Key Components of the History Taking and the Physical Examination in Children with chronic constipation

Bibliographic InformationStudy type & Evidence levelNumber of patients & prevalencePopulation CharacteristicsType of test and Reference standardSensitivity, Specificity, PPV and NPVReviewer comment
Borowitz et al. Precipitants of constipation during early childhood. 2003. Journal of the American Board of Family Practice 16[3], 213-218United States. Borowitz, 2003Study type:
Case-control

Evidence level:
III

Study aim:
To determine the precipitants to constipation in early childhood
220 children

Inclusion criteria:
Aged 2y 0m to 6y 11m, at least average intelligence
-

patients: First time presentation to physician with constipation

-

controls: no history of constipation

Exclusion criteria:
Underlying medical condition, medication that could account for constipation
220 children
-

Patients

n=125

  • mean age (months): 44±13 49% male
-

Controls

n=95

  • mean age (months): 46±18 54% male
Country:
USA
Setting:
26 primary care facilities (15 paediatricians, 11 family medicine centres)
Test
History of events occurring in the 3 months prior to onset of constipation:
-

large/painful bowel movement

-

toilet training

-

started day care

-

travelling

-

liquid to solid foods

-

breast to bottle

-

family move

-

vomiting/dehydration

-

new medication

-

parental separation

-

birth of a sibling

-

tent camping

-

high fever

-

surgery

-

extended bed rest-trauma in bathroom -sexual abuse

-

family death

Reference Standard
None
Degree of difficulty with toilet training (mean ± SD)
(0=none, 4=extreme)

Patients: 2.1±1.3
Controls: 1.4±1.1
p<0.001

Degree of difficulty passing some bowel movements (% children)

None: patients 3 , controls 49
Mild: patients 86, controls 49
Moderate: patients 80, controls 10
Extreme: patients 76, controls 5

p<0.001 (patients as compared to controls in each category)

Degree of pain passing some bowel movements (% children)

None: patients 5, controls 56
Mild: patients 82, controls 40
Moderate: patients 69, controls 8
Severe: patients 67, controls 6

p<0.001 (patients as compared to controls in each category)

Children expressing worry about passing bowel movements (% children)
Patients: 75
Controls: 8

p<.001
-

Family history of constipation and initial age of toilet training no significantly different between the 2 groups

-

Subgroup analysis: children grouped according to whether they became constipated before or after their second birthday. The events parents reported having occurred in the 3 months before the onset of constipation were similar in the two groups, with the exception of toilet training having occurred more often before constipation in the older children (40% vs. 20%), and making the dietary transition from breast to bottle and from liquid to solid diets having occurred more often before constipation in the younger children (30% vs. 0). Large or painful bowel movements were seen by far the most frequent precipitating event for both age groups. Toilet training was seen as more of a precipitant for older onset children (20% vs. 10%), whereas transition from breast to bottle and from liquid to solid foods was seen to be more of a problem for younger-onset children (25% vs. 0)

Additional information from study
Constipation defined as passage of < 3 bowel movements each week for at least 2 consecutive weeks

22 non-patient siblings matched as controls, an additional 73 non-sibling controls recruited from advertisements

Likert scale: 0 to 4. 0 being not at all difficult and 4 being extremely difficult

Questionnaire for parents to fill out describing children's bowel habits.
-

indication of how difficult toilet training had been for bowel movements using Likert scale

-

parents to indicate if any of 18 different events occurred in the 3 months preceding the onset of constipation, and which of these they believed contributed to the onset of constipation

Both groups comparable regarding age and sex

Reviewer comments
Potential recall bias

Source of funding: NIH grant RO1HD 28160
Freedman et al. The crying infant: Diagnostic testing and frequency of serious underlying disease. 2009. Pediatrics 123[3], 841-848United States. Freedman, 2009Study type:
Retrospective case series

Evidence level:
III

Study aim:
To determine the proportion of children evaluated in an emergency department because of crying who have a serious underlying aetiology
238 patients

Inclusion criteria:
-

less than 12 months age

-

afebrile

-

presenting to ED during 9 month eligibility period with chief complaint of crying

Exclusion criteria:
Not stated
238 patients

Males 124 (52%)
Median age 2.3 months (range 1.0 to 5.4)

Country:
Canada
Setting:
Tertiary care referral hospital
Tests
Abdominal radiograph

Abdominal ultrasound

Reference Standard
History taking and physical examination
-

Positive findings on history and/or physical examination alone suggested the final diagnosis in 66.4% (158 of 238) of the crying children

-

11 cases of constipation were diagnosed, all diagnosed by category 1 data source – positive history and physical examination only

Constipation defined as history of difficult, infrequent, hard stools, palpation of small pellets on abdominal examination

Abdominal radiograph – performed 14 times with 0 positive findings
Abdominal ultrasound – performed 16 times with positive findings 2 times (12.5%) contributing only to the diagnosis of intussusception and acute cholecystitis, but not constipation
-

History and examination were found to be the most important aspect in the evaluation of the crying infant. Investigations only helpful in 3% of sample in this study

Additional information from study
Patients presenting with chief complaint of crying identified retrospectively by searching electronic database using a chief complaint family word root search for: “cry”, “irritable”, “fuss”, “scream” and “colic”. Afebrile defined as < 38°C

37,549 ED visits during 9 month eligibility period, of which 238 children met inclusion criteria

Patients and their final diagnoses grouped into 1 - 4 categories according to the sources of data that contributed the diagnosis
Data source categories:
  1. Diagnosis was based on the history (Hx) and/or physical examination (PE) alone
  2. Diagnosis was based on positive test results obtained after the Hx and PE failed to suggest a cause
  3. Diagnosis was based on tests ordered to investigate positive findings from the Hx and/or PE that suggested a cause
  4. Neither Hx, PE nor investigations were diagnostic
Required sample size calculated to yield stable estimates (±5%) of the primary outcome measure (proportion of infants who had potentially serious underlying aetiology). Estimated that 10% sample would have underlying serious aetiologies. Minimum sample of 138 subjects required. Anticipated follow-up telephone call response rate of only 75%. Final size after adjustment:: 245

Reviewer comments
No data on follow up care of accuracy of constipation cases

Minimum sample size required not achieved

Source of funding: Not stated
Lewis et al. Diagnosing Hirschsprung's disease: increasing the odds of a positive rectal biopsy result. 2003. Journal of Pediatric Surgery 38[3], 412-416 Lewis et al., 2003Study type:
Retrospective cohort

Evidence level:
III

Study aim:
To test the hypothesis that key features in the history, physical examination and radiographic evaluation would allow to avoid unnecessary rectal biopsies
315 children

Inclusion criteria:
-

Cohort 1:

Children presenting with constipation to diagnose Hirschsprung's disease (HD)

-

Cohort 2:

idiopathic constipation

Exclusion criteria:
Patients undergoing re-evaluation for constipation after pull-through procedure for HD
315 children:
-

265 children who had undergone rectal biopsy

-

50 children, concurrent selected cohort (cohort 2)

Country:
USA
Tests:
Rectal biopsy
Clinical features in children with Hirschsprung's disease and idiopathic constipation (IC, n=40)
-

Onset of constipation <1 year old

Delayed passage of meconium (%)

  • HD: 65
  • IC: 13
  • P< 0.05

Abdominal distension (%)

  • HD: 80
  • IC: 42
  • P< 0.05

Vomiting (%)

  • HD: 72
  • IC: 21
  • P< 0.05

Faecal impaction requiring manual evacuation (%)

  • HD: 6
  • IC: 30
  • P< 0.05

Enterocolitis (%)

  • HD: 13
  • IC: 15
  • NS
-

Onset of constipation >1 year old

Delayed passage of meconium (%)

  • HD: 81
  • IC: 1
  • P< 0.05

Abdominal distension (%)

  • HD: 53
  • IC: 7
  • P< 0.05

Vomiting (%)

  • HD: 23
  • IC: 0
  • P< 0.05

Faecal impaction requiring manual evacuation (%)

  • HD: 46
  • IC: 30
  • NS

Enterocolitis (%)

  • HD: 13
  • IC: 14
  • NS
Age at onset of symptoms
-

Hirschsprung's (HD) (n=46)

  • Mean: 8 months (range 1 day to 9 years)
  • 1rst week of life: 60 %
  • 1rst month of life: 70%
  • 1rst year of life: 87%
  • after 1 year of life: 13%
-

Idiopathic constipation (IC) (n=40)

  • Mean: 15 months (range 7 days to 16 years)
  • 1rst week of life: 15%
  • 1rst month of life: 55%
  • 1rst year of life: 68%
  • after 1 year of life: 32%
At least 34% of HD patients had the classic triad (delayed passage of meconium + vomiting + abdominal distension). At least 1 feature of the triad noted in 98% of patients with HD. Only 60% of patients with IC had a history of delayed passage of meconium, vomiting or abdominal distension. 100 % HD patients vs. 64% IC patients had 1 or more of the following: delayed passage of meconium, vomiting, abdominal distension and a transition zone on contrast enema. 36% of IC patients had none of these features.
Additional information from study
Questionnaires, telephone interviews and patients visits used to compile long-term data. In reporting features listed in the questionnaire only patients with definite information were included: the number of patients in each analysis varies to exclude those with missing data
Delayed passage of meconium defined as failure to pass meconium in the first 48h of life. These data were available in 59% of cases

Abdominal distension determined from parental response to questionnaire or data noted during patients visits

Enterocolitis defined as diarrhoea associated with fever

Reviewer comments:
Data on clinical features not available for all children

Unclear what kind of rectal biopsy was performed and how the diagnosis of HD was made
Source of funding: Not stated

From: Appendix J, Evidence tables

Cover of Constipation in Children and Young People
Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care.
NICE Clinical Guidelines, No. 99.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2010.
Copyright © 2010, National Collaborating Centre for Women's and Children's Health.

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