Wroclaw Medical University

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, Poland

Abstract 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 completed 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 constipation, 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 podstawie 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, dodatniego 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 poszczególnych objawów klinicznych zaparć czynnościowych istotny wpływ mają wiek i płeć pacjentów, a także wiek wystąpienia 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.

520 Constipations are defined as defecations occurring less than 3  times a  week or at intervals longer than three days or any defecation with difficulties 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 procedures to exclude other causes, as constipations in children may also be related to anatomical abnormalities, 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 children with constipations constituted about 3–5% of all visits in pediatric outpatient clinics [5, 6], and about 25% of all children referred to gastroenterologists 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 patients experience increased rectal tenesmus, abundant 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 sometimes 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 significant distress, both for children and their parents, as well as may alter the proper psychosocial development 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.

M. Reich, B. Iwańczak

Material and Methods Patients Patients were consecutively recruited between January 2006 and December 2008 from children admitted to the 2nd Department of Pediatrics, Gastroenterology and Nutrition of Wroclaw Medical University (Poland) to diagnose and treat chronic constipations. Among 137 pre-identified individuals 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, median: 34 months) and the duration of chronic constipations 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 duration, family history of chronic constipations, coexistence of allergic disorders, coexistence of urinary tract infection, presence of emotional problems, the fact of previously performed treatment of constipations, as well as the value of Body Mass Index (BMI). A  detailed characteristics of included patients is shown in Table 1.

Study Description The study was approved by Local Ethic Committee 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 following formula: BMI = weight [kg] / (height [m])2  The BMI values below the 10th percentile for children in Poland [12] were considered as underweight, between the 10th and 90th percentile as normal weight, and over the 90th percentile as overweight. In addition, the urine bacteriological culture was done in 97 patients and barium enema of large intestine was performed in 96 subjects.

521

Functional Constipation in Children

Statistical Analysis All results were analysed statistically using Statistica® 7.0 Pl (Statsoft, Kraków, Poland). Means, standard 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 < 7 N (%)

≤3 N (%)

>3≤7 N (%)

Gender (Płeć)

Age – years (Wiek – lata)

Abdominal pain

Symptoms (Objawy)

Tabela 2. Objawy kliniczne zaparć czynnościowych w stosunku do wieku, płci, czasu wystąpienia i czasu trwania choroby

Table 2. Clinical symptoms of functional constipations according to age, gender, disease onset and disease duration

12 months N (%)

  0 (0)   2 (22.2)   3 (33.3)   1 (11.1)

  0 (0)   4 (44.4)   1 (11.1)   4 (44.4)

9 (56.2)

> 6 ≤ 12 months N (%)

  1 (7.7)   4 (30.8)   3 (23.1)   0 (0)

  1 (7.7)   1 (7.7)   2 (15.4)   9 (69.2)

13 (44.8)

≤ 6  months N (%)

  0 (0)   2 (15.4)

0.36

0.08

< 0.01

P

  1 (2.3)   4 (9.3)

  5 (11.6)   9 (20.9) 17 (39.5)   2 (4.6)

  2 (4.6) 10 (23.3)   6 (14) 25 (58.1)

43 (74.1)

> 36 months N (%)

M. Reich, B. Iwańczak 0.4

0.97

0.03

0.17

0.13

< 0.001

0.39

0.35

0.61

0.12

P

Disease duration (Czas trwania choroby)

  0 (0)   2 (14.3)   6 (42.9)   0 (0)     0 (0)   1 (7.1)

  0 (0)   6 (42.9)   0 (0)   8 (57.1)

14 (60.9)

> 12 ≤3 6 months N (%)

Age at disease onset (Czas wystąpienia choroby)

522

  9 (34.6) 14 (53.9)   3 (11.5)

  2 (7.7)   9 (34.6)   2 (7.7)   4 (15.4)   4 (15.4)   0 (0)   3 (11.5)   2 (7.7)

19 (73.1)   6 (23.1)   1 (3.8)

Defecation    spontaneous    after provocation    no data

Stool characteristic    normal    tight    plentiful/big    bean-like    tight and plentiful/big    tight and bean-like    plentiful/big and bean-like    no data

Stool retention on palpation    yes    no    no data 36 (59) 20 (32.8)   5 (8.2)

  4 (6.6) 18 (29.5)   7 (11.5)   8 (13.1)   6 (9.8)   5 (8.2)   1 (1.6) 12 (19.7)

* Percentage according to patient suffering from abdominal pain. * Odsetek w zależności od pacjentów cierpiących na ból brzucha.

34 (87.2)   4 (10.2)   1 (2.6)

  2 (5.1) 12 (30.8)   6 (15.4)   4 (10.3)   5 (12.8)   2 (5.1)   1 (2.6)   7 (17.9)

42 (68.8)   7 (11.5) 12 (19.7)

45 (73.8)   3 (4.9)   7 (11.5)

27 (69.2)   5 (12.8)   1 (2.6)

22 (84.6)   0 (0)   1 (3.8)

15 (38.5) 15 (38.5)   9 (23.1)

  6 (9.8)

  6 (15.4)

  3 (11.6)

0.03

0.72

< 0.001

0.28

P

51 (76.1) 12 (17.9)   4 (6)

  3 (4.5) 20 (29.9) 10 (14.9)   7 (10.4) 10 (14.9)   3 (4.5)   3 (4.5) 11 (16.4) 38 (64.4) 18 (30.5)   3 (5.1)

  5 (8.5) 19 (32.2)   5 (8.5)   9 (15.3)   5 (8.5)   4 (6.8)   2 (3.4) 10 (16.9)

31 (52.5) 17 (28.8) 11 (18.6)

49 (83)   3 (5.1)   3 (5.1)

45 (67.1)   5 (7.5)   6 (9) 35 (52.2) 19 (28.4) 13 (19.4)

  4 (6.8)

girls N (%)

11 (16.4)

boys N (%)

>7 N (%)

≤3 N (%)

>3≤7 N (%)

Gender (Płeć)

Age – years (Wiek – lata)

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

Symptoms (Objawy)

0.25

0.78

0.99

0.15

P

Tabela 2. Objawy kliniczne zaparć czynnościowych w stosunku do wieku, płci, czasu wystąpienia i czasu trwania choroby – cd.

Table 2. Clinical symptoms of functional constipations according to age, gender, disease onset and disease duration – cont.

27 (69.2)   9 (23.1)   3 (7.7)

  3 (7.7) 14 (35.9)   4 (10.3)   4 (10.3)   7 (17.9)   1 (2.6)   3 (7.7)   3 (7.7) 19 (82.6)   4 (17.4)   0 (0)

  1 (4.3)   5 (21.7)   5 (21.7)   4 (17.4)   2 (8.7)   1 (4.3)   1 (4.3)   4 (17.4)

11 (47.8)   6 (26.1)   6 (26.1)

40 (69) 15 (25.9)   3 (5.2)

  4 (6.9) 17 (29.3)   6 (10.3)   8 (13.8)   6 (10.3)   5 (8.6)   1 (1.7) 11 (19)

35 (60.3) 11 (19) 12 (20.7)

43 (74.2)   4 (6.9)   5 (8.6)

17 (74)   1 (4.3)   1 (4.3)

29 (74.4)   3 (7.7)   2 (5.1) 17 (43.6) 19 (48.7)   3 (7.7)

  6 (10.3)

> 36 months N (%)

  4 (17.4)

> 12 ≤3 6 months N (%)

  5 (12.8)

≤ 12 months N (%)

0.65

0.7

0.03

0.93

P

Age at disease onset (Czas wystąpienia choroby)

16 (55.2) 11 (37.9)   2 (6.9)

  3 (10.3)   6 (20.7)   2 (6.9)   6 (20.7)   3 (10.3)   0 (0)   2 (6.9)   7 (24.1)

15 (93.8)   0 (0)   1 (6.2)

  0 (0)   4 (25)   2 (12.5)   3 (18.8)   4 (25)   1 (6.2)   0 (0)   2 (12.5)

  5 (31.2)   5 (31.2)   6 (37.5)

55 (73.3) 17 (22.7)   3 (4)

  5 (6.7) 26 (34.7) 11 (14.7)   7 (9.3)   8 (10.7)   6 (8)   3 (4)   9 (12)

45 (60) 20 (26.7) 10 (13.3)

53 (70.7)   7 (9.3)   4 (5.3) 14 (87.5)   0 (0)   1 (6.2) 22 (75.9)   1 (3.5)   3 (10.3) 13 (44.8) 11 (37.9)   5 (17.3)

11 (14.7)

> 12 months N (%)   1 (6.2)

> 6 ≤ 12 months N (%)

  3 (10.3)

≤ 6  months N (%)

0.01

0.41

0.27

0.45

P

Disease duration (Czas trwania choroby)

Functional Constipation in Children

523

524

Age at Disease Onset Patients who were younger than 1 year at the disease onset complained less commonly of abdominal pain (38.5%) when compared to the other groups (60.9% and 74.1%, respectively, p < 0.01). They also significantly more frequently defecated 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 findings occurred with similar frequency in all analyzed subgroups (Table 2).

Disease Duration It was observed that the duration of functional constipations significantly influenced the frequency of soiling and refraining from defecation. Children suffering from functional constipations less than 6 months significantly rarer had soiling (p <