Evidence‐Based Diagnosis and Treatment of Functional Constipation

See “Practice Patterns of Pediatricians and Trainees for the Management of Functional Constipation Compared With 2006 NASPGHAN Guidelines” by Yang and Punati on page 308. Professional organizations develop clinical practice guidelines with the hope that they will help improve quality of care, reduce variation of practice, and ensure that evidence is actually used in clinical practice whenever possible. Despite the existence of guidelines and protocols, a gap between recommended care and clinical practice often exists (1). In this issue of the Journal of Pediatric Gastroenterology and Nutrition, Yang and Punati (2) report findings of a survey study conducted in California involving pediatric attending physicians and trainees at 7 academic centers. Trainee physicians who were on the American Academy of Pediatrics section e-mail list were also invited to participate. A questionnaire designed to evaluate the diagnostic and therapeutic approaches for functional constipation (FC) with and without fecal incontinence (FI) was e-mailed to 8223 individuals. Nine hundred sixty-seven completed responses were included in the data analysis; 80% were trainees and 20% were attending physicians. Eighty-four percent of the pediatric attending physicians and trainees reported that they were unfamiliar or slightly familiar with 2006 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) FC guidelines. Similar findings have been reported in a survey study evaluating the awareness of pediatric Rome criteria for the diagnosis of functional gastrointestinal disorders (FGIDs), in which only 28% of the surveyed general pediatricians were aware of the Rome criteria compared with 99% of pediatric gastroenterologists (3). Although the 2006 NASPGHAN FC guidelines have since been revised (4), updated guidelines were not published when the Yang and Punati study was conducted. The lack of awareness of FC guidelines and Rome criteria among general pediatricians raises a few questions. The methods for dissemination of guidelines may be ineffective. It also makes one wonder whether the guidelines are perceived as cumbersome to implement in clinical practice. Because the 2006 NASPGHAN guidelines were mostly based on expert opinion, pediatricians may not agree with some of the recommendations and are therefore reluctant to adopt them into clinical practice. Unfortunately, the updated joint European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and NASPGHAN FC guidelines published in 2014 are also predominantly based on expert opinion because of lack of good published evidence for the diagnosis and treatment of FC. For example, the recommendation regarding the role of digital rectal examination was based on 1 study alone. There were no studies evaluating the prevalence of hypothyroidism, celiac disease, and hypercalcemia in children with FC that met the guidelines’ inclusion criteria. The level of evidence for role of fiber and fluid in childhood constipation was graded as “low.” Similarly, evidence for the role of polyethylene glycol for disimpaction and the efficacy of maintenance therapy with polyethylene glycol, lactulose, and milk of magnesia was graded “very low.” The expert committee working on FC guidelines has done a tremendous job despite major challenges they must have faced because of lack of good published evidence in the field. A wide variability in the diagnosis and treatment of FC exists, and guidelines are meant to reduce this variability. A study evaluating the care of FC in Italy, the Netherlands, and the United States surveyed 383 primary care physicians in these countries (5). Sixty-three percent of surveyed physicians were convinced that hard stool could be softened by drinking more water. Abdominal x-ray was used by 49% to diagnose FC. Only 11% of physicians in the Netherlands used digital examination during evaluation of FC compared with 54% in the United States. Almost 60% of the surveyed attending physicians and trainees in the Yang and Punati (2) study reported using digital examination rarely or never in the evaluation of children with FC. The joint ESPGHAN and NASPGHAN FC guidelines recommend that digital rectal examination is not necessary in patients presenting with a typical history and in the absence of red flags (4). It is important to emphasize, however, that judicious use of digital rectal examination in patients presenting with an atypical history with onset of symptoms in early infancy, delayed passage of meconium, and alarm symptoms can be helpful. Inspection of the perianal region without digital examination can be easily performed in most children and can help to identify a malpositioned anal opening, the absence of anal wink (which can suggest spinal abnormalities), and the presence of anal fissure (which points toward FC with passage of large-caliber stools). Published data regarding the role of abdominal x-ray to diagnose FC are controversial. One reason for this could be the lack of a standardized scoring system to evaluate colon stool burden and severity of rectal impaction. The updated joint FC guidelines identified 5 studies that met their inclusion criteria, but only 1 study specifically evaluated the value of abdominal x-ray to discriminate children with constipation from those without (6). This study found that abdominal x-ray has poor discriminative value in differentiating children with FC from those without. Current evidence does not support the use of abdominal x-ray to diagnose FC (4). In the Yang and Punati (2) study, the majority of the surveyed pediatricians acknowledged using abdominal x-ray sometimes or often to diagnose FC. FI is a common problem in children with FC and up to 80% of children with FI have associated FC (7). In the Yang and Punati study, 75% of the surveyed pediatricians reported that only 0% to 10% of their patients with FC had FI, suggesting that they may underestimate the association of FC and FI. Fecal soiling is a distressing symptom and difficult to conceal because of the odor associated with stool leakage. Soiling accidents at school can lead to stigmatization, peer rejection, and bullying (8,9). Children with constipation and FI commonly demonstrate social withdrawal and school avoidance behavior and have poor health-related quality of life (9,10). When treating children with FC-associated FI, achieving social continence is critical, especially in middle- and high school–age children. If the standard therapeutic modalities are not successful, referral to a pediatric gastroenterologist or a pediatric motility center for further evaluation and management should be considered. Cecostomy for antegrade enemas can help achieve social continence in a select group of children (11). Long-term data regarding success of sacral neuromodulation in treating constipation and FI are lacking, but promising results have been reported from the Netherlands (12). FC and FGIDs are common problems for which parents seek medical advice. The average health care cost in the United States for the management of children with constipation is estimated to be approximately $3430/year compared with $1099/year for children without constipation (13). This amounts to an additional health care expenditure of $3.9 billion/year. Despite the high prevalence and significant health care expenditure associated with the diagnosis and treatment of FC, there have been no organized public health awareness campaigns. Our professional organizations need to prioritize issues regarding better dissemination of published guidelines and evidence, consider a public awareness campaign that includes general pediatricians, and provide support to help generate better evidence for the diagnosis and treatment of FC.