A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder.

Children with autism spectrum disorder (ASD) are often delayed in achieving bowel continence, resulting in negative outcomes. In this pilot trial, 20 children with ASD and encopresis were randomly assigned to multidisciplinary intervention for encopresis (MIE; n = 10) or a waitlist control group (n = 10). The MIE group was treated for constipation and received a 10-day behavioral intervention that utilized suppositories to produce predictable bowel movements that were reinforced. Caregivers were trained to implement the intervention. Results support the feasibility of clinical trials of MIE, with high enrolment, competition, attendance, and caregiver acceptability. Preliminary outcomes were positive, with six of 10 in the MIE group achieving continence by the end of treatment compared to 0 in the control group (p = 0.005).Registered at clinicaltrials.gov (https://clinicaltrials.gov); ID: NCT02383732.

[Atomoxetine Treatment For Encopresis In A Child With Attention Deficit Hyperactivity Disorder]. / Dikkat Eksikligi ve Hiperaktivite Bozuklugu'nda Atomoksetin Ile Düzelen Bir Enkoprezis Olgusu.

Letter to the editor.

Increased Frequency of Encopresis in a Child Diagnosed With Attention Deficit/Hyperactivity Disorder and Encopresis After Atomoxetine Use: A Case Report.

Attention deficit hyperactivity disorder (ADHD) is among the most frequently reported coexisting psychiatric conditions in children with encopresis. Some case reports state that atomoxetine-a selective presynaptic norepinephrine reuptake inhibitor-approved for treatment of ADHD is also effective in the treatment of coexisting encopresis. Contrasting those reports, here we present a case diagnosed with ADHD and secondary encopresis without constipation whose encopretic symptoms increased after atomoxetine treatment and discuss possible mechanisms.

Effect of Octreotide on Colonic Motility in Pediatric Patients With Chronic Recalcitrant Constipation.

OBJECTIVE: The aim of the present study was to study the effect of octreotide on colonic motility in pediatric patients with recalcitrant chronic constipation/encopresis and other suspected colonic motility disorders. METHODS: This was a nonrandomized, single-center, open-label, prospective study evaluating the effect of a single subcutaneous dose of octreotide on colonic motility. RESULTS: Thirteen patients (5 boys) were enrolled in the study. The age range was 4.6 to 16.2 years. Eleven patients (84%) had normal colonic manometry and 2 patients (16%) had colonic neuropathy. Motility Index (MI) (mmHg) for the 15 minutes before and after octreotide infusion was 6.03 ±â€Š1.26 (95% confidence interval [CI] 5.35-6.72) and 5.32 ±â€Š1.66 (95% CI 4.42-6.23), respectively, with P value of 0.08. MI for the 30 minutes before and after octreotide infusion was 6.89 ±â€Š1.37 (95% CI 6.14-7.64) and 6.71 ±â€Š1.47 (95% CI 5.91-7.52), respectively, with P value of 0.55. MI for the 45 minutes before and after octreotide infusion was 7.73 ±â€Š1.32 (95% CI 7.01-8.45) and 7.53 ±â€Š1.38 (95% CI 6.78-8.28), respectively, with P value of 0.8. CONCLUSION: Our study showed that the administration of octreotide resulted in no significant changes in colonic MI in pediatric patients with chronic recalcitrant constipation.

Effect of OROS methylphenidate on encopresis in children with attention-deficit/hyperactivity disorder.

OBJECTIVES: Although encopresis shows a high rate of comorbidity in patients with attention-deficit/hyperactivity disorder (ADHD), the etiologic origin of this relationship and the effect of ADHD drugs on encopresis are unclear. In this chart review, we explored the effect of OROS long-acting methylphenidate (MPH) treatment on encopresis in children with ADHD. We also evaluated the relationship between the clinical variables of ADHD and encopresis. METHODS: The sample consisted of 21 children and adolescents (20 boys and 1 girl) with encopresis and coexisting ADHD 7-15 years of age. Their clinical characteristics and baseline (visit 1) and end of the second months' (visit 2) Conners' Parent Rating Scale (CPRS) subscores were recorded. Retrospective clinician determinations were made using the Clinical Global Impressions-Severity subscale (CGI-S) for encopresis severity and the Clinical Global Impressions-Improvement subscale (CGI-I) for encopresis response. RESULTS: According to the CGI-I, 14 subjects (71.4 %) showed much or very much improvement in their encopresis at the second visit. All of the CPRS scores showed a significant reduction during the second visit. No association was found between the CGI-I score and the changes in any of the CPRS scores. Baseline oppositional defiant disorder (ODD) and conduct disorder (CD) scores were correlated with the CGI-S score; however, no association was found between core ADHD symptom severity and the CGI-S score. With regard to the encopresis outcome, the baseline CD score was negatively correlated with the CGI-I score, and the baseline ODD score was prone to show a negative correlation with the CGI-I score. CONCLUSIONS: These results suggest that coexisting behavioral problems may be a vulnerability factor based on the severity of encopresis, and that MPH treatment may have a positive effect on encopresis in children and adolescents with ADHD.

Effect of intravenous erythromycin on the colonic motility of children and young adults during colonic manometry.

PURPOSE: Erythromycin is successfully used as a gastroduodenal prokinetic agent. Given the limited available treatments for colonic dysmotility, further investigation into erythromycin's effect on colonic motility is warranted. We aimed to study the effect of erythromycin on colonic motility in pediatric patients with recalcitrant chronic constipation/encopresis and other suspected colonic motility disorders. METHODS: Patients referred for colonic manometry were eligible for enrollment. Fasting motility was recorded for 1 to 2 hours, then erythromycin lactobionate (EL), 3 mg/kg, was administered intravenously, and colonic motility was monitored for 1 to 2 hours after erythromycin. Manometry was then continued per routine. The motility index (MI) of pressure tracings at each pressure transducer was calculated for each patient for a period of 15 and 60 minutes before and after EL infusion. Change in MI was compared by Wilcoxon signed rank test. RESULTS: Twenty patients were enrolled. The most common indication was constipation with encopresis. Seventy percent of patients had normal colonic manometry, and 30% of patients demonstrated a neuropathy. Average MI for the 60-minute period before and after EL infusion were 254 +/- 74 mm Hg/h and 253 +/- 94 mm Hg/h, respectively (P = .55). Average MI for the 15-minute period before and after EL infusion were 64 +/- 23 mm Hg/15 min and 69 +/- 32 mm Hg/15 min, respectively (P = .45). CONCLUSIONS: Administration of intravenous EL resulted in no changes in colonic MI in pediatric patients referred for colonic manometry. Further studies on potential colokinetic agents are warranted in this population of patients.

Detection of polyethylene glycol-based laxatives in stool.

The ability to test stool for laxatives is an important part of patient care in some clinical circumstances. Some patients take or are given laxatives surreptitiously. Additionally, failure to take prescribed laxatives may result in treatment failure in children with constipation or encopresis. Although laboratory methods have been available to identify many laxatives in the stool, tests are not available for detecting polyethylene glycol (PEG)-based laxatives. PEG-based laxatives are frequently used in the treatment of children with constipation. We developed a mass spectrometry (MS)-based analysis for detecting PEG in stool and verified the technique in an adult volunteer. We then piloted the assay on stools from children taking PEG for constipation versus children with diarrhea who were not taking PEG. Eleven subjects with diarrhea and 8 receiving PEG were enrolled. Nine of the children with diarrhea and 7 receiving PEG were evaluated by MS. All 3 subjects with PEG who had a stool osmolal gap determined had elevated gaps. Stools of all 7 subjects with PEG were positive for PEG by MS, whereas none of the 9 subjects with diarrhea had stool positive for PEG. This new MS methodology to test stool for PEG is described. It is likely to prove useful in the documentation of surreptitious PEG administration and in evaluation of PEG treatment failure.

[Encopresis revealing myotonic dystrophy in 2 children]. / Encoprésie révélatrice d'une dystrophie myotonique de Steinert : à propos de 2 observations.

Gastrointestinal symptoms are very frequent in myotonic dystrophy but largely unrecognized. They can be the revealing factors of the disease. We report 2 cases of 10 and 17-year-old children with persistent encopresis starting at the age of 3 and 5 years in spite of laxative treatment. Neurological examination and anorectal manometry provided the diagnosis of myotonic dystrophy. Procainamide treatment was introduced and the digestive symptoms improved. Any child with encopresis should have complete evaluation to rule out the diagnosis of myotonic dystrophy and physicians should look for upper and/or lower gastrointestinal symptoms in every patient with myotonic dystrophy.

[Functional constipation: prospective study and treatment response]. / Estreñimiento funcional: estudio prospectivo y respuesta al tratamiento.

OBJECTIVE: To assess the prevalence of functional constipation (FC) with and without encopresis, the factors involved in its onset, and treatment response. PATIENTS AND METHODS: A prospective study of 62 children was performed using a standard questionnaire (onset-age, regular toilet use, encopresis, complications, dietary habits and environmental and psychological factors) and physical and anthropometric assessment. FC was defined as a stool frequency of less than 3 bowel movements/week, with passage of large or scybalous stools, with or without 2 or more soiling episodes per week, without underlying disease. Treatment included demystification, behavioral modification and drugs (mineral oil and senna). Each child was periodically re-evaluated, and treatment was considered successful when the defecation rate was 3 or more bowel movements/week, discomfort was absent, and fecal soiling frequency was 2 or fewer episodes/ month. RESULTS AND CONCLUSIONS: FC accounted for 13 % of all first consultations (60 % boys, 40 % girls; mean age at diagnosis 6.1 years). The most frequent manifestations were painful defecation (60 %), rectorrhagia (42 %), obstructive episodes (34 %) and anal fissure or hemorrhoids (17 %); 19 patients (31 %) had encopresis. Nutritional assessment revealed that 84 % of the patients was well nourished and 16 % was overweight. Fiber intake was deficient in more than 60 %. Sixteen (26 %) patients underwent successful relief of impaction with senna (20-30 mg/dose) combined with mineral oil. Maintenance treatment included mineral oil (15-30 ml/day) and senna at the minimum effective dose (5-15 mg/day). Satisfactory results were achieved 1 month later in 32 % of the children, 3-6 months later in 71 %, and 6-12 months later in 85 %; successful response was closely related to regular toilet habits, dietary modification and a shift in the family's attitude.

Estreñimiento funcional: estudio prospectivo y respuesta al tratamiento / Functional constipation: prospective study and treatment response

Objetivo: Analizar la prevalencia del estreñimiento funcional asociado o no a encopresis, los factores implicados en su desarrollo y la respuesta al tratamiento. Pacientes y métodos: Estudio prospectivo de 62 niños en el que se incluyó cuestionario estándar (edad de comienzo, hábito higiénico, encopresis, complicaciones, encuesta dietética y factores psicológico-ambientales) y exploraciones clínica y antropométrica. Se definió estreñimiento funcional a la frecuencia de defecación inferior a 3 veces/semana con heces voluminosas o escíbalos, acompañado o no de 2 manchados/semana, sin causa orgánica. El tratamiento incluyó desmitificación, corrección de hábitos y fármacos (lubricantes y senósidos). Se reevaluaron periódicamente considerándose respuesta positiva si la defecación fue igual a 3 veces/semana, sin molestias y menos de 2 manchados/mes. Resultados y conclusiones: El estreñimiento funcional supuso el 13 % de las primeras consultas, siendo el 60 % niños y el 40 % niñas, con edad promedio de 6,1 años. Las principales manifestaciones fueron dolor a la defecación (60 %), rectorragia (42 %), episodios obstructivos (32 %) y fisuras y/o hemorroides (18 %); en 19 casos (31 %) se asoció encopresis. El 84 % estaba normonutrido y el 16 % tenían sobrepeso, siendo la alimentación deficitaria en fibra en más del 60 %. Requirieron desimpactación 16 niños con la combinación de senósidos (20-30 mg/dosis) y aceite de parafina, con total eficacia. El tratamiento de mantenimiento incluyó lubricantes (15-30 ml/día) y senósidos en la dosis mínima eficaz (media: 5-15 mg/día). La respuesta al mes fue positiva en el 32 %, a los 3-6 meses en el 71 % y a los 6-12 meses en el 85 % y se relacionó de forma estrecha con la modificación de los hábitos higiénico-dietéticos y el cambio en la actitud familiar

Objective To assess the prevalence of functional constipation (FC) with and without encopresis, the factors involved in its onset, and treatment response. Patients and methods A prospective study of 62 children was performed using a standard questionnaire (onset-age, regular toilet use, encopresis, complications, dietary habits and environmental and psychological factors) and physical and anthropometric assessment. FC was defined as a stool frequency of less than 3 bowel movements/week, with passage of large or scybalous stools, with or without 2 or more soiling episodes per week, without underlying disease. Treatment included demystification, behavioral modification and drugs (mineral oil and senna). Each child was periodically re-evaluated, and treatment was considered successful when the defecation rate was 3 or more bowel movements/week, discomfort was absent, and fecal soiling frequency was 2 or fewer episodes/ month. Results and conclusions FC accounted for 13 % of all first consultations (60 % boys, 40 % girls; mean age at diagnosis 6.1 years). The most frequent manifestations were painful defecation (60 %), rectorrhagia (42 %), obstructive episodes (34 %) and anal fissure or hemorrhoids (17 %); 19 patients (31 %) had encopresis. Nutritional assessment revealed that 84 % of the patients was well nourished and 16 % was overweight. Fiber intake was deficient in more than 60 %. Sixteen (26 %) patients underwent successful relief of impaction with senna (20-30 mg/dose) combined with mineral oil. Maintenance treatment included mineral oil (15-30 ml/day) and senna at the minimum effective dose (5-15 mg/day). Satisfactory results were achieved 1 month later in 32 % of the children, 3-6 months later in 71 %, and 6-12 months later in 85 %; successful response was closely related to regular toilet habits, dietary modification and a shift in the family's attitude

PEG 3350 (Transipeg) versus lactulose in the treatment of childhood functional constipation: a double blind, randomised, controlled, multicentre trial.

BACKGROUND: Recently, polyethylene glycol (PEG 3350) has been suggested as a good alternative laxative to lactulose as a treatment option in paediatric constipation. However, no large randomised controlled trials exist evaluating the efficacy of either laxative. AIMS: To compare PEG 3350 (Transipeg: polyethylene glycol with electrolytes) with lactulose in paediatric constipation and evaluate clinical efficacy/side effects. PATIENTS: One hundred patients (aged 6 months-15 years) with paediatric constipation were included in an eight week double blinded, randomised, controlled trial. METHODS: After faecal disimpaction, patients <6 years of age received PEG 3350 (2.95 g/sachet) or lactulose (6 g/sachet) while children > or =6 years started with 2 sachets/day. Primary outcome measures were: defecation and encopresis frequency/week and successful treatment after eight weeks. Success was defined as a defecation frequency > or =3/week and encopresis < or =1 every two weeks. Secondary outcome measures were side effects after eight weeks of treatment. RESULTS: A total of 91 patients (49 male) completed the study. A significant increase in defecation frequency (PEG 3350: 3 pre v 7 post treatment/week; lactulose: 3 pre v 6 post/week) and a significant decrease in encopresis frequency (PEG 3350: 10 pre v 3 post/week; lactulose: 8 pre v 3 post/week) was found in both groups (NS). However, success was significantly higher in the PEG group (56%) compared with the lactulose group (29%). PEG 3350 patients reported less abdominal pain, straining, and pain at defecation than children using lactulose. However, bad taste was reported significantly more often in the PEG group. CONCLUSIONS: PEG 3350 (0.26 (0.11) g/kg), compared with lactulose (0.66 (0.32) g/kg), provided a higher success rate with fewer side effects. PEG 3350 should be the laxative of first choice in childhood constipation.

Polyethylene glycol for constipation in children younger than eighteen months old.

BACKGROUND: Polyethylene glycol (PEG) is a safe and effective treatment for constipation in children older than 18 months. Data on its safety and efficacy in infants are lacking. The goal of this study was to determine safety, efficacy, and optimal dose of polyethylene glycol powder for treatment of constipation in patients younger than 18 months. METHODS: The authors reviewed the charts of patients younger than 18 months treated with PEG 3350 for constipation. The initial dose, effective maintenance dose, response to therapy, duration of therapy, and side effects were recorded. RESULTS: Twenty-eight patients younger than 18 months of age treated with PEG were identified (3, age 0-5 months; 9, age 6-11 months; 16, age 12-17 months). Mean duration of therapy was 6.2 +/- 5 months (range, 3 weeks-21 months). Mean initial dose was 0.88 g/kg/day (range, 0.26-2.14 g/kg/day). Mean effective maintenance dose was 0.78 g/kg/day (range, 0.26-1.26 g/kg/day). PEG relieved constipation in 97.6% of patients. One infant experienced increased gas per rectum and four others experienced transient diarrhea that resolved after adjusting the dose. CONCLUSION: Oral powdered polyethylene glycol at a maintenance dose of 0.78 g/kg/day is safe and effective for patients younger than 18 months. Dose and safety profiles are similar for those reported in older children.

Posterior myotomy/myectomy for persistent stooling problems in Hirschsprung's disease.

BACKGROUND: Hirschsprung's disease (HD) patients after pull-through (PT) may have recalcitrant constipation or recurrent enterocolitis (EC). Posterior myotomy/myectomy (POMM) are possible options for these problems. This study analyzed the outcome of POMM in HD patients post-PT. METHODS: Records of 348 HD patients were reviewed, and 32 were found to have undergone a POMM post-PT (1981 to 2002). Outcomes after this procedure were assessed. Statistics used linear and logistic regression. RESULTS: Of the 32 patients, 29 had complete records for analysis. Of those with pure constipation (12), 6 had aganglionosis post-PT. Of those with recurrent EC (17) only 1 had aganglionosis post-PT. POMM was performed at a mean of 3.1 years post-PT (11 myotomy, 18 myectomy). Average follow-up was 8.6 years (range, 0.7 to 21). Type of POMM had no correlation with overall functional outcome (P =.44). Of those with chronic constipation, 60% had good results after POMM; the remainder required a redo-PT or colostomy. Interestingly, most patients with retained aganglionosis and chronic constipation did not respond after POMM (83%). Of those with recurrent EC, 75% became free of symptoms; none of the patients not responding have required redo-PT. CONCLUSIONS: POMM to treat chronic constipation or recurrent EC in patients with HD post-PT is moderately successful. Because of the unsuccessful outcome with POMM in patients with a combination of constipation and aganglionosis, one should defer to a redo-PT in this group.