Publications

Abstract

Introduction: 

Constipation is a frequent cause of abdominal pain in children. It is common in the West, its prevalence in the Indian subcontinent is increasing. We used a structured interview format to study the demographics, clinical profile, and associated factors in childhood constipation in the South Indian scenario and devise a module thereafter for health education.

Material and Methods: 

All patients who presented to the pediatric surgical outpatient department at a tertiary teaching hospital in South India with functional constipation were included. They were interviewed by a single trained person using a validated questionnaire detailing demographic data, disease details, and possible factors (dietary, psychological, and socioenvironmental) associated with functional constipation.

Results: 

Fifty children and their parents/caretakers were recruited. Seventy percent of the children were aged 4–10 years and were largely males (66%); 58% were chronically affected. Most were in preschool (42%) or middle school (32%). Common clinical symptoms included hard and dry stool (84%), painful defecation (72%), and withholding of stool (62%). Unfavorable dietary habits (66%) and grossly inadequate water intake (80%) were common. There was a significant association between withholding of stool and soiling in the 4–10 years age group (P < 0.05) and abdominal pain and feeling of incomplete defecation in the 11–15 age group. Females had a higher prevalence of abdominal pain, abdominal distension, and painful defecation.

Conclusion: 

Functional childhood constipation is prevalent in South Indian society; identifiable factors must be addressed by lifestyle modification and health education at home and school.

INTRODUCTION

Constipation affects the physical and mental health of a child, decreases the quality of life, and increases healthcare costs. The worldwide prevalence of pediatric constipation ranges from 0.7% to 29.6%, with children aged 6–7 being largely affected.[1,2] It accounts for 3% of visits to the general pediatric clinic, up to 35% of visits to pediatric gastroenterologists,[3] and a significant number of hospital revisits. In poorly treated or untreated cases, it persists into early adulthood. Diet and sociocultural factors contribute to the problem and vary across the globe. An accurate identification of causative factors in specific geographical regions can help modify them and alleviate the disorder. The exact burden of this problem in the Indian context is not known. Nonetheless, it is a frequent presenting complaint of a substantial number of patients in any pediatric outpatient department (OPD). Functional constipation constitutes an important medical problem, as they cause significant distress, both for children and their parents.[2] We used a structured interview format and studied the demographics, clinical profile, and associated factors in childhood constipation in a South Indian scenario to devise a module thereafter for health education.

MATERIAL AND METHODS

The descriptive case study was conducted in the pediatric surgery OPD over 6 months. The study population included all children attending the pediatric surgery OPD. Children aged 4–15 years with a diagnosis of functional constipation as per Rome III criteria[4] were included. Those on medications for chronic diseases, with global developmental delay or organic causes for constipation, were excluded. A questionnaire was created by reviewing the literature to gather comprehensive information about children presenting with constipation. It had three sections and opinions from experts (pediatric surgery and pediatric nursing faculty) from four tertiary teaching institutions helped in the development of this tool, whose reliability was established by using the split-half method. The reliability coefficient was found to be r = 0.72 using Karl Pearson’s method and Spearman’s Brown formula; hence, the tool was reliable.

Questionnaire - section 1 collected demographic data (age, gender, and education status), Section 2 recorded disease details (symptoms, disease duration, and previous treatment), and Section 3 consisted of a structured interview of the caretaker on known factors (dietary, socioenvironmental, and psychological) contributing to functional constipation. Dietary factors evaluated included intake of vegetables, fruits, fast food, fried food, snacks, bakery products, and caffeinated drinks. Water intake was deemed adequate based on the NICE guidelines 2010.[5] Socioenvironmental factors included “school factors” (lack of or suboptimal washroom facilities at school-poor hygiene or water scarcity, lack of privacy, fear of bullying, restricted time and access), “home factors” (washroom facility, morning hurry before school), and “psychological–social factors” (family environment–family members with serious illness, frequent punishment to child, frequent arguments and fight in the family, imposition of strict discipline; School environment-learning difficulty, scholastic performance, peer interactions, teasing or bullying at school, burden of assignments, problems with teacher). The scoring of each was specific-dietary factors (1–30, 1–15 - favorable, and 16–30 - unfavorable), socioenvironmental factors (0–11, 0–5 – favorable, and 6–11 - unfavorable), and psychological factors (0–12, 0–6 - favorable, and 7–12 - unfavorable). The questionnaire was translated into local languages, and a structured interview schedule of the caretakers was used to collect data after informed consent.

A pilot study confirmed that the study was feasible and practicable. For statistical analysis, baseline variables were calculated as frequency and percentage. Chi-square test was used to find the association between the clinical symptoms and its contributory factors with selected baseline variables. Prevalence with confidence intervals was calculated, and P < 0.05 was considered significant. Ethical clearance was obtained from the Institutional Ethical Review Board (IEC no-209/2015).

RESULTS

Sixty-three children presenting to the Pediatric Surgery OPD with habitual constipation were recruited. Of these, 4 were excluded for organic causes (Hirschsprung disease - 2, ectopic anus - 1, and neurogenic bowel bladder - 1) and 9 for incomplete data. Finally, data of 50 children were analyzed. Most were in the 4–10 year age group (70%), with male predominance (66%) and in preschool or middle school (74%) [Table 1]. 

Table 1:

Distribution of children – age, gender, educational status, duration of disease, frequency of defecation, and previous treatment (n=50)

Common clinical symptoms [Table 2] were hard and dry stool (84%), painful defecation (72%), withholding of the stool defecation (62%), and a corresponding decrease in appetite (60%). Extreme symptoms such as soiling (20%) and rectal bleeds (10%) were occasional. Fourteen percent were not toilet trained and defecated in standing position with posturing,; 6% of them presented with urinary symptoms like increased frequency secondary to constipation. In 82%, the stool frequency was <1–2/week, only 18% had a daily bowel movement [Table 1]. Fifty-eight percent had a chronicity of over 3 years before they sought attention. Forty-three (86%) had received some form of treatment for functional constipation previously. Unfavorable dietary habits (66%) and grossly inadequate water intake (80%) was common; while a third had unfavorable psychological (40%) and socioeconomic (32%) factors [Table 2]. There was a significant association between withholding of stool and soiling in the 4–10 years age group (P < 0.05) and abdominal pain and feeling of incomplete defecation in the 11–15 age group. Females had a higher prevalence of abdominal pain, abdominal distension, and painful defecation DISCUSSION

Habitual constipation is an established malady of urbanization associated with a shift in dietary habits and sedentary lifestyle. There has been a progressive increase in childhood constipation in the recent decades. Functional constipation is the most common type of constipation in Asia. This study analysed the Epidemiological factors in 50 children attending outpatient services in tertiary teaching center of South India with a structured interview.

We noted functional constipation predominantly in boys in the age group of 4–10 years, with hard stool and painful defecation being the most common symptoms. Nearly 60% had decreased fiber and fluid intake, 40% had psychological stressors, and 32% had contributory socioeconomic factors. Like Dehghani et al. who reported a mean duration of constipation of 2.2 ± 1.9 years,[4] the majority (58%) sought intervention after being symptomatic for >3 years. The prevalence of hard and dry stools, painful defecation and abdominal pain, and fecal soiling was similar to others;[4,6-9] however, a greater proportion (20% vs. 10.8%) had rectal bleeds than reported elsewhere.[10] In another study,[11] 21.8% of 87 children with constipation reported urinary incontinence; in our study, this was 3%. Bowel bladder dysfunction is a dreaded sequelae of constipation, and prevention and early intervention are vital to preventing this complication.

Children in kindergarten and middle school were found to have a higher prevalence of constipation than children in primary and high school. The toddler age group is a period of bladder-bowel training and habituation to establish lifelong practices of toilet hygiene and independence. The timing of initiating toilet training depends on the ethnicity, socio-cultural norms, and traditional practices. For example, in Vietnam, bowel training is initiated at 6 months of age with 98% habituated by 24 months. In contrast, only 5% of Swedish children attained similar habituation by 24 months, as initiation is late.[12] Traditional practices in South India, as elsewhere in the South Asian subcontinent, encourage early toilet training. Factors that facilitate this include verbal cues, a squatting posture, daily early morning ritual of bowel movement, imitation of older siblings, and positive reinforcement to use the toilet after a meal. A deviation from these traditional practices with nuclear families, working parents, lack of time devoted to oversee toilet training, use of diapers, and western toilets perpetuates the problem.

In this study, 66% of children had unfavorable dietary factors. South Indian food is rich in fiber (coconut, banana, jackfruit, green leafy vegetables, and root vegetables) and fermented foods. Yet, it was evident that children were opting for processed foods rather than home-cooked food. Sanchez and Bercik report that children with inadequate intake of fruits and vegetables were 13 times more likely to suffer from functional constipation than otherwise.[13] Inadequate water intake is another major contributing factor. Education of the caretaker regarding adequate vegetable and fluid intake is important to prevent constipation at an early age. Likewise, there is a need to educate the school authorities and children about the ill effects of eating junk food that is common on most school premises.

Some young children postpone using the toilet due to fear of defecation or strained family dynamics, both perpetuating the withholding behavior.[14] Emotional and peer problems are common among children with functional constipation. All three major forms of abuse (physical, emotional, and sexual) predispose children to develop functional constipation.[15] Studies endorse that parents of children with functional constipation are overly strict, overprotective, and have authoritative parenting styles with rigid attitudes.[16,17] Even though there was no statistical significance between psychological or socio-economic factors and functional constipation, these factors cannot be discounted, and population-based studies would elucidate these better. In our center, primary counseling and treatment (diet, toilet training, and laxatives) is done by the treating surgeon, and the child is followed up as per IAP constipation recommendations protocol[18] monthly for the first 3 months and 2 monthly for a year thereafter. Psychological and social factors are analyzed at the child guidance clinic, where the child and parents are interviewed separately by child psychologists, and therapy is initiated by positive reinforcement of good toilet training practices.

There are few studies on this topic from South Asia.[19-21] Our study is unique in that it takes the psychosocial and socioeconomic factors into consideration; these are sparsely documented in literature. It describes the demographics of functional constipation and the associated symptomatology. Despite a small sample size being its limitation, it is comparable to many Western population-based studies. As we have included the interviews of the caretakers and not the children, there is a possibility of bias. It is a misconception that constipation is a Western malady and not a serious problem in Asian countries. Multicenter studies will elucidate regional factors better to plan interventions that suit the local dietary and cultural practices. We advocate an early diagnosis of functional constipation in children, primary prevention through social activism, and a compassionate team-based approach when psychosocial stressors are detected. Designing age-specific questionnaires directed to get his/her perspective of the disease may yield additional information.

CONCLUSION

Chronic functional constipation is prevalent in South India, and its sequelae of encopresis and enuresis are distressing. There is immense scope for prevention by health education to reinforce traditional dietary and social practices. Psychosocial support should be provided where necessary at the home or school to alleviate the malady. A structured questionnaire which is geographically relevant can help doctors, healthcare professionals, and caregivers in managing children with constipation.