Lack of benefit of laxatives as adjunctive therapy for functional nonretentive fecal soiling in children.

OBJECTIVES: To determine whether the combination of laxative treatment and biofeedback therapy (BF) is more effective for management of functional nonretentive fecal soiling than biofeedback therapy alone. STUDY DESIGN: In a prospective nonblinded study, 48 children were randomized in 2 groups: treatment with oral laxatives (LAX) and 5 sessions of BF (BF + LAX) or 5 sessions of BF alone (BF) during a treatment intervention period of 7 weeks. Biofeedback was performed with perfused manometry catheters and rectal balloon distension. Training focused on awareness of balloon distension and instruction in correct defecation dynamics. Successful treatment was defined as <1 encopresis episode per 2 weeks. RESULTS: At the end of the intervention period, the number of encopresis episodes was significantly decreased in both groups: from 7 (2 to 24) to 2 (0 to 17) in the BF group and from 7 (3 to 25) to 2 (0 to 14) in the BF + LAX group. However, children given BF alone had significantly higher success rates than children treated with BF and additional oral laxatives (44% to 11%). CONCLUSIONS: There is no additional effect of laxative treatment in functional nonretentive fecal soiling. Children treated with BF in combination with laxatives showed a significantly lower success percentage compared with those treated with BF alone. These results suggest that children with functional nonretentive fecal soiling should be treated differently from children with constipation and encopresis.

Treatment of defaecation problems in children: the role of education, demystification and toilet training.

UNLABELLED: To evaluate the effect of education in children with chronic defaecation problems, a prospective 6-week intervention study was designed. A total of 54 children (5-14 years) underwent an education programme, with demystification of symptoms and advice about diet and toilet training. The present treatment was continued. After 6 weeks, children with persistent problems received biofeedback training with a follow up of 1 year. The intervention programme was successful in 8 children (15%). Biofeedback training was successful in 49% of the remaining group after 1 year. CONCLUSION: A total of 15% of the children with chronic defaecation problems seen at a referral centre could surprisingly be helped by a simple education programme with, demystification and toilet training. Further studies evaluating treatment in children with defaecation problems should account for the primary effect of these measures.

Randomised trial of biofeedback training for encopresis.

AIMS: To evaluate biofeedback training in children with encopresis and the effect on psychosocial function. DESIGN: Prospective controlled randomised study. PATIENT INTERVENTIONS: A multimodal treatment of six weeks. Children were randomised into two groups. Each group received dietary and toilet advice, enemas, oral laxatives, and anorectal manometry. One group also received five biofeedback training sessions. MAIN OUTCOME MEASURES: Successful treatment was defined as less than two episodes of encopresis, regular bowel movements, and no laxatives. Psychosocial function after treatment was assessed using the Child Behaviour Checklist. RESULTS: Children given laxatives and biofeedback training had higher success rates than those who received laxatives alone (39% v 19%) at the end of the intervention period. At 12 and 18 months, however, approximately 50% of children in each group were successfully treated. Abnormal behaviour scores were initially observed in 35% of children. Most children had improved behaviour scores six months after treatment. Children with an initial abnormal behaviour score who were successfully treated had a significant improvement in their behavioural profiles. CONCLUSIONS: Biofeedback training had no additional effect on the success rate or behaviour scores. Psychosocial problems are present in a subgroup of children with encopresis. The relation between successful treatment and improvement in behavioural function supports the idea that encopresis has an aetiological role in the occurrence and maintenance of behavioural problems in children with encopresis.

Biofeedback training in treatment of childhood constipation: a randomised controlled study.

BACKGROUND: Because abnormal defaecation dynamics, which can be modified by biofeedback, are considered to be the underlying problem in constipation, biofeedback training may be a useful treatment for constipation. This treatment has mainly been studied in uncontrolled trials. We evaluated defaecation dynamics and clinical outcome in chronically constipated children in a randomised study comparing conventional treatment and conventional treatment with biofeedback training. METHODS: Patients, 5 to 16 years old, were referred to the Academic Medical Center in Amsterdam by general practitioners, school doctors, paediatricians, and psychiatrists. They had to fulfil at least two of four criteria for paediatric constipation and were included if they had been treated medically for at least one month before randomisation. Patients had a medical history, abdominal and rectal examination, and anorectal manometry at the start and end of the 6-week intervention period. The conventional group received laxative treatment with additional dietary advice, toilet training, and maintenance of a diary of bowel habits. The biofeedback group received the same conventional treatment and additionally five biofeedback training sessions. During the first 3 weeks, patients visited the outpatient clinic weekly; two subsequent visits were twice monthly. FINDINGS: 94 patients were randomised to conventional treatment (CT) and 98 to conventional treatment with additional biofeedback training (CT+BF). Normal defaecation dynamics increased in the CT group from 41% to 52% (not significant) and in the CT+BF group from 38% to 86% (p = 0.001). At 6 weeks, more patients in the CT+BF group showed normal defaecation dynamics, compared to the CT group (p < 0.001). This result was unaltered by controlling for baseline status in a logistic regression model. At 1 year, successful treatment (defaecation frequency > or = 3/week, soiling and/or encopresis < 2/month, and no laxatives) was accomplished in 59% of the CT and 50% of the CT+BF group (p = 0.24). The results were maintained after 1 1/2 years follow-up. No association was found between achievement of normal defaecation dynamics and clinical outcome. INTERPRETATION: Additional biofeedback training compared to conventional therapy did not result in higher success rates in chronically constipated children. Furthermore, achievement of normal defaecation dynamics was not associated with success: abnormal defaecation dynamics seem not to play a crucial role in the pathogenesis of childhood constipation. Intensive conventional laxative treatment should remain the first choice in chronically constipated children.

Treatment of faecal incontinence in a child with sacral agenesis: the use of biofeedback training.

The case of a 14-year-old girl is presented who was born with sacral agenesis and severe, chronic constipation not responding to laxative treatment. Biofeedback was employed in the treatment of the constipation and soiling. After six treatment sessions over four months, the constipation and soiling ceased and there was no relapse during follow-up of 12 months. Although this child had an absence of S3-S5 and the coccyx, with possible innervation abnormalities, this case illustrates that biofeedback training might be a useful adjunct to existing therapies.

[Chronic constipation in children; good results of biofeedback training as supplementary therapy]. / Chronische obstipatie bij kinderen; gunstige effecten van biofeedback-training als aanvullende therapie.

In two children with refractory constipation biofeedback training was successfully used as a supplementary therapy. In this treatment, a balloon tied to the end of the catheter is inserted into the rectum and inflated with ever-decreasing amounts of air, so as to increase rectal sensibility. In addition, the defaecation pattern is displayed on a monitor. The child learns to control contraction and relaxation of the musculature involved in defaecation.

Biofeedback training in chronic constipation.

Twenty nine patients, aged 5-16 years, were studied to evaluate whether biofeedback training is effective in treating children with chronic constipation and encopresis; the clinical outcome at six weeks and 12 months was also evaluated. Patients received on average five biofeedback training sessions. The existence of external anal contraction or decreased rectal sensation in 16 (55%) and eight (27%) of the children, respectively was identified on manometry. After biofeedback training, 26 (90%) of the patients learned to relax the external anal sphincter; 18 (63%) normalised rectal sensation. The training resulted in a significant increase in defecation frequency and a significant decrease in encopresis. At six weeks, 16 (55%) of the patients were clinically symptom free. At follow up after 12 months the results were sustained. Only three patients showed a relapse within six months, of whom two were successfully treated with one extra training session. Biofeedback training might be a useful therapeutical approach in children with chronic constipation and encopresis.