Polyethylene Glycol Maintenance Treatment for Childhood Functional Constipation: A Randomized, Placebo-controlled Trial.

OBJECTIVE: The aim of this study was to investigate the long-term efficacy of polyethylene glycol (PEG) during maintenance treatment of childhood functional constipation (FC) in a randomized, double-blinded, placebo-controlled trial. METHODS: Children (2-16 years) with FC according to the Rome III criteria were randomly assigned to maintenance treatment with PEG or placebo for 24 weeks. Children reporting treatment failure before 24 weeks were switched to conventional treatment. Primary outcome was successful treatment, defined as absence of any Rome III criteria with or without use of medication after 24 weeks. RESULTS: A total of 102 children were included: PEG/placebo: 49/53. At 24 weeks, significantly more patients in the PEG group, compared to the placebo group, were successfully treated (33 [67%] vs 19 [36%] hazard ratio (95% confidence intervals) = 3.21 [1.73-5.94]). Significantly fewer children in the PEG group switched to rescue medication (2 [4%] vs 30 [57%], P < 0.001). Time before the change to rescue medication was 13 and 27 days, respectively, for each of the 2 children in the PEG group who required rescue medication. Median time to shift to rescue medication was 27 days (range: 3-64 days) in the placebo group. At 24 weeks after initiation of treatment, 33 children (67%) in the PEG group were successfully treated, compared to 19 children (32%) in the placebo group (hazard ratio (95% confidence intervals) = 3.21 [1.73-5.94]). No serious adverse event related to use of the medication was registered. CONCLUSIONS: Maintenance treatment with PEG is significantly more effective than placebo in preventing relapse of constipation symptoms during long-term maintenance treatment in childhood FC. We therefore recommend that maintenance treatment commence after disimpaction.

Follow-up in Childhood Functional Constipation: A Randomized, Controlled Clinical Trial.

OBJECTIVES: Guidelines recommend close follow-up during the treatment of childhood functional constipation. Only sparse evidence exists on how follow-up is best implemented. Our aim was to evaluate whether follow-up by phone or self-management through Web-based information improved treatment outcomes. METHODS: In this randomized controlled trial, conducted in secondary care, 235 children, ages 2 to 16 years, who fulfilled the Rome III criteria of childhood constipation, were assigned to 1 of the 3 follow-up regimens: control group (no scheduled contact), phone group (2 scheduled phone contacts), and Web group (access to Web-based information). PRIMARY OUTCOME: number of successfully treated children after 3, 6, and 12 months. SECONDARY OUTCOMES: phone contacts, relapse, fecal incontinence, and laxative use. RESULTS: After 3 and 6 months, significantly more children in the Web group (79.7%/75.9%) were successfully treated compared with the control and phone groups (59.7%/63.6% and 63.3%/64.6%) (P = 0.007/P = 0.03). No difference was found after 12 months (control, 72.7%; phone, 68.4%; Web group, 78.5%; P = 0.40). Extra phone consultations were significantly more frequent in the Web group (44.3%) compared with the control group (28.6%) (P = 0.04). Before 3 months, 45.5% of phone consultations were completed in the Web group versus 28.8% and 25.8% in the control and phone groups (P = 0.05/P = 0.02). Relapses, fecal incontinence, and laxative use were not different between interventions. CONCLUSIONS: Improved self-management behavior caused by access to self-motivated Web-based information induced faster short-term recovery during the treatment of functional constipation. Patient empowerment rather than health care-promoted follow-up may be a step toward more effective treatment for childhood constipation.

Identifying faecal impaction is important for ensuring the timely diagnosis of childhood functional constipation.

AIM: Most research on functional constipation has been carried out at a tertiary level. We focused this study on a secondary-level hospital outpatients' department, assessing the distribution of diagnostic criteria for childhood functional constipation and evaluating the consequences of current diagnostic practice based on current guidelines. METHODS: We enrolled 235 children, aged two to 16 years of age, with functional constipation according to the Rome III criteria and assessed them using medical histories and physical examinations, including rectal examinations and ultrasound measurements of rectal diameter. Faecal impaction was a rectal diameter exceeding 3 cm. RESULTS: The most frequently reported symptom was painful bowel movements (72.3%) and 39.1% had faecal incontinence. Rectal examination identified faecal impaction in 149 children (66.2%), and ultrasound showed a mean rectal diameter of 3.4 ± 0.6 cm, compared to 2.2 ± 0.6 cm in children without impaction (p < 0.001). Of the 149 children with faecal impaction, 19 (12.8%) only had one additional Rome III criterion. The rectal diameter exceeded 3 cm in 79.9% of cases. CONCLUSION: Identifying faecal impaction is important for ensuring the timely diagnosis of childhood functional constipation at the secondary care level. Ultrasound examination proved a reliable alternative to rectal examination or abdominal radiography when identifying faecal impaction.

Transabdominal ultrasound measurement of rectal diameter is dependent on time to defecation in constipated children.

AIM: To study whether diurnal variations and time in relation to defecation has to be taken into account when measurements of rectal diameter are used to determine faecal impaction in constipated children. METHODS: Repeated ultrasound measures of rectal diameter were performed in 28 children (14 constipated/14 healthy, aged between 4 and 12 years) every third hour during 24 h. After defecation, three additional scans were performed at 1-h intervals. RESULTS: No diurnal variation in rectal diameter was found in the healthy group. In the constipated group, mean rectal diameter was significantly larger at 2 pm (P = 0.038) and 5 pm (P = 0.006). There were significant differences between rectal diameter in the healthy group and the constipated group at 2 pm (P = 0.016) and 5 pm (P = 0.027). When we omitted the rectal diameter of five constipated children who had their first bowel movement after 5 pm, there were no difference between groups (2 pm (P = 0.103)/5 pm (P = 0.644) ). Only in the constipated group, rectal diameter exceeded 3 cm without the patients feeling the urge to defecate. CONCLUSION: We found no independent daily variation in either group without relation to defecation. There was a relation between defecation and changes in rectal diameter in both healthy children and constipated children during maintenance treatment.Asking for defecation signals before scanning should be considered a routine question, and a positive answer should cause postponement of the scan.

PET/MRI in paediatric inflammatory bowel disease - a prospective accuracy study.

Cross-sectional imaging supplements endoscopy in detecting disease manifestations in inflammatory bowel diseases (IBD). This study aimed to evaluate the accuracy of PET/MRI in a paediatric population suspected of IBD. This prospective study consecutively included patients aged 8-17 years under diagnostic evaluation for IBD. Forty-three patients underwent a PET/MRI scan and subsequent ileocolonoscopy, of whom 26 patients diagnosed with IBD participated in a follow-up scan, hereof 19 with Crohn's disease (CD), five with Ulcerative colitis and two with unclassified IBD. The results of PET alone, MRI alone, and PET/MRI combined were compared to a reference standard of endoscopy and histopathology. Of the 208 intestinal segments analysed, 109 showed inflammation, and 99 had no inflammation. In the per-segment analysis PET had a sensitivity of 0.83 (95% CI 0.73-0.93), specificity of 0.59 (95% CI 0.47-0.71), and area under the receiver operating characteristic curve (AUROC) of 0.73 (95% CI 0.67-0.80). MRI had a sensitivity of 0.52 (95% CI 0.41-0.64), specificity 0.89 (95% CI 0.82-0.96), and AUROC of 0.72 (95% CI 0.66-0.77). PET/MRI had a sensitivity of 0.83 (95% CI 0.74-0.94), specificity of 0.57 (95% CI 0.44-0.69), and AUROC of 0.77 (95% CI 0.71-0.84). At follow-up, PET and MRI scores decreased, and the change in MRI was able to identify patients with a clinical response. The accuracy of the PET/MRI scan in detecting inflammation in the terminal ileum and colon was moderate and not superior to either modality alone. With technological advances and combined reading, PET/MRI may still be valuable in selected cases.

Eosinophilic oesophagitis in infants and children in the region of southern Denmark: a prospective study of prevalence and clinical presentation.

OBJECTIVE: Eosinophilic oesophagitis (EE) is a clinical entity characterised by a set of symptoms and eosinophilic infiltration of the oesophageal epithelium. Recent reports indicate that EE is increasingly diagnosed in paediatric patients. We aimed to evaluate the epidemiology of paediatric EE in a European population. DESIGN: Infants and children in the Region of Southern Denmark were prospectively referred for further evaluation of symptoms of gastroesophageal reflux disease (GERD) after treatment failure with a proton pump inhibitor. The evaluation included endoscopy, 24-hour oesophageal pH-metry, histology of oesophageal biopsies, and investigations for food allergy (double-blind, placebo-controlled food challenge, skin prick test, S-IgE antibodies, atopy patch test). RESULTS: Of the 78 referred patients, 28 qualified for a diagnosis of GERD. Six children had >15 eosinophils per high-power field in biopsies from the oesophageal mucosa and qualified for the diagnosis of EE. The median age at diagnosis was 9.6 years. In 4 of the 6 patients, food allergy was confirmed by double-blind, placebo-controlled food challenge. In the Region of Southern Denmark with a paediatric population of 256,164 between 0 and 16 years of age, a yearly incidence of EE of 0.16/10,000 was estimated. CONCLUSION: We report a European prospective study of EE. It was documented in 6 of 78 patients with symptoms of GERD corresponding to an annual incidence of 0.16/10,000 infants and children.

Pediatric Inflammatory Bowel Diseases: Should We Be Looking for Kidney Abnormalities?

Background: Kidney disease has been reported in adults with inflammatory bowel disease (IBD) and is regarded an extraintestinal manifestation or more rarely a side effect of the medical treatment. Methods: In this cross-sectional study we describe the extent of kidney pathology in a cohort of 56 children with IBD. Blood and urine samples were analyzed for markers of kidney disease and ultrasonography was performed to evaluate pole-to-pole kidney length. Results: We found that 25% of the patients had either previously reported kidney disease or ultrasonographic signs of chronic kidney disease. The median kidney size compared with normal children was significantly reduced. In a multivariate linear mixed model, small kidneys significantly correlated with the use of infliximab, whereas the use of enteral nutritional therapy was associated with larger kidneys. Conclusion: Children with IBD are at risk of chronic kidney disease, and the risk seems to be increased with the severity of the disease.