Functional retentive overflow incontinence (retentive FI) is the most common cause of fecal soiling in children. Based on the clinical experiences, the treatment of retentive FI in patients with comorbid psychiatric disorders was accelerated when Risperidone was used as treatment for their psychiatric comorbidities; therefore, this study was conducted to evaluate the effect of risperidone in the treatment of retentive FI in children and adolescents.

In this double-blind, randomized, placebo-controlled trial, 140 patients aged 4-16 years eligible for the study were randomized into two groups, receiving either 0.25-0.5 mg of Risperidone syrup (n = 70) or maltodextrin syrup (placebo group, n = 70) every 12 h daily for 12 weeks. Sociodemographic data, including age, sex, weight, height, BMI, BMI z-score, and socioeconomic status, was recorded, and the number of nocturnal FI, diurnal FI, and painful defecations was measured.

136 participants (69 on Risperidone and 67 on placebo) were included in the study. Mean age of participants in the intervention and placebo groups were 7.2 ± 2.4 years and 8.0 ± 3.1 years, respectively. The mean number of nocturnal FI (Ptrend=0.39) and diurnal FI (Ptrend=0.48) in patients without psychiatric comorbidities, and the number of painful defecations for participants with and without psychiatric comorbidities (P = 0.49, P = 0.47, respectively) were not significantly different between the groups, but a significant effect was observed in diurnal FI after Risperidone treatment in patients with psychiatric comorbidities (P < 0.001).

Risperidone, when used along with other non-pharmacological interventions, may be helpful in treating FI in pediatric patients with psychiatric comorbidities.

Children with autism spectrum disorder (ASD) may achieve continence later than other children. Little is known about factors associated with toileting resistance in children with ASD and other developmental delays/disabilities (DD). We sought to describe toileting resistance in children with ASD and DD and those from the general population (POP) and identify factors associated with toileting resistance in children with ASD and DD.

Families and children aged 24 to 68 months were enrolled in the Study to Explore Early Development, a multisite case-control study on ASD. Children with ASD (N = 743) and DD (N = 766) and those from the POP (N = 693) who were 48 months or older were included in this study. Parents reported toileting resistance, gastrointestinal issues, behavior problems, and ASD symptoms in their children. Children completed an in-person evaluation to determine ASD status and developmental level.

Toileting resistance was more common among children with ASD (49.1%) than children with DD (23.6%) and those from the POP (8.0%). Diarrhea and deficits in social awareness were significantly associated with toileting resistance in children with ASD and DD. Constipation, expressive language delays, and low social motivation were significantly associated with toileting resistance only in children with ASD; very low visual reception skills and oppositional behaviors were significantly associated with toileting resistance in only children with DD (all p ≤ 0.05).

Evaluating gastrointestinal issues, developmental delays, and social deficits before toileting training may help identify children with atypical development who are likely to present with toileting resistance. These evaluations can be incorporated into health supervision visits.

The gastrocolic reflex is a response of the colon to the presence of food in the stomach. Our goal was to observe bowel movements in healthy infants and toddlers not yet toilet trained, in response to a meal. Stool behavior of 40 toddlers, aged 18-27 months, was monitored. We observed a bowel movement within the first hour after a meal in 75% of the children. This occurred 15, 30 or 60 minutes after a meal in, respectively, 25%, 48% and 66% of the observations. If we limit to the ones that actually defecated, 37% would defecate within 15 minutes and 72% within half an hour. Fifty-nine percent of all children defecated in the morning, 54% at noon and 28% in the evening. In conclusion, we believe the gastrocolic reflex can be used as a facilitating factor to help a child to defecate on the potty, 15-30 minutes after a meal. In 50% of the cases, a child will have a bowel movement on the potty and learn to defecate on it much easier.

To establish the cogency of recommendations for the appropriate age for pull-through and ileostomy closure in Total Colonic Aganglionosis-Hirschsprung Disease's (TCA-HD).

Medline, PubMed, Cochrane, and the ClinicalKey databases were searched without date restriction. The studies that reported TCA-HD cases were evaluated for the number of cases, age at the definitive procedure, age at the ileostomy closure, reported complications, and the type of procedure. Perianal excoriation and diaper rash rates were analyzed using SPSS software, with p < 0.05 considered significant.

Twenty-five studies mentioned TCA-HD findings between 1968 and 2019. The total number of patients who had definitive surgery was 218. Analysis showed no correlation between development of diaper rash and the age of the patient at the time of the definitive surgery or ileostomy closure. Studies scored between six and nine of nine possible stars on the NOS scoring system.

There is no correlation between age of surgery and postoperative diaper rash. Delaying the definitive procedure or ileostomy closure for TCA-HD has limited support on a review of current studies. The perianal excoriation/diaper rash is not reported in the literature at a high enough frequency to warrant keeping a diverting ileostomy until toilet trained of urine.

Systematic review and meta-analysis. Levels of evidence IV.

Functional constipation (FC) is a common health problem in paediatrics that causes significant physical and emotional distress to patients and their families.

In the current work, we assessed the presence of behavioural problems in children with functional constipation and their pattern and relation to various demographic and disease-associated factors.

A cross-sectional case-control study was conducted, including 55 consecutive children aged 4-16 years diagnosed with functional constipation and 55 healthy age and sex-matched controls. Psychological assessment was done using the Pediatric Symptom Checklist - 17 (PSC-17).

Twenty-six (47.3%) patients with FC had positive total PSC-17 scores while none of the controls had positive scores (p-value < 0.001). Positive internalising and externalising behaviours scores and attention problems were found in 36 (65.5%), 15 (27.3%) and 12 (21.8%) of the patients respectively in contrary to controls where only 6 (10.9%) had positive scores in internalising behaviour, and non-showed externalising behaviour and 4 (7.3%) were inattentive. Older age, longer duration of illness, residency in rural areas and presence of encopresis were found to have a significant association with the presence of such problems.

Children with FC have more behavioural disorders compared to healthy controls. Integration of psychosocial aspects and their management is recommended during dealing with patients with FC.

We examined the literature to identify reports of sensory integration concerns in children with functional defecation issues and to explore whether difficulty processing sensation may be related to their challenging bowel management behaviors.

A scoping review was used to address the research question. We sourced articles from six databases in three languages, searched reference lists of all included articles, and identified additional articles through discussion with experts in the field.

Twelve articles were included in the final synthesis, identifying 15 challenging behaviors potentially related to sensory integration concerns.

We summarize research documenting sensory integration concerns in children with functional defecation issues, providing researchers and clinicians with an overview of the current state of understanding.

Functional constipation (FC) is a significant health problem in children and contrary to common belief, has serious ramifications on the lives of children and their families. It is defined by the Rome criteria which encourage the use of multiple clinical features for diagnosis. FC in children has a high prevalence (0.7%-29%) worldwide, both in developed and developing countries. Biopsychosocial risk factors such as psychological stress, poor dietary habits, obesity and child maltreatment are commonly identified predisposing factors for FC. FC poses a significant healthcare burden on the already overstretched health budgets of many countries in terms of out-patient care, in-patient care, expenditure for investigations and prescriptions. Complications are common and range from minor psychological disturbances, to lower health-related quality of life. FC in children also has a significant impact on families. Many paediatric clinical trials have poor methodological quality, and drugs proved to be useful in adults, are not effective in relieving symptoms in children. A significant proportion of inadequately treated children have similar symptoms as adults. These factors show that constipation is an increasing public health problem across the world with a significant medical, social and economic impact. This article highlights the potential public health impact of FC and the possibility of overcoming this problem by concentrating on modifiable risk factors rather than expending resources on high cost investigations and therapeutic modalities.

Although a child may meet the physiologic, developmental, and behavioral milestones required for potty training, the process of potty training remains a formidable task for many parents and toddlers. The primary care physician must be prepared to discuss the signs of readiness as well as the setbacks that may occur in the process of potty training, which include resistance to training, fears of toileting, stool toileting refusal, accidents, and persistent nocturnal enuresis. [Pediatr Ann. 2016;45(6):e199-e201.].

Parenting factors are assumed to play a role in the development and maintenance of childhood constipation. However, knowledge about the association between parenting factors and childhood constipation is limited. This study investigates the association between parental child-rearing attitudes and prominent symptoms of functional constipation and assesses the strength of this association.

Cross-sectional data of 133 constipated children and their parents were collected.

The gastrointestinal outpatient clinic at the Emma Children's Hospital in the Netherlands.

Children with functional constipation aged 4-18 years referred by general practitioners, school doctors and paediatricians.

Parental child-rearing attitudes were assessed by the Amsterdam version of the Parental Attitude Research Instrument (A-PARI). Symptoms of constipation in the child were assessed by a standardised interview. Negative binomial and logistic regression models were used to test the association between child-rearing attitudes and constipation symptoms.

Parental child-rearing attitudes are associated with defecation and faecal incontinence frequency. Higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence. More and stronger associations were found for children aged ≥6 years than for younger children.

Parental child-rearing attitudes are associated with functional constipation in children. Any parenting issues should be addressed during treatment of children with constipation. Referral to mental health services is needed when parenting difficulties hinder treatment or when the parent-child relationship is at risk.

ISRCTN2518556.

Symptom measurement in pediatric chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (IBS-C) trials requires appropriately developed clinical outcome assessments (COAs).

Literature was reviewed to identify symptom COAs meeting regulatory standards. Searches were conducted in Pubmed/Medline, EMBASE, and PsychINFO. Title/abstracts were reviewed to identify qualitative studies and those using COAs to measure pediatric CIC/IBS symptoms. Pediatric functional gastrointestinal experts provided input on relevant symptom-concepts to measure.

Review of 1,105 abstracts identified 1 relevant qualitative article and 113 articles including COAs. Symptoms most frequently measured in CIC studies were frequency of bowel movements, fecal incontinence/encopresis, abdominal pain, stool consistency, and painful defecation. Symptoms most frequently measured in IBS were abdominal pain, abdominal distention/bloating, stool consistency, frequency of bowel movements, and gas. Evidence of development/validity of COAs was limited. Expert feedback was broadly consistent with the literature.

Findings demonstrate consistency in the literature on key CIC/IBS symptoms to measure in pediatric trials, but existing COAs do not meet regulatory standards.

Toilet refusal syndrome (TRS) is a common, benign disorder in toddlers defined by the use of diapers and refusal of toilet for defaecation, but has not been described systematically in preschool children yet. The aim of the study was to analyse and identify possible subgroups of TRS.

Retrospective analysis of all of the consecutive children with TRS presented as outpatients in a clinic for elimination disorders. Patients had received a detailed paediatric and child psychiatric assessment, including the Child Behavior Checklist questionnaire. Three typical case vignettes are presented of TRS with constipation, oppositional defiant disorder, and sibling rivalry.

Twenty-five children (10 boys) with a mean age of 5.2 (3.4-7.3) years were included-representing 2.5% of all of the children (n = 1001) presented. They had high rates of constipation (60%) and elimination disorders (24%-44%). Child psychiatric International Classification of Diseases-10th Edition disorders were common (40%) and heterogeneous, with significantly more boys affected, but no differences between children with and without constipation.

This study shows that TRS occurs also in older preschool (and even school) children. At this later age, it is associated with constipation and behavioural disorders. The case vignettes show differences in therapy and may represent different subgroups of TRS. TRS is associated with constipation, elimination disorders, and psychiatric disorders. Owing to this variety of comorbid disorders, different therapeutic approaches are needed. A general screening for behavioural symptoms is recommended.

The purpose of this study was to investigate the prevalence, clinical characteristics, and management of functional constipation at pediatric gastroenterology clinics. A prospective survey using the Rome III criteria was distributed to a group of parents of children with a constipation history and its control group in May 2008. The mean prevalence of constipation was 6.4%, which was similar to those in other countries. Statistically significant variables for children without constipation were that more children had a body mass index of below the 10th percentile even though they received more mother's care and ate balanced meals compared to the constipation group. Meanwhile, the constipation group frequently showed a history of constipation in infancy, picky-eating, lack of exercise, and retentive posturing. When analyzed with the Rome III criteria, the children showed greater than 60% rate of hard stools, painful stools, a history of large fecal mass in rectum, and its disappearance of constipation symptoms after passing a large stool. Our study found different approaches amongst pediatric gastroenterologists like rectal examinations, disimpaction, or drug treatment. Several factors addressed in our study can provide better guidelines for clinicians treating constipation and its future research.

Constipation is one of the most common pediatric disorders, especially in developed population, which categorized to organic or functional (non-organic) constipation. Furthermore, obesity is a growing chronic pediatric problem that could cause any compromise in weight and height. The aim of this study is the evaluation of probable relation between obesity and pediatric functional constipation.

This study was conducted as a case-control investigation on 2-14-years-old children those referred to Baqiyatallah University clinic during 2009-2011. The constipated children with organic causes were excluded. The control group of children was those who had not any disorders affecting on height and weight. Quantitative variables were expressed by mean and standard deviation and the correlation was tested with chi2 through SPSS version 17.

A total of 259 children (male 51.7%) consisting 124 cases and 135 controls were enrolled. The mean age in constipated and normal children was 69.47 ± 35.03 and 74.15 ± 39.68, respectively. BMI over 95% in the control group was 11.9% and in the constipated group was 17.7% that the difference was not statistically significant either (P = 0.188). The only significant association was found between obesity and the duration of constipation and also age (P = 0.008, 0.042, respectively).

Although we found a significant relationship between duration of constipation and obesity, there was not a clear association between obesity and presence of constipation. Furthermore, we suggest extended cohort or clinical trial study regarding to the regional nutritional and growth patterns to confirm weight decrease or increase the effect on defecation.

The aim of the present study was to describe the prevalence of childhood constipation, stool characteristics, and their relationship with toilet training and age of introduction of cow's milk.

A total of 4231 children born in 2004, from a birth cohort study, were assessed at 12, 24, and 48 months of age, when their mothers provided information on sociodemographic characteristics, bowel habits, toilet training, and age of introduction of cow's milk and other foods.

The prevalence of constipation was 27.3% and 31.0% at 24 and 48 months of age, respectively. Among girls, at 48 months of age, it was 34.4% versus 27.4% in boys (P<0.001). The most common features of constipation were scybalous stools (47.7% and 41.0% at 24 and 48 months, respectively), evacuation difficulty (24.3% and 23.1%), and hard stools (17.8% and 34.1%). Toilet training starting before 24 months was associated with constipation at 24 months and its persistence up to 48 months. Among children who did not receive cow's milk in their first year of life, 22% had constipation at 24 months, 22.6% at 48 months, and 8.3% at 24 and 48 months. Among children who started cow's milk before 30 days of life, the respective proportions of children with constipation was 28.2%, 33%, and 12.4%.

The prevalence of constipation increases with age and cannot be detected using only information on evacuation interval. Toilet training before 24 months and introduction of cow's milk before 1 year of age is positively associated with constipation at 24 months and its persistence up to 48 months.

Human defecation involves integrated and coordinated sensorimotor functions, orchestrated by central, spinal, peripheral (somatic and visceral), and enteric neural activities, acting on a morphologically intact gastrointestinal tract (including the final common path, the pelvic floor, and anal sphincters). The multiple factors that ultimately result in defecation are best appreciated by describing four temporally and physiologically fairly distinct phases. This article details our current understanding of normal defecation, including recent advances, but importantly identifies those areas where knowledge or consensus is still lacking. Appreciation of normal physiology is central to directed treatment of constipation and also of fecal incontinence, which are prevalent in the general population and cause significant morbidity.

To study the relationship between the age of completion of toilet training during daytime and the onset of dysfunctional elimination syndrome (DES).

The present study was designed as a case-control study. A total of 80 patients with DES were allocated to the case group and 80 patients age- and gender-matched without DES were allocated to the control group. The patients with DES were seen in a tertiary center and the control patients were seen in a primary care center. Early completion of toilet training was considered to be before 24 months.

Patients were aged 3-17 years (mean: 7.55); 24 were male (30%) and 56 female (70%). The most frequent lower urinary tract symptoms were: urgency (77%), incontinence (75%), holding maneuvers (30%), high urinary frequency (61%) and low urinary frequency (16%). There was a history of urinary tract infection (UTI) in 62% of the DES group. The first UTI episode was before toilet training in 40%. The completion of toilet training was before the age of 2 years in 48% of DES patients and in 50% of the control group (p = 0.752) [odds ratio (OR) 0.91, 95% confidence interval (CI) 0.49-1.62].

The completion of toilet training before 24 months of age was not associated with DES. Some patients had DES symptoms such as UTI, infrequent voiding and constipation before toilet training. These findings suggest that DES may precede toilet training and this possibility should be confirmed in further studies.

To report the relationship between the ages initiating toilet training for urinary continence (TTU) and bladder function in healthy kindergarteners.

In 3 years, we evaluated urinary continence status and bladder function in 318 healthy kindergarteners. Children with congenital anomaly, neurological disorder, or developmental disability were excluded. A parent completed the questionnaire including the age at initiation and the duration of TTU, the current status of daytime and nighttime continence, the age of attaining daytime and nighttime continence, frequency of defecation and Bristol Stool Scale. All children underwent uroflowmetry and post-void residual urine (PVR) examinations.

Finally, 235 respondents (106 boys/129 girls, mean age = 4.8 ± 0.9 years) were eligible for analysis. The mean age initiating TTU was 24.4 ± 8.4 months (range: 1-52 months). Girls started TTU earlier than boys (23.3 months vs. 25.7 months, P = 0.03). Children started daytime TTU earlier (≤ 18, 19-24, and >24 months, N = 66, 71, and 98, respectively) was associated with earlier attainment of both daytime and nighttime continence (correlation coefficient = 0.60 and 0.31, respectively, P < 0.01). Children started nighttime TTU earlier (<30 months vs. ≥ 30 months) was associated with early attainment of nighttime continence and lower rate of enuresis (14.3% vs. 33.3%, P < 0.01). The prevalence rate of repeat abnormal uroflow patterns and repeat elevated PVR (>20 ml) was not different between early and late TTU.

Early toilet training for urine was associated with early attainment of both daytime and nighttime urinary continence, and does not appear to be associated with bladder dysfunction.

Behavior problems are common in children with functional constipation. This study assessed the prevalence of overall, internalizing, and externalizing behavior problems in children with functional constipation and explored which clinical characteristics of constipation are associated with these behavior problems.

Children who had functional constipation, were aged 4 to 18 years, and were referred to the gastrointestinal outpatient clinic at the Emma Children's Hospital were eligible for enrollment. This study made use of baseline data of 133 children who participated in a randomized, controlled trial that evaluated the clinical effectiveness of behavioral therapy compared with conventional treatment. Prevalence of behavior problems was assessed by the Child Behavior Checklist. Univariate and multivariate logistic regression models were used to test the association between clinical characteristics and behavior problems.

The prevalence rate of overall, internalizing, and externalizing behavior problems was considerable: respectively 36.8%, 36.1%, and 27.1% compared with 9% in the Dutch norm population. A long duration of treatment was found to have the strongest association with overall and externalizing behavior problems in children with constipation. Children with constipation and nighttime urinary incontinence have an increased risk for having overall behavior problems. Fecal incontinence and the production of large stools seemed to be exclusively related to externalizing behavior problems.

Behavior problems are common in children who have constipation and are referred to gastrointestinal outpatient clinics, suggesting that a behavioral screening should be incorporated into the diagnostic workup of children with constipation.

Immaturity of neurons in normoganglionic colon in Hirschsprung disease (HD), anorectal malformation (AM), idiopathic constipation (IC), and normal controls (C) was assessed using polysialyated neural cell adhesion molecule.

Polysialyated neural cell adhesion molecule immunoreactivity in 3 sections of normoganglionic colon from HD (n = 48), AM (n = 25), IC (n = 36), and C (n = 18) were scored semiquantitatively according to age; 1 day to 11 months (G1), 1 to 4 years (G2), and 5 years and older (G3).

Neurons in all specimens appeared mature irrespective of age on hematoxylin-eosin stain. Polysialyated neural cell adhesion molecule was positive (immaturity) in all specimens during G1 (1.34 in HD, 1.60 in AM, 0.89 in IC, and 1.59 in C) and decreased significantly with age in C (0.34* for G2, 0.25* for G3; *P < .01), decreased after 4 years old in IC (0.93 for G2, 0.10(#) for G3; (#)P < .05), decreased gradually in AM (1.10 for G2, 0.75( section sign) for G3; ( section sign)P < .05), but remained strongly positive in HD (1.34 for G1, 1.26 for G2, and 1.21 for G3; P = not significant), which after 4 years was significantly higher than C (P < .05).

Postoperative colonic dysmotility may be because of persistence of immature neurons in HD and impaired maturation of neurons in AM and IC.

It has been suggested that the addition of behavioral interventions to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. Our aim was to evaluate the clinical effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood.

In this randomized, controlled trial conducted in a tertiary hospital in The Netherlands, 134 children aged 4 to 18 years with functional constipation were randomly assigned to 22 weeks (12 visits) of either behavioral therapy or conventional treatment. Primary outcomes were defecation frequency, fecal incontinence frequency, and success rate. Success was defined as defecation frequency of > or = 3 times per week and fecal incontinence frequency of < or = 1 times per 2 weeks irrespective of laxative use. Secondary outcomes were stool-withholding behavior and behavior problems. Outcomes were evaluated at the end of treatment and at 6-months follow-up. All of the analyses were done by intention to treat.

Defecation frequency was significantly higher for conventional treatment. Fecal incontinence frequency showed no difference between treatments. After 22 weeks, success rates did not differ between conventional treatment and behavioral therapy (respectively, 62.3% and 51.5%), nor did it differ at 6 months of follow-up (respectively, 57.3% and 42.3%). The proportion of children withholding stools was not different between interventions. At follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7% vs 29.2%).

Behavioral therapy with laxatives has no advantage over conventional treatment in treating childhood constipation. However, when behavior problems are present, behavioral therapy or referral to mental health services should be considered.

Constipation is a common problem in primary care. Nurse practitioners should be able to diagnose and treat constipation appropriately and to recognize which children require referral to a gastroenterologist. Referral to a gastroenterologist is necessary for the child with simple constipation or encopresis fails to respond to treatment, an organic etiology is suspected, or complex management is required.

Encopresis is defined as functional faecal incontinence at 4 years of age or older and affects 1-3% of all school children. The two most important subtypes are encopresis with and without constipation. In preschoolers toilet refusal syndrome can occur. Comorbid behavioural disorders and urinary incontinence are common. The current state-of-the-art regarding aetiology, assessment and therapy is presented in this overview. A symptom-oriented behavioural approach (toilet training) is most successful, with the addition of laxatives (polyethylene glycol) if constipation is present. Biofeedback is not effective. Other forms of psychotherapy are indicated only in case of comorbid behavioural disorders. The long-term outcome has been poor and needs improvement.

To release a newly protocolized behavioral intervention program for children with chronic constipation aged 4-18 years with guidance from literature about underlying theories from which the treatment techniques follow.

Articles until July 2006 were identified through electronic searches in Medline, PsychInfo and Picarta. There was no limit placed on the time periods searched. Following keywords were used: constipation, encopresis, fecal incontinence, psychotherapy, emotions, randomized controlled trials, parent-child relations, parents, family, psychology, behavioral, behavioral problems, psychopathology, toilet, social, psychosocial, pain, retentive posturing, stool withholding, stool toileting refusal, shame, stress, anxiety. A filter was used to select literature referring to children 0-18 years old. Key constructs and content of sessions for a protocolized behavioral intervention program are derived from literature.

Seventy-one articles on chronic childhood constipation are critically reviewed and categorized into sections on epidemiology, symptomatology, etiology and consequences, treatment and effectivity, and follow-up on chronic childhood constipation. This is followed by an extensive description of our protocolized behavioral intervention program.

This is the first article on childhood constipation presenting a full and transparent description of a behavioral intervention program embedded in literature. In addition, a theoretical framework is provided that can serve as a trial paradigm to evaluate intervention effectiveness.

This article can serve as an extensive guideline in routine practice to treat chronically constipated children. By releasing our protocolized behavioral intervention program and by offering a theoretical framework we expect to provide a good opportunity to evaluate clinical effectivity by both randomized controlled trials and qualitative research methods. Findings will contribute to the implementation of an effective treatment for chronic constipation in childhood.

A systematic review of the published literature was performed to assess the prevalence, incidence, natural history, and comorbid conditions of functional constipation in children.

Articles were identified through electronic searches in Medline, Embase, Cochrane Central Library, Cinhal and PsychInfo databases. Study selection criteria included: (1) epidemiology studies of general population, (2) on the prevalence of constipation without obvious organic etiology, (3) in children from 0 to 18 yr old, and (4) published in English and full manuscript form.

Eighteen studies met our inclusion criteria. The prevalence of childhood constipation in the general population ranged from 0.7% to 29.6% (median 8.9; inter quartile range 5.3-17.4). The prevalence of constipation defined as defecation frequency of < 3/wk varied from 0.7% to 29.6% (median 10.4; inter quartile range 1.3-21.3). Identified studies originated from North America (N = 4), South America (N = 2), Europe (N = 9), the Middle-East (N = 1), and Asia (N = 2). Variance of gender specific prevalence was reported in seven studies and five of seven studies reported no significant difference between boys and girls. The age group in which constipation is most common could not be assessed with certainty. Socioeconomic factors were not found to be associated with constipation.

Childhood constipation is a common problem worldwide. Most studies report similar prevalence rates for boys and girls. Large epidemiologic studies with the use of generally accepted diagnostic criteria are needed to define the precise prevalence of constipation.

Constipation is common in children, with prevalences ranging from 0.3% up to 28%. In most children, constipation is functional (ie, without objective evidence of a pathological condition). Painful defecation has been proposed as the primary precipitant of functional faecal retention in early childhood. Faecal soiling is often secondary to constipation, and may occur during spontaneous relaxation of the sphincters precipitated by rectal distension. Management in general practice combines behavioural modification techniques with prolonged courses of laxatives. Treatment is usually successful, but may take up to 6-12 months. Significant numbers of children with initially good responses to therapy for constipation relapse in the long term. Long-term relapse is more frequent in children under 4 years at onset of symptoms and in whom there is a history of faecal soiling associated with constipation.

Children represent one of the patient groups most affected by constipation. Our objective was to identify and describe the risk factors associated with childhood constipation.

The study had a case-control, retrospective, open and multicenter design. Clinical data on possible risk factors were collected through an ad-hoc questionnaire. Two groups were studied: children with and without constipation.

Nine hundred twenty-one children were recruited; of these, 898 (97.6%) were included in the statistical analysis. There were 408 (45.4%) children in the constipated group and 490 (54.5%) in the non-constipated group. Most of the children with constipation (53.6%) had a maternal history of constipation compared with 21.4% of children without constipation (p < 0.05). More than half (53.2%) of the constipated children reported a lack of regularity in their toilet habits while 64.9 % of the children without constipation went to the toilet regularly. Toilet training started slightly earlier (at 3 years) in children without constipation (93.2%) than in those with the disorder (83.8%) (p < 0.05). At school, 57.4% of the children with constipation never used the toilet compared with 26.8% of those without constipation (p < 0.05). A total of 73.4% of children with constipation drank less than four glasses of water per day compared with 47.1% of those without constipation (p < 0.05). Consumption of vegetables and legumes in the diet was significantly lower in children with constipation than in those without (p < 0.05). The risk factors linked to childhood constipation found in this study were a familial history of constipation, irregular toilet habits, low dietary fiber contents and no fruit intake. The main preventive factors against constipation were water and vegetable consumption and training on the use of the toilet at school.

Daily toilet training and dietary changes are needed to prevent constipation among children and to achieve regular defecation. This preventive intervention should be reinforced at school.