Search

Background: Antropyloric motility is important for regulation of gastric emptying and has not been adequately characterised in premature infants. Aim: To evaluate fed patterns of antropyloric motility in premature infants. [...]

Background/Aims:: Lifestyle intervention is the only established therapy for non-alcoholic fatty liver disease (NAFLD). The optimal treatment schedule and predictors of response of this treatment have not been established in children. We aimed to evaluate the 2-year efficacy of an inpatient versus ambulatory intensive lifestyle intervention for treating NAFLD in children with severe obesity. Methods:: A cohort study of 51 severely obese non-diabetic children (mean age 14.7 (±2.4) years; BMI-z-score 3.5 (±0.5)) with liver steatosis were non-randomly allocated to inpatient treatment (2 or 6 months), ambulatory treatment or usual care. Proton Magnetic Resonance Spectroscopy determined liver steatosis and serum alanine aminotransferase (ALT) at 6 months were the primary outcome measures. Baseline variables were evaluated as predictors of treatment response. Results:: Liver steatosis had disappeared in 43, 29 and 22% and serum ALT normalized in 41, 33 and 6% at the end of 6 months in the inpatient, ambulatory or usual care treatment groups, respectively. Only the proportions of ALT normalization in inpatient and ambulatory treatment compared with usual care were significantly higher. Treatment effects of inpatient and ambulatory treatment were sustained at 1.5 years follow-up. No baseline characteristic, including PNPLA3 polymorphism or leptin, was consistently predictive for treatment response. Conclusions:: A 6-month intensive inpatient and ambulatory lifestyle treatment in children with severe obesity reverses NAFLD in a minority of patients. This study suggests that inpatient compared with ambulatory intensive treatment does not importantly increase treatment success. Further efforts to optimize and individualize lifestyle interventions and additional treatments options are needed particular for children with severe obesity resistant to conventional lifestyle interventions.

There is an inverse relationship between gestational age, birth weight and the time of first neonatal bowel movement. The authors hypothesized that delayed passage of meconium might result from a delayed maturation of the recto‐anal inhibitory reflex (RAIR) in premature infants. To evaluate whether the RAIR is absent in very preterm infants 28‐32 weeks postmenstrual age with delayed meconium production. Anorectal manometry was performed in 10 preterm infants (seven male) with delayed meconium production (no meconium in the first 48 hours). Median postmenstrual age was 30 weeks (28‐31 weeks). Birth weight ranged from 780 to 1930 g (median, 1395 g). A micromanometric assembly (outer diameter, 2.0 mm) was used which incorporated a 1.5‐cm‐long sleeve sensor for measurement of resting anal sphincter pressure and relaxation. Four side‐holes recorded anal and rectal pressures. Rectal distension was performed with direct air insufflation to elicit the RAIR. The time from birth to passage of meconium ranged from 48 to 105 hours (median, 82 hours). The mean anal sphincter pressure, rectal pressure, and anal sphincter oscillation frequency were 22.0 ± 5.0 mm Hg, 6.9 ± 2.0 mm Hg, and 9.8 ± 1.9/min, respectively. A normal RAIR was elicited in all infants. Anorectal manometry recordings in premature infants with delayed passage of meconium showed normal anorectal pressures and a normal RAIR, suggesting that delayed meconium passage is not related to the absence of a RAIR.

Population‐based studies on the prevalence of encopresis in children are scarce and generally outdated. Prevalence estimates based on clinical studies are unreliable because parents tend to be reticent to seek medical help for this problem. Professional help is necessary, however, because encopresis can lead to serious psychosocial health problems. The authors examined the prevalence of encopresis in children, the frequency of visits made to general practitioners for encopresis and the psychosocial health problems of encopretic children. This population‐based study involved 13,111 parents and their 5‐ to 6‐year‐old children and 9,780 parents and their 11‐ to 12‐year‐old children, all residents of Amsterdam, the Netherlands. The prevalence of encopresis was 4.1% in the 5‐to‐6 age group and 1.6% in the 11‐to‐12 age group. Encopresis was more frequent among boys and children from the very depressed areas of the city. Encopresis was less frequent among Moroccan and Turkish children. A defecation frequency of less than three per week was found in 3.8% of the 5‐ to 6‐year‐olds and 10.1% of the 11‐ to 12‐year‐olds with encopresis. Only 37.7% of the 5‐ to 6‐year‐olds and 27.4% of the 11‐ to 12‐year‐olds who had encopresis had ever been taken to see a doctor for this problem. Psychosocial problems were far more common among children with encopresis than among normal children. Encopresis is a common condition that is often associated with psychosocial health disorders but only a small proportion of the children with encopresis are taken to a general practitioner to discuss their problem.

Transient relaxation of the lower esophageal sphincter (TLESR) is the predominant mechanism of gastroesophageal reflux (GER) in adults and children. Baclofen 4-amino-3-(p-chlorophenyl)-butanoic acid, a gamma-aminobutyric acid (GABA)-B receptor agonist used for the management of spasticity, has been recently shown to significantly inhibit GER in healthy adults without any relevant side effects. The objective of this study was to evaluate the pharmacokinetics of baclofen in a pediatric population with GER disease. In an open-label single-dose pharmacokinetic study, eight children with the diagnosis of GER made on clinical grounds received an oral dose of baclofen, 2.5 mg. Blood samples were drawn from an indwelling venous catheter, and urine was collected during a postdose period of 8 hours. The concentration of baclofen in these body fluids was determined using a validated high-performance liquid chromatography (HPLC) method with electrochemical detection after OPA-sulfite derivatization. Pharmacokinetic data were analyzed using the nonlinear regression program Scientist. Serum concentration–time curves could be best described using a two-compartment open model with a lag time. Mean plasma clearance (Cl) was 315.9 mL/h/kg; volume of distribution (Vd) was 2.58 L/kg; and half-life (T½) was 5.10 hours. No side effects were noted. As half-lives were comparable with those found in adult studies, the risk for accumulation seems not greater in children than in adults. Body composition can have a strong influence on the Vd of baclofen and, therefore, on the dose needed to obtain therapeutic plasma levels. Dosing according to clearly defined age groups with the help of therapeutic drug monitoring seems preferable. In view of the negative correlation between body weight and Vd, dosing according to body weight using adult pharmacokinetic data does not seem an effective way for using baclofen in children.

In adults, slow-transit constipation is a wellestablished form of constipation with abdominal pain and an empty rectum on examination. Marker studies in these patients, mainly women, show a markedly slowed transit time in all colonic segments. No studies in constipated children are available that assess the existence of slowtransit constipation. In a prospective study, a total of 94 referred constipated pediatric patients, 63 boys and 31 girls (median age, 8.0 years), underwent colonic-transittime measurements using radioopaque markers to evaluate the pattern of transit. In addition, orocecal-transittime measurements using the hydrogen breath (lactulose) test, anorectal manometry, and behavior studies using the Child Behavior Checklist were performed in all children. Based on the upper limit (mean + 2 SD) of total colonic transit time (CTT) in constipated children, we arbitrarily separated patients into two groups. Children with CTTs >100 h were said to have pediatric slow-transit constipation (PSTC), while patients with CTTs <100 h were said to have normal- or delayed-transit constipation (NDTC). In 94 constipated children, PSTC was found in 24 children; in 70 children, total CTT was <100 h (NDTC). Total and segmental CTTs were significantly prolonged in PSTC (median, 189 h; range, 104.4-384) versus NDTC (median, 46.8 h; range, 3.6-99.4) hours. No significant differences were found in orocecal transit time. Significant clinical differences in children with PSTC versus those with NDTC existed regarding nighttime soiling (71 vs. 11%); daytime soiling episodes (14 vs. 7 each week, median), and nighttime soiling episodes (5 vs. 0 each week, median); absent urge to defecate (33 vs. 14%); and palpable abdominal (71 vs. 39%) and/or rectal (71 vs. 13%) masses. All manometric parameters were comparable in the two groups, except for a significantly lower maximal squeeze pressure with PSTC. Using the Child Behavior Checklist, both groups differed significantly from controls (26 and 43%, respectively), with no significant differences in behavior problems found between the NDTC and the PSTC groups. In conclusion, based on objective marker studies, our findings suggest the existence of pediatric slow-transit constipation. This entity can be recognized by clinical features, most importantly nighttime soiling and a palpable rectal mass. The probability of PSTC with both of these symptoms was 0.82; in the absence of these two symptoms, it was 0.07. It is of interest that CTTs in PSTC are comparable with CTTs in adults with slow-transit constipation, although the clinical presentation is clearly different. Further studies are needed to investigate whether the prolonged CTT characterizes a distinct form of constipation in children or is an epiphenomenon of the underlying constipation itself. The mechanisms responsible for the slow transit in these children and the appropriate therapeutic approach need to be studied.

It is still unclear how to evaluate the existence of faecal retention or impaction in children with defaecation disorders. To objectivate the presence and degree of constipation we measured segmental and total colonic transit times (CTT) using radio-opaque markers in 211 constipated children. On clinical grounds, patients (median age 8 years (5–14 years)) could be divided into three groups; constipation, isolated encopresis/soiling and recurrent abdominal pain. Barr-scores, a method for assessment of stool retention using plain abdominal radiographs, were obtained in the first 101 patients, for comparison with CTT measurements as to the clinical outcome. Of the children with constipation, 48% showed significantly prolonged total and segmental CTT. Surprisingly, 91% and 91%, respectively, of the encopresis/soiling and recurrent abdominal pain children had a total CTT within normal limits, suggesting that no motility disorder was present. Prolonged CTT through all segments, known as colonic inertia, was found in the constipation group only. Based on significant differences in clinical presentation, CTT and colonic transit patterns, encopresis/soiling children formed a separate entity among children with defaecation disorders, compared to children with constipation. Recurrent abdominal pain in children was in the great majority, not related to constipation. Barr-scores were poorly reproducible, with low inter-and intra-observer reliability. This is the first study which shows that clinical differences in constipated children are associated with different colonic transit patterns. The usefulness of CTT measurements lies in the objectivation of complaints and the discrimination of certain transit patterns.

Normal anal manometric and profilometric values and normal endosonographic features of the anal canal are required for evaluation of pathological conditions such as slow-transit constipation, anorectal outlet obstruction, and Hirschsprung's disease, status after surgery for imperforate anus, and other anal abnormalities. Anorectal manometry, profilometry (rapid-pull-through, three-dimensional, eight-channel radial manometry), and endosonography were carried out in 13 healthy children. A significant correlation was demonstrated between conventional manometric and profilometric maximal squeeze pressure of the external anal sphincter (EAS). However, the maximal anal resting tone of the sphincter complex in profilometry was twice as high as in manometry due to reflexive contraction of a pelvic floor muscle, probably the EAS. With profilometry a positive correlation was found between age and sphincter length. Endosonographically assessed thickness of the EAS, puborectal muscle, and levator ani complex showed a significant correlation with age. However, no correlation was demonstrated between age and internal anal sphincter thickness. Thus, the development of the essential structures of the anal canal in children is age dependent. In addition, these measurements of normal physiology and anatomy of the anal canal provide the basis for detecting pathological conditions of the anorectal region in children.

Background: Sacral nerve neuromodulation (SNM) therapy has been successfully applied in adult patients with urinary and fecal incontinence. Recently, SNM therapy showed good results in adults with refractory functional constipation. No data, however, are available of SNM therapy as a treatment option in children with refractory functional constipation.Aim: To describe the preliminary results of SNM therapy in children with chronic functional constipation refractory to intensive conservative treatment.Material and methods: Children with functional constipation according to the ROME III criteria not responding to intensive conservative treatment (laxatives, enemas and colonic lavage) were assigned for SNM therapy. When improvement of symptoms was seen during the percutaneous nerve evaluation (PNE) with a permanent electrode in the 3 weeks testing phase, a permanent sacral nerve neuromodulator was implanted. Patients were followed up for at least six months after implantation by interviews and bowel diaries. Improvement was defined as spontaneous defecation = 3 times a week.Results: 5 patients (all females) 14 - 18 years old with functional constipation were included. None of them had spontaneous defecation at presentation. Duration of symptoms varied from 6 - 18 years and the duration of treatment from 1 -17 years. In all patients the testing phase was successful. After implantation of the permanent neuromodulator, all children had spontaneous defecation = 3 times a week without medication.Conclusion: SNM is a promising new treatment option in children with refractory functional constipation not responding to intensive conservative therapy. However, larger prospective studies with long-term follow up are required.