Factors associated with outcome in management of defecation disorders.

Abstract

SUMMARY Simple, incentive based behaviour modification, with or without a modest programme of psychotherapy involving outpatient visits every four to six weeks, seems to be associated with a useful cure rate in children with lower bowel function disorders.Appreciable social disadvantage seems to be the most important factor mitigating against a successful outcome, associated with non-compliance with treatment. Failure to respond to treatment was associated with important psychological problems. These were more common in the socially disadvantaged groups.Children from satisfactory social backgrounds who have lower bowl disturbances can be effectively treated by fairly simple programmes. More elaborate and expensive strategies should be reserved for those whose psychosocial circumstances make it possible to predict a less satisfactory outcome.Faecal soiling with or without faecal retention is a common cause of referral to general paediatric outpatient services and accounts for some 25% of the gastroenterological workload. Primary or secondary referral to child psychiatry services is also considerable. Methods of treatment include pharmacological, 2 behavioural,3 behavioural and medical,4 dietary,6 psychological,7 and surgical.8 The diversity of treatment is a reflection both of the multifactorial nature of the problem and the difficulty encountered in applying recommended management programmes in clinical practice because of the considerable demands they make on valuable outpatient time.The published results of treatment show cure rates of between 45% and 70% and failure rates of between 25% and 35%o, depending on selection of cases, criteria of assessment of outcome, and (possibly) intensity of treatment. In view of the non-fatal and self limiting nature of the problem the issue of cost effectiveness is a major one. A regimen with a high success rate that overwhelms available resources or diverts attention from more serious matters would clearly be unsatisfactory. This study was devised not to find a regimen with an optimal cure rate but to test the effectiveness of fairly modest programmes of behaviour therapy or psychotherapy, or both, that would not seriously tax the resources of busy district paediatric or child psychiatry services. For example, one British study involved weekly or biweekly visits in comparison with the monthly or six weekly visits employed here.We report our experience with 47 children who presented with faecal soiling, with or without constipation, who were treated by incentive based behavioural modification, plus or minus psychotherapy, and consider factors that might predict the outcome for a non-intensive approach. In particular, we wish to draw attention to social background as a prognostic indicator, a factor not previously reported. Material and methods

Diagnostic Approach to Constipation in Children

“…It is relevant to the practice of both general paediatricians and paediatric gastroenterologists and accounts for 3% and 25% of outpatient visits respectively (Levine, 1975;Taitz et al, 1986). International prevalence rates range from 0.7% to 29.6% which is similar for males and females (van den Berg et al, 2006).…”

Nonpharmacologic Treatments for Childhood Constipation: Systematic Review

“…No RCTs on the effects of physical movement, multidisciplinary treatment, or alternative medicine (acupuncture, homeopathy, mind-body therapy, musculoskeletal manipulations such as osteopathic and chiropractic manipulations, or spiritual therapies such as yoga) for children with constipation were found. All studies were hospital-based; 3 were conducted in a general pediatric department 14,18,19 and 6 were conducted in a pediatric gastroenterology department. [11][12][13][15][16][17] The studies were highly diverse with regard to the participants, interventions, and outcome measures; therefore, a meta-analysis of all included studies could not be performed.…”

“…12 The systematic review included 1 lowquality RCT that compared behavioral interventions (education) and a system of rewards from a pediatrician with monthly psychotherapy with a child psychiatrist. 19 The method of randomization was not stated clearly. Blinding in this case was not possible for the care provider or the patient.…”

Constipação crônica na infância: quanto estamos consultando em Gastroenterologia Pediátrica?

“…Não está claro se existe um aumento real na prevalência ou maior procura por consulta médica especializada para avaliação deste problema (14) . As referências relativas ao percentual de consultas relatam a constipação como sendo responsável por 3% das consultas em Pediatria Geral (15,16) e 25% das consultas de Gastroenterologia Pediátrica (17,18) . Tais publicações vêm sendo citadas com freqüência e repetidamente desde então, como referência na literatura correspondente.…”